Correspondence

Tuberculosis in a Neighborhood Bar

N Engl J Med 1996; 334:334February 1, 1996

Article

To the Editor:

In the report of Kline et al. describing an outbreak of tuberculosis among bar patrons (July 27 issue),1 4 of the 14 active tuberculosis cases occurred among patients seronegative for the human immunodeficiency virus who had positive tuberculin tests but normal chest radiographs. This is not a new phenomenon2; among contacts of patients with active tuberculosis on Navy ships, 3 to 25 percent of those whose tuberculin skin tests converted from negative to positive had positive sputum cultures despite having normal chest films and sputum smears.3 Kent et al. obtained daily cultures for one month from 12 patients with recently converted tuberculin skin tests and isolated Mycobacterium tuberculosis from 10 of them (83 percent).4 Given the more sensitive techniques now available for detecting M. tuberculosis, the actual proportion may be even higher.5 The optimal treatment for culture-positive patients with normal chest radiographs and their degree of infectiousness are not known.

All four patients in the study by Kline et al. who had positive cultures with normal chest radiographs had cough, and two had weight loss. This suggests that tuberculin conversion may not always be asymptomatic, that these symptoms may be common among people with a history of alcohol and cigarette use, or that active tuberculosis disease was in the process of developing in these patients. Perhaps tuberculosis infection, like primary HIV infection, may be characterized by a distinct symptom complex.6

The authors conducted a prompt and thorough investigation in a difficult context, effectively limiting the further spread of tuberculosis. The thoroughness of their evaluations may have identified several patients with positive cultures in whom active tuberculosis would not have developed.

Thomas R. Frieden, M.D., M.P.H.
New York City Department of Health, New York, NY 10013

Timothy R. Sterling, M.D.
Keesler Medical Center, Keesler AFB, MS 39534

Patricia M. Simone, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333

6 References

1. 1

   Kline SE, Hedemark LL, Davies SF. Outbreak of tuberculosis among regular patrons of a neighborhood bar. N Engl J Med 1995;333:222-227
   Full Text | Web of Science | Medline

2. 2

   Husen L, Fulkerson LL, Del Vecchio E, Zack MB, Stein E. Pulmonary tuberculosis with negative findings on chest x-ray films: a study of 40 cases. Chest 1971;60:540-542
   CrossRef | Web of Science | Medline

3. 3

   Kent DC. Tuberculosis epidemics, U.S. Navy. Bull Int Union Tuberc 1968;41:79-82
   Medline

4. 4

   Kent DC, Reid D, Sokolowski JW, Houk VN. Tuberculin conversion: the iceberg of tuberculous pathogenesis. Arch Environ Health 1967;14:580-584
   Medline

5. 5

   Chin DP, Yajko DM, Hadley WK, et al. Clinical utility of a commercial test based on the polymerase chain reaction for detecting Mycobacterium tuberculosis in respiratory specimens. Am J Respir Crit Care Med 1995;151:1872-1877
   Web of Science | Medline

6. 6

   Cooper DA, Gold J, Maclean P, et al. Acute AIDS retrovirus infection: definition of a clinical illness associated with seroconversion. Lancet 1985;1:537-540
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Charles F. Gilks, Peter Godfrey-Faussett, Barry I.F. Batchelor, Josephine C. Ojoo, Sylvia J. Ojoo, Richard J. Brindle, John Paul, Joseph Kimari, Marian C. Bruce, Joab Bwayo, Francis A. Plummer, David A. Warrell. (1997) Recent transmission of tuberculosis in a cohort of HIV-1-infected female sex workers in Nairobi, Kenya. AIDS 11:7, 911-918
   CrossRef