1056 TUBERCULOSIS Sokolove et al.

TUBERCULOSIS PRESENTATION

BRIEF REPORTS ratory isolation of patients with

pulmonary TB.3,4 One possible ex-
The Emergency Department Presentation of planation for this is that the clinical
presentation of patients in the ED
Patients with Active Pulmonary Tuberculosis may be atypical. This can be partic-
ularly true for HIV-infected pa-
PETER E. SOKOLOVE, MD, LORCA ROSSMAN, MD, tients, in whom clinical symptoms
STUART H. COHEN, MD may be confused with Pneumocystis
carinii pneumonia (PCP), sputum
stains and cultures may be less sen-
sitive, and radiographic findings are
Abstract. Objective: To determine the clinical presentation of emer- frequently atypical.511 Even immu-
gency department (ED) patients with active pulmonary tuberculosis nocompetent patients may present
(TB). Methods: This was a retrospective medical record review of adult to the ED with nonspecific symp-
patients, identified through infection control records, diagnosed as toms or for illness or injury that is
having active pulmonary TB by sputum culture over a 30-month pe- coincidental to having active pul-
riod at an urban teaching hospital. The ED visits by these patients monary TB.
from one year before to one year after the initial positive sputum cul- In order to more readily identify
ture were categorized as contagious or noncontagious, using defined patients who may be at risk for pul-
clinical and radiographic criteria. The medical records of patients with monary TB, emergency physicians
contagious visits to the ED were reviewed to determine chief com- must be familiar with the clinical
plaint, presence of TB risk factors and symptoms, and physical ex- presentation of this disease. Under-
amination and chest radiograph findings. Results: During the study standing patient presentation is also
period, 44 patients with active pulmonary TB made 66 contagious ED an essential step in the development
visits. Multiple contagious ED visits were made by 12 patients (27%; of ED triage screening protocols as
95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95% recommended by the Centers for
CI = 22% to 46%), medical but nonpulmonary 41% (95% CI = 29% to Disease Control and Prevention.12
54%), infectious but nonpulmonary 14% (95% CI = 6% to 24%), and One such protocol was only moder-
traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk ately sensitive (63%) for isolating
factor was identified in 57 (86%; 95% CI% = 76 to 94%) patient visits patients with pulmonary TB at ED
and at least one TB symptom in 51 (77%; 95% CI = 65% to 87%) pa- triage.13 This study was performed
tient visits. Cough was present during only 64% (95% CI = 51% to to determine the ED presentation of
75%) of the patient visits and hemoptysis during 8% (95% CI = 3% to patients with active pulmonary TB.
17%). Risk factors and symptoms that, if present, were likely to be
detected at triage were foreign birth, homelessness, HIV positivity, METHODS
hemoptysis, and chest pain. Conclusions: Patients with active pul-
monary TB may have multiple ED visits, and often have nonpulmon- Study Design. We reviewed the
ary complaints. Tuberculosis risk factors and symptoms are usually TB surveillance records of the Divi-
present in these patients but often missed at ED triage. The diversity sion of Epidemiology and Infection
of clinical presentations among ED patients with pulmonary TB will Control in order to identify adult pa-
likely make it difficult to develop and implement high-yield triage tients diagnosed as having active
screening criteria. Key words: tuberculosis; emergency department; pulmonary TB by sputum culture at
triage; symptoms. ACADEMIC EMERGENCY MEDICINE 2000; 7: our institution between January
10561060 1994 and June 1996. We then con-
ducted a retrospective medical rec-
ord review to select patients who
The recent resurgence of tuberculo- presented to the ED for care from
From the Division of Emergency Medi- sis (TB) in the United States has led one year before to one year after
cine (PES) and Division of Infectious Dis- to a number of nosocomial outbreaks their initial positive sputum culture.
eases (SHC), UC Davis School of Medi- of this disease.1 Emergency depart- This study was deemed exempt from
cine, Sacramento, CA; and Department ment (ED) personnel are at in- informed consent by the Human
of Emergency Medicine, Alameda creased risk of contracting TB be- Subjects Review Committee at the
County Medical Center, Highland Cam- cause patients often present to the UC Davis Medical Center.
pus, Oakland, CA (LR). ED with undiagnosed disease. Puri-
Received December 20, 1999; revision re- fied protein derivative (PPD) skin Study Setting and Popula-
ceived April 4, 2000; accepted April 20,
test conversion rates for ED person- tion. The UC Davis Medical Cen-
2000. Presented at the SAEM annual
nel have been reported to be as high ter is an urban teaching hospital in
meeting, Washington, DC, May 1997.
Address for correspondence and reprints:
as 30% overall, with risk of conver- Sacramento County with an ED that
Peter E. Sokolove, MD, Division of sion increasing as a function of time has an annual census of approxi-
Emergency Medicine, UC Davis Medical of employment.2 mately 65,000 patients. Our insti-
Center, 2315 Stockton Boulevard, PSSB It has previously been demon- tution is the de facto public hospital
2100, Sacramento, CA 95817. Fax: 916- strated that there is frequently a de- in the Sacramento geographic area,
734-7950; e-mail: pesokolove@ucdavis.edu lay in the identification and respi- which serves a population of 400,000
ACADEMIC EMERGENCY MEDICINE September 2000, Volume 7, Number 9
within city limits and about 1.5
million in the surrounding area.
Approximately 60% of ED patients
are medically indigent or insured
through government programs. In
1995, the Sacramento metropolitan
area had a tuberculosis case rate of
10.0 cases per 100,000 population.14
In order to select patients with
active, potentially contagious pul-
monary TB, each patient visit was
reviewed and categorized as either a
contagious (capable of disease trans-
mission) or noncontagious visit. A
patient was considered to be conta-
gious if any of the following criteria
were met: 1) positive sputum culture
for Mycobacterium tuberculosis dur-
ing hospitalization, 2) any visit sub-
sequent to the positive culture but
prior to starting antimycobacterial
therapy, 3) any visit prior to a posi-
tive sputum culture when the chest
radiograph (CXR) was suggestive of
pulmonary TB, or 4) any visit within
one month prior to the initial posi-
tive sputum culture if a CXR was
not taken. Using these criteria, pa-
tient visits were categorized by the
consensus of the three authors,
which included an infectious dis-
eases specialist (SHC).
Study Protocol. We abstracted
the medical records of patients hav-
ing contagious visits to the ED to de-
termine demographic information,
chief complaints, presence of TB risk
factors and symptoms, physical ex-
amination and CXR findings, anti-
biotic resistance patterns of M. tu-
berculosis isolates, and whether the
patient was placed in respiratory
isolation. Chief complaints were
taken from the triage nursing note
and were categorized as either pul-
monary (e.g., dyspnea, cough, he-
moptysis), infectious but nonpul-
monary (e.g., fever), medical but
nonpulmonary (e.g., chest pain, ab-
dominal pain, vomiting), or trau-
matic/orthopedic (e.g., extremity
pain, back pain, motor vehicle colli-
sion). Chief complaints were catego-
rized as pulmonary if any pulmo-
nary symptoms were noted at triage,
even if other complaints were also
noted.
We reviewed the triage nursing
note, ED report, and initial admit-
ting team note in order to determine
the presence of TB risk factors and
symptoms, as well as physical exam
findings. For the risk factors of
homelessness and foreign birth, we
also reviewed the initial ED regis-
tration sheet to determine current
address and place of birth. Risk fac-
tors, symptoms, and exam findings
were considered to be present only if
documented in the medical record.
Cough was considered to be present
if patients reported a cough of any
duration. When TB risk factors or
symptoms were present, we re-
corded the location where these pos-
itive findings were first noted (e.g.,
at triage, in the ED, or at the time
of hospital admission).
Chest x-ray readings were taken
from the dictated attending radiolo-
gist note. For data analysis, CXR
readings were recorded as upper
lobe infiltrate, diffuse interstitial in-
filtrate, other infiltrate, mediastinal
lymphadenopathy, cavitary lesion,
mass or coin lesion (not cavitary),
pleural effusion, other finding (e.g.,
rib fracture, hyperinflation), or nor-
mal. These categories of CXR read-
ings were taken from a prior inves-
tigation of a TB triage screening
procedure.14 All positive findings
were recorded for each CXR. Medi-
cal record review was performed by
a single author (LR) using a stan-
dardized data collection form.
Data Analysis. Descriptive sta-
tistical analysis was performed us-
ing Microsoft Excel version 4.0 (Mi-
crosoft Corporation, Redmond, WA).
The frequency of patient chief com-
plaints, TB risk factors, TB symp-
toms, and physical exam findings
were determined. Corresponding
95% confidence intervals (CIs) were
calculated using Stata 5 (Stata Cor-
poration, College Station, TX).
RESULTS
There were 44 patients with active
pulmonary TB treated in the ED
during the study period. These 44
patients made a total of 134 visits
within one year of their initial posi-
tive sputum culture (median 1, IQR
1:3, range 130). Sixty-six (49%) of
these visits were categorized as con-
tagious. The number of contagious
visits per patient ranged from 1 to 7
(median 1). Of the 44 patients, 12
(27%, 95% CI = 15% to 43%) made
two or more and 3 patients (7%, 95%
CI = 1 to 19%) made three or more
contagious ED visits.
1057
Patient visits to the ED while
having active pulmonary TB had the
following characteristics. Patients
had a mean SD age of 47 14
years, and 86% were male. The dis-
tribution of patient ethnicity was
white 42%, Asian 24%, Hispanic
20%, African American 8%, Native
American 3%, and other ethnicity
3%.
Chief complaints recorded at tri-
age were categorized as pulmonary
33% (95% CI = 22% to 46%), medical
but nonpulmonary 41% (95% CI =
29% to 54%), infectious but nonpul-
monary 14% (95% CI = 6% to 24%),
and traumatic/orthopedic 12% (95%
CI = 5% to 22%). Patients were
found to have a variety of chief com-
plaints (Table 1).
The frequency of various risk fac-
tors, symptoms, and physical exam
findings detected in patients with
active pulmonary TB are shown in
Table 2. These values reflect docu-
mentation in either the triage nurs-
ing note, the ED record, or the ini-
tial admission note. Treating health
care providers identified at least one
TB risk factor in 57 (86%; 95% CI =
76% to 94%) patient visits, and in 51
(77%; 95% CI = 65% to 87%) visits,
the patient had at least one symp-
tom of TB. For three patient visits
(5%; 95% CI = 3% to 17%) no risk
factors or symptoms were identified.
Of the 89 total risk factors that
could be identified from the medical
records, 66% were initially docu-
mented at triage, 24% in the ED,
and 10% on admission. Foreign birth
and homelessness were always doc-
umented at triage, while recent PPD
positive results, immunosuppressive
medications, and TB exposure were
never documented at triage. The
proportions of other risk factors first
noted at triage were HIV positivity
(82%), history of TB (47%), and in-
travenous drug use (17%). When not
documented at triage, TB exposure
and HIV positivity were always doc-
umented in the ED. Recent incarcer-
ation was only first documented
on the admission note. The pro-
portions of other risk factors first
documented on the admission note
were immunosuppressive medica-
tions (67%), recent PPD positivity
(40%), intravenous drug use (17%),
and history of TB (13%).
Of the 191 total symptoms that
could be identified from the medical
1058 TUBERCULOSIS
TABLE 1. Patient Chief Complaints during 66 Contagious Tuberculosis (TB) Visits
to the Emergency Department
Chief Complaint
Pulmonary
Dyspnea
Cough (any duration)
Hemoptysis
Abnormal chest radiograph
Referred for pulmonary TB
Spiders in lung
Medical nonpulmonary
Abdominal pain
Chest pain
Seizures
Weak
Hematemesis
Syncope
Found down
Dizzy
Groin pain
High home fingerstick glucose result
Losing voice
Neck mass
Tremor
Infectious nonpulmonary
Fever
Sore throat
Infected hand
Thigh abscess
Traumatic/orthopedic
Back pain
Gunshot wound to thigh
Hip pain
Multiple burns
Motor vehicle collision
Shoulder pain
records, 24% were initially docu-
mented at triage, 47% in the ED,
and 29% on admission. The propor-
tions of symptoms first noted at tri-
age were hemoptysis (80%), chest
pain (56%), cough (38%), dyspnea
(33%), fever (19%), and weight loss
(5%). Chills, night sweats, and mal-
aise were never documented at tri-
age. When not documented at triage,
hemoptysis was always documented
in the ED. The proportions of other
symptoms first documented on the
admission note were night sweats
(80%), malaise (56%), chills (52%),
weight loss (40%), fever (26%), dysp-
nea (20%), and chest pain (6%).
Fifty-two patients (79%) had a
CXR taken during their ED visits,
all of which had at least one positive
finding. The distribution of CXR
findings was upper lobe infiltrate
(45%), diffuse interstitial infiltrate
Sokolove et al. TUBERCULOSIS PRESENTATION
Number of Visits Frequency (95% CI)
22 33% (22%, 46%)
9 14% (6%, 24%)
7 11% (4%, 21%)
3 5% (1%, 13%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
27 41% (29%, 54%)
6 9% (3%, 19%)
3 5% (1%, 13%)
3 5% (1%, 13%)
3 5% (1%, 13%)
2 3% (0.4%, 11%)
2 3% (0.4%, 11%)
2 3% (0.4%, 11%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
9 14% (6%, 24%)
4 6% (2%, 15%)
3 5% (1%, 13%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
8 12% (5%, 22%)
3 5% (1%, 13%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
1 1.5% (0%, 8%)
(22%), other infiltrate (29%), cavi-
tary lesion (16%), mass or coin lesion
(15%), pleural effusion (13%), other
findings (29%), and mediastinal
lymphadenopathy (2%). Thirteen
CXRs (25%; 95% CI = 14% to 39%)
were atypical for pulmonary TB (de-
fined as absence of either an upper
lobe infiltrate, a diffuse interstitial
infiltrate, or a cavitary lesion).
These CXRs had the following find-
ings: pleural effusion (4), upper lobe
nodules (3), middle or lower lobe
infiltrates (3), mediastinal lymph
adenopathy only (1), pulmonary
nodule (1), and degenerative skele-
tal changes (1).
Of the 44 patients, 36 (82%) were
admitted on their first ED visits and
42 (95%) were ultimately admitted
during a contagious visit. During a
contagious visit, 35% of the patients
were placed in respiratory isolation
in the ED. An additional 11% were
first isolated on the ward, while 55%
were never isolated. Mycobacterium
tuberculosis antimicrobial resistance
patterns were available for 42 of the
44 patients (95%) with active pul-
monary TB, of which six isolates
(14%; 95% CI = 5% to 29%) showed
resistance to at least one of the five
primary antimycobacterial drugs,
and two isolates (5%; 95% CI = 0.6%
to 16%) showed resistance to both
isoniazid and streptomycin.
DISCUSSION
In our study population, the patients
with active, potentially contagious,
pulmonary TB often had multiple
ED visits, with 27% having two or
more and 7% having three or more
visits during the study period. It is
possible that certain patients at risk
for contagious TB had delayed iden-
tification due to the presence of con-
founding comorbid disease or famil-
iarity to the ED staff. For example,
a 45-year-old male patient with fre-
quent alcohol-related visits pre-
sented to the ED 30 times during
the study period. Tuberculosis was
not considered in this patient until
he had made six potentially conta-
gious visits. Another patient who
had a history of alcohol abuse made
seven visits during a one-year pe-
riod, and all were potentially conta-
gious and unrecognized as such.
We were surprised to find a wide
variety of chief complaints in these
patients. Only 36% of the patients
reported any pulmonary complaint
at triage (cough, shortness of breath,
hemoptysis), whereas most patients
presented with a variety of general
medical complaints (e.g., chest pain,
abdominal pain, fever). The high de-
gree of variability of chief com-
plaints appears to be due to two fac-
tors. First, some patients with active
pulmonary TB have chief complaints
that are nonspecific, but probably
caused by TB infection (e.g., chief
complaints of chest pain, fever,
weakness, or abdominal pain). Sec-
ond, many ED visits by patients
with active pulmonary TB are for ill-
ness or injuries that are coincidental
to having TB infection (e.g., gunshot
wound to thigh, seizures, multiple
burns, syncope). This highlights one
of the difficulties in identifying pa-
tients with active TB at triage. At
ACADEMIC EMERGENCY MEDICINE September 2000, Volume 7, Number 9 1059

some institutions, ED screening pro- TABLE 2. Patient Tuberculosis (TB) Risk Factors, Symptoms, and Physical Exam
tocols for TB are applied only to pa- Findings during 66 Contagious Visits to the Emergency Department
tients complaining of cough. Al- Number of Visits Frequency (95% CI)
though TB patients with an active
cough are generally more contagious Risk factors
than those without a cough,12 even a Foreign born 28 42% (30%, 55%)
perfectly sensitive protocol for eval- Homelessness 18 27% (17%, 40%)
uating coughing patients would History of TB 15 23% (13%, 35%)
HIV positivity 11 17% (9%, 28%)
have missed nearly two-thirds of the
PPD* within 2 years 5 8% (3%, 17%)
contagious patients in this study.
Chemotherapy or steroids 3 5% (1%, 31%)
Risk factors for TB were present Jail within 2 years 1 1.5% (0%, 8%)
in 86% of contagious visits and TB exposure 1 1.5% (0%, 8%)
symptoms in 77%. Despite this high None of the above 9 14% (6%, 24%)
prevalence, few TB risk factors and
symptoms were reliably identified at Symptoms
triage, more commonly being first Cough 42 64% (51%, 75%)
documented in the ED medical rec- Dyspnea 30 45% (33%, 58%)
ord or inpatient admission notes. Fever 27 41% (29%, 54%)
Risk factors that, if present, were Chills 25 38% (26%, 51%)
Weight loss 20 30% (20%, 43%)
likely to be detected at triage were
Chest pain 18 27% (17%, 40%)
foreign birth, homelessness, and
Night sweats 15 23% (13%, 35%)
HIV positivity. The high rate of iden- Malaise 9 14% (6%, 24%)
tification of foreign birth and home- Hemoptysis 5 8% (3%, 17%)
lessness was due to documentation None of the above 15 23% (13%, 35%)
by ED registration rather than by
nursing at triage. This patient infor- Physical exam findings
mation may or may not have been Abnormal lung exam 38 58% (45%, 70%)
available to the triage nurse. Thus, Temperature > 100F 16 24% (15%, 36%)
HIV positivity was the only risk fac- Wasting 12 18% (10%, 30%)
tor reliably detected at triage itself. Respiratory rate > 24 breaths/min 9 14% (6%, 24%)
Hemoptysis and chest pain were of- Generalized adenopathy 4 6% (2%, 15%)
None of the above 13 20% (11%, 31%)
ten first detected at triage, but the
remaining TB symptoms were de- *PPD = purified protein derivative positive result.
tected at triage in fewer than 50% of
patients. It appears that the identi-
fication of constitutional symptoms have been further delayed. Overall, itations, many inherent in its
of TB was particularly rare at triage. during a contagious visit only 35% of retrospective design. We relied on
Efforts to better recognize these risk the study patients were placed in medical record documentation to de-
factors and symptoms might im- respiratory isolation in the ED, termine the presence of TB risk fac-
prove the early identification of TB which is similar to the 51% ED iso- tors and symptoms, and patients
patients. lation rate reported by Moran et al.3 may have had risk factors or symp-
Among our patients with active While formal PPD conversion toms that were either never as-
pulmonary TB, 80% had an abnor- rates were not calculated, three ED sessed or never documented. This
mal physical exam. Most commonly, personnel converted their PPD to would lead us to underestimate the
this involved the presence of either positive during the study period. prevalence of these historical items.
fever or an abnormal lung exam on This included one physician in 1994, We sought to minimize this possibil-
auscultation. The finding of a nor- one clerk in 1995, and one registra- ity by including the hospital admis-
mal physical exam (absence of fever, tion worker in 1996. It is interesting sion history and physical note, on
tachypnea, cachexia, adenopathy, or to note that, despite many visits by the presumption that it might con-
abnormal findings on lung exam) in patients with apparently unrecog- tain a more thorough history. This
20% of patients illustrates that nized active pulmonary TB, few
usually increased the number of his-
physical exam alone cannot be used health care workers suffered ad-
torical items identified, and for cer-
to exclude active pulmonary TB. verse consequences. This may have
tain items (night sweats, malaise,
Chest radiographs were obtained been due to a number of factors, in-
recent incarceration, immunosup-
in 79% of patients, and of these, a cluding proper ventilation in the
pressive medications), the risk fac-
high proportion (75%) had findings ED, limited direct exposures to
typical of TB, with upper infiltrates, tor or symptom was usually docu-
these patients, and a low degree of
cavitary lesions, or diffuse intersti- mented only on the admission note.
infectivity among some patients.
tial patterns. Indeed, a CXR consis- The increase in recognition of
tent with pulmonary TB may have more subtle factors on the admission
been the initial clue that suggested LIMITATIONS AND FUTURE note may be the result of increased
the diagnosis in a number of cases. QUESTIONS interviewer sensitivity after learn-
In the 21% of visits when a CXR was ing the results of a CXR obtained in
not obtained, the diagnosis may This study has a number of lim- the ED. There is also a potential pa-
1060 TUBERCULOSIS
tient recall bias, as patients would
be more likely to report positive re-
sponses once they are being admit-
ted for pulmonary TB. Thus, a pa-
tient with chest pain, admitted for a
suspicious cavitary lesion on CXR,
might acknowledge having night
sweats and recent incarceration in
jail when questioned by an admit-
ting physician concerned about TB.
Similarly, it is impossible to know
whether factors assessed in the ED
were asked before or after the re-
sults of the CXR were known.
Our study did not have a control
group, so we are unable to compare
the prevalences of risk factors, com-
plaints, and physical findings in TB-
infected patients with those among
the entire ED population. Our objec-
tive, however, was to determine the
clinical presentation of ED patients
with active pulmonary TB. In addi-
tion, we deliberately chose liberal
criteria for categorizing patients as
contagious, and are unable to defin-
itively say whether all patients hav-
ing contagious visits could in fact
transmit TB. Because one goal of
this study was to identify factors
that might be useful in developing
screening protocols, we believed that
it was important to classify cases
that were questionable as conta-
gious visits.
It should be noted that the non-
independence of patient visits might
have influenced our findings. Be-
cause some patients had multiple
visits, their presentation had a
greater influence on the described
presentation of the entire popula-
tion. However, we chose to analyze
our data by patient visits, rather
than patients, because this more ac-
curately reflects the way patients
present to the ED.
We used hospital infection con-
trol records to identify patients for
enrollment into the study. Because
patients with less classic presenta-
tions might be less likely to be ad-
Sokolove et al. TUBERCULOSIS PRESENTATION
mitted and eventually diagnosed as
having TB, there is a potential se-
lection bias toward identifying pa-
tients with more typical presenta-
tions of the disease. The hospitals
infection control records are based
on positive TB cultures obtained pri-
marily in the inpatient setting, and
we may therefore have selected for a
group of patients ill enough to re-
quire admission and inpatient treat-
ment. Similarly, we may have
missed patents who were seen in our
ED while contagious, but eventually
diagnosed as having TB elsewhere.
All of these factors would likely re-
sult in the true presentation of ED
patients with active TB being even
less typical than described in our
study patients.
CONCLUSIONS
Patients with active pulmonary TB
may have multiple ED visits, and of-
ten have nonpulmonary complaints.
Tuberculosis risk factors and symp-
toms are usually present in these 9. Perlman DC, el-Sadr WM, Nelson ET,
patients, but often missed at ED tri-
age. One-third of the patients in this
study denied having a cough, and
hemoptysis was rare. Chest radio-
graphs usually appeared typical of
TB. The diversity of clinical presen-
tations among ED patients with pul-
monary TB will likely make it diffi-
cult to develop and implement
high-yield triage screening criteria.
The authors thank Margaret Morita,
CIC, from the Division of Epidemiology
and Infection Control for her assistance
with identifying study patients.
References
1. Menzies D, Fanning A, Yuan L, Fitz-
gerald M. Tuberculosis among health
care workers. N Engl J Med. 1995; 332:
928.
2. Sokolove PE, Mackey D, Wiles J,
Lewis RJ. Exposure of emergency de-
partment personnel to tuberculosis: PPD
testing during an epidemic in the com-
munity. Ann Emerg Med. 1994; 24:418
21.
3. Moran GJ, McCabe F, Morgan MT,
Talan DA. Delayed recognition and in-
fection control for tuberculosis patients
in the emergency department. Ann
Emerg Med. 1995; 26:2905.
4. Rao VK, Iademarco EP, Fraser VJ,
Kollef MH. Delays in the suspicion and
treatment of tuberculosis among hospi-
talized patients. Ann Intern Med. 1999;
130:40411.
5. Pierce JR, Sims SL, Holman GH.
Transmission of tuberculosis to hospital
workers by a patient with AIDS. Chest.
1992; 101:5812.
6. Klein NC, Duncanson FP, Lenox TH
3rd, Pitta A, Cohen SC, Wormser GP.
Use of mycobacterial smears in the di-
agnosis of pulmonary tuberculosis in
AIDS/ARC patients. Chest. 1989; 95:
116092.
7. Samb B, Sow PS, Kony S, et al. Risk
factors for negative sputum acid-fast ba-
cilli smears in pulmonary tuberculosis:
results from Dakar, Senegal, a city with
low HIV seroprevalence. Int J Tuberc
Lung Dis. 1999; 3:3306.
8. Pitchenik AE, Rubinson HA. The ra-
diographic appearance of tuberculosis in
patients with the acquired immune de-
ficiency syndrome (AIDS) and pre-AIDS.
Am Rev Respir Dis. 1985; 131:3936.
et al. Variation of chest radiographic pat-
terns in pulmonary tuberculosis by de-
gree of human immunodeficiency virus-
related immunosuppression. Clin Infect
Dis. 1997; 25:2426.
10. Haramati LB, Jenny-Avitall ER, Al-
terman DD. Effect of HIV status on chest
radiographic and CT findings in patients
with tuberculosis. Clin Radiol. 1997;
52(1):315.
11. Asimos AW, Ehrhardt J. Radio-
graphic presentation of pulmonary tu-
berculosis in severly immunosuppressed
HIV-seropositive patients. Am J Emerg
Med. 1996; 14:35963.
12. Centers for Disease Control and Pre-
vention. Guidelines for preventing the
transmission of Mycobacterium tubercu-
losis in health-care facilities, 1994.
MMWR. 1994; 43(RR-13):131.
13. Sokolove PE, Lee BS, Krawczyk JA,
et al. Implementation of an emergency
department triage procedure for the de-
tection and isolation of patients with ac-
tive pulmonary tuberculosis. Ann Emerg
Med. 2000; 35:32736.
14. Centers for Disease Control and Pre-
vention. Reported Tuberculosis in the
United States, 1996. Atlanta: CDC, 1997,
p 35.