Written as an editorial commentary regarding Geraci T, Spellberg B. Pulmonary Tuberculosis at an Urban Hospital in the United States: A 5-Year Experience on pages 182-186 of the journal.
In this issue of Infectious Diseases in Clinical Practice, Geraci et al report a 5-year experience with pulmonary tuberculosis (TB) at an urban public hospital in the United States. The study is of interest in that it emphasizes the need for a high index of suspicion of TB in the United States, because of the frequent lack of classic signs and symptoms.
Although the number of TB cases has declined in the United States since 1993, TB remains a significant concern in urban hospitals in the United States.1-3 The authors aimed to enlighten physicians about the specific characteristics of patients with pulmonary TB to make possible the earlier diagnosis of TB. The clinical presentation of TB was multifaceted and complex. Of the 49 patients with newly diagnosed pulmonary TB, only 36 (73%) reported a history of cough. Less than 60% of patients complained of fevers, night sweats, or weight loss. Thirteen patients (26%) had none of the classic constitutional systems of TB on presentation. Drug resistance was frequent. The uniform components of medical history, physical examination, laboratory tests, and radiologic images were individually insufficient to exclude the diagnosis of TB. The authors concluded that a high index of suspicion must be maintained based on the total clinical picture to make a timely diagnosis of TB.
The decrease in rates of TB infection in the United States has also resulted in the decline of physician experience with TB.3 Delays in TB diagnosis may be due to decreased awareness of TB among patients and providers.1-3 Patients may be less likely to seek medical attention, and health care providers may have a lower index of suspicion.3 There is less emphasis on TB education for students in schools of medicine and allied health.4 Studies have shown that there is insufficient TB awareness among US health care providers.3
In addition to improved diagnostic tests for TB; innovative approaches are needed to improve TB awareness in the United States. Checklist strategies have been successfully implemented in surgery and hospital intensive care units5 and could be used to support TB awareness. A multidisciplinary approach is needed to increase TB education for students in schools of medicine and allied health.4 Web-based TB curricula could provide greater access to TB educational materials for all levels of health care providers.4 The motto "Think TB" encourages health care providers and patients to recognize the signs and symptoms of TB.6
1. Kramer F, Modilevsky T, Wallany AR, et al. Delayed diagnosis of tuberculosis in patients with human immunodeficiency virus infection. Am J Med
2. Mathur P, Sacks L, Auten G, et al. Delayed diagnosis of pulmonary tuberculosis in city hospitals. Arch Intern Med
3. Wallace RM, Kammerer JS, Iademarco MF, et al. Increasing proportions of advanced pulmonary tuberculosis reported in the United States: are delays in diagnosis on the rise? Am J Respir Crit Care Med
4. Harrity S, Jackson M, Hoffman H, et al. The National Tuberculosis Curriculum Consortium: a model of multi-disciplinary educational collaboration. Int J Tuberc Lung Dis
5. Gawande A. The Checklist Manifesto: How to Get Things Right
. New York, NY: Holt, Henry & Company, Inc; 2009.