tuberculosis medscape

As with other scourges of the preantibiotic era, tuberculosis (TB) until recently was considered of passing historical significance to emergency physicians practicing in the developed world. In 1985, due primarily to the newly recognized HIV epidemic and to a growing indigent population, TB resurfaced in inner-city emergency departments. In 1991, highly virulent multi–drug-resistant (MDR) strains ofMycobacterium tuberculosis were reported by the Centers for Disease Control and Prevention (CDC). These strains not only produced fulminant and fatal disease among patients infected with HIV (TB exposure to death in 2-7 mo) but also proved highly infectious (conversion rates of up to 50% in exposed healthcare workers) (CDCMMWR , 1994). Recent recognition of the potential for catastrophic outbreaks resulting from MDR TB has led to national efforts for both surveillance and control.
Because of the prevalence of MDR strains, recommendations for pharmacologic management as well as exposure prophylaxis have evolved over the past decade. To avoid selecting drug-resistant organisms, treatment should begin with at least 4 medications until drug susceptibilities are known. (One in 106 tuberculous bacilli mutate and become isoniazid [INH] resistant.) In 1996, the CDC also provided recommendations for potential use of bacille Calmette-Guérin (BCG) vaccine in healthcare workers (see Special Concerns).
By virtue of the association between TB and poverty, the emergency physician may be a patient's only opportunity for recognition of mycobacterial infection. Note that drug treatment can and should be initiated in the emergency department (ED) for anyone suspected of having active TB infection and that these patients should be isolated and hospitalized.

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