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Tuberculosis -- California

California recorded 4,520 new tuberculosis cases in 1981, for a rate of 18.7 per 100,000 population, compared with a national rate of 11.9/100,000. Since special tuberculosis hospitals and sanitoria no longer exist, tuberculosis may now be seen by any health care provider or clinic. Following are two examples in which the disease was not initially considered.

Case 1: On November 19, 1982, a 39-year-old Chinese-speaking housewife was discovered to have laboratory-confirmed (sputum and culture positive) pulmonary tuberculosis. She had immigrated from Burma in 1972, and, at that time, her chest x-ray was normal. Throughout the summer of 1982, she felt unwell and developed fever and some weight loss. She sought medical advice in July, but no diagnosis was established. Her symptoms persisted, and she presented again in September with an eight-pound weight loss, a frequent cough, and fatigue. Again no diagnosis was established, and she was given vitamins. In early November, her cough became productive of heavy sputum. She returned to her physician later that month after a 2-year-old child she was tending was found on routine examination to have a significant tuberculin skin test. This child was subsequently admitted to a hospital with pleurisy and x-ray findings compatible with tuberculosis; the child was started on therapy.

Investigation revealed that the woman tended four or five children each day. Three other children in this group (ages 2 1/2 years, 3 years, and 21 months) were found to have significant skin test reactions and had x-ray findings compatible with pulmonary tuberculosis. All three are being treated as patients. One other child also under her care had a significant reaction to purified protein derivative (PPD) and was placed on isoniazid (INH). In addition, her own children (ages 5, 11, and 15 years) and her husband had significant reactions to PPD and were placed on INH.

Case 2: The second patient is a 38-year-old native of the Philippines whose father had died of tuberculosis during the patient's childhood. This patient had a significant PPD reaction before his arrival in the United States in 1969. He underwent a renal transplant 20 months ago, and because of problems with chronic rejection, continues on immunosuppressive medication. He did not take INH at the time of surgery. On December 5, 1982, he was admitted to a hospital with productive cough, night sweats, fever and chills, and a progressive weight loss of 25 pounds during the past 2-3 months. On admission, his posterior pharynx was erythematous, and the tonsils were ulcerated and covered with a whitish exudate. Chest x-ray showed several cavities, and numerous acid-fast bacilli (AFB) were found on sputum smear. Culture was subsequently positive. AFB were also recovered in large numbers from the tonsils. He was placed on triple drug therapy and a week later, was discharged home as improved.

In the 2 months before his hospitalization, the patient had sought medical attention several times. Antibiotics for 'flu' were prescribed on one visit, and on a subsequent visit in November, he received Nystatin for a presumed fungus infection of mouth and tonsils.

Editorial Note

Editorial Note: Refugees from Southeast Asia and other immigrants from Asia, Latin America, and the Pacific Basin are coming to California in large numbers. This trend can be expected to continue. Tuberculosis must be considered in these patients who come from high incidence areas and present with cough and fever. Although the risk of developing current tuberculosis is greatest during the first few years after arrival, these persons remain at higher risk of developing current tuberculosis than the general population. Reported in California Morbidity, January 14, 1983.

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