ChesterCountyMedicineWinter2018 - 35

www.CHESTERCMS.org

A Case of Missed
Opportunities
BY RENÉE M. CASSIDY, MD, FAAP, FACP
PUBLIC HEALTH PHYSICIAN, CHESTER COUNTY HEALTH DEPARTMENT

T

he following case is based on a Chester
County Health Department (CCHD)
investigation of an actual Chester County
resident who died in 2016. All identifying information
has been withheld to protect the innocent (or the
guilty, perhaps).
K, a 74-year-old woman from India, presents to a
primary care practice for the first time. She has moved
in with her son and daughter-in-law and plans to stay
in the United States permanently. Her medical history
is significant for hypertension and dyslipidemia, and she
has noted several months of joint pain, mostly in the
hands and knees.

FACT: The United States Preventive Services Task Force
recommends screening for latent tuberculosis infection in
adults at increased risk for tuberculosis infection.
Populations at increased risk of tuberculosis infection (TBI),
which is also known as latent tuberculosis infection, include
people who were born in or lived in countries with higher
prevalence of tuberculosis. Essentially, this is everywhere in
the world except the United States, Western Europe, Canada,
Australia, and New Zealand. In addition, adults who have lived
in high-risk congregant settings, such as correctional facilities and
homeless shelters, also have an increased risk for TBI and should
be screened.
Two different tests for screening are available in the US:
the Mantoux tuberculin skin test (TST) and the interferon
gamma release assay (IGRA). TST involves placing 0.1 ml
of tuberculin purified protein derivative (PPD) intradermally
in the inner surface of the forearm, creating a wheal 6 to 10
mm in diameter. The forearm is examined between 48 and 72
hours later for induration, a palpable, raised, hardened reaction
caused by delayed-type hypersensitivity response mediated by
T-lymphocytes. Erythema, bruising, or other reactions which
do not cause induration are not counted as positive. The level
at which the TST is read as positive depends on the person's risk
of being infected and the risk of progression to active disease if
infected. See Figure 1 for current guidelines from the Centers for
Disease Control and Prevention.
Continued on next page >

WINTER 2018 | CHESTER COUNT Y Medicine 35
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