AN OUTBREAK OF TUBERCULOSIS AMONG HOSPITAL PERSONNEL CARING FOR A PATIENT WITH A SKIN ULCER

Extrapulmonary tuberculosis is rarely considered contagious. However, any situation in which organism, can he aerosolized represents a risk for hospital personnel. An 84-year-old woman was admitted to a community hospital with skin ulcer on her thigh and deep venous thrombosis of the leg, Frequent dressing changes and debridement of the ulcer were required. The patient died after 31 days in the hospital. and autopsy showed the ulcer to be a granulomatous lesion containing numerous acid fast bacilli. Subsequent contact investigation showed that of the 59 staff members involved in the patient's care who were previously tuberculin nonreactive, 11 (19%) became tuberculin reactive Ten of these 11 tuberculin-reactive employees recalled being in the patient's room during debridement or dressing changes. Two of the three nurses who did not receive isoniazid prophylaxis developed pleural tuberculosis. Skin lesions can result in nosocomial spread of tuberculosis, probably through aerosolization of infected material.