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U.S. Department of Health and Human Services


TB Notes Newsletter

No. 2, 2005


Misdiagnosis in Rural Colorado

Background. Colorado is a low-incidence state, with a 2004 tuberculosis (TB) case rate of 2.8 per 100,000 population. However, the number of reported cases increased from 111 cases in 2003 to 127 in 2004. The Denver metro area typically reports 70% to 75% of the state’s active TB cases each year. Though the metro area accounts for most of the cases, misdiagnosis still occurs if physicians do not “think TB” or if they have never seen a TB case before.  In 2004 three rural counties in Colorado reported at least one active case of TB for the first time in at least 8 years. These counties have few health care facilities available and no TB expertise locally.

Case Report. On April 29, 2004, the Colorado Department of Public Health and Environment TB Program (CDPHE) received a call from an infectious disease (ID) physician in Denver.  The physician was very concerned after diagnosing TB in a patient referred to her from a rural community clinic. This patient had sought care repeatedly and was misdiagnosed over a 4-month period of time. A discussion with the physician ensued regarding the consequences of the loss of TB diagnostic expertise in low-incidence areas such as Colorado, but especially in rural communities.

The patient was a 35-year-old female who had traveled to the United States from Uganda with an 18-month worker’s visa. She arrived in a rural county in the Rocky Mountains of Colorado in December 2003. Her employer’s international office actively recruits employees from around the world, including many from countries with a high incidence of TB. No health screening or tuberculin testing is required upon employment.

The patient sought care with the community clinic 11 times from December 2003 through April 2004. The clinician at this rural community clinic treated the patient repeatedly for pneumonia. The patient received several rounds of antibiotics and inhalers before being referred to the ID physician in Denver. The patient’s symptoms included cough, chest pain, weight loss, and fever. The patient states her symptoms started approximately 1 week after arrival in Colorado, although she did not feel well on the flight over. Chest x-rays of December 2003 and March 2004 showed left upper and lower lobe infiltrates. The chest x-ray of April 2004 exhibited worsening infiltrates with cavitation. The patient had a history of a negative HIV test in 1998.

The ID physician immediately hospitalized the patient in Denver after her evaluation. Sputa collected were reported as 4+ on smear and four-drug therapy with INH, rifampin, ethambutol, and PZA was initiated. The rural county nursing service was contacted and the suspected TB case was reported to the nursing director and the public health nurse on April 29, 2004. The public health nurse, though experienced in nursing, was new to public health and had just finished her tenth day on the job. This rural county had not reported an active case of TB in over 10 years.

The CDPHE TB program nurse consultant immediately provided the community clinic staff with an educational inservice training; information included TB diagnosis and treatment and the contact investigation process. TB educational materials, including the CDC tuberculin skin testing video, guidelines for the treatment of TB, and the Colorado State TB Manual, were distributed during this session. A county commissioner was noted among the audience. Discussions took place to answer questions and alleviate concerns. The TB program nurse consultant found that meeting with the community clinic staff was useful in the long and arduous process of contact investigation and case management of patients.

Many concerns and questions came from the private clinicians and public health staff, as well as the community. The CDPHE TB program nurse consultant made many trips to the county (a 200-mile round trip) to provide assistance and consultation. Building relationships improved the comfort level of the providers in the community to ask questions and follow recommendations. However, it was difficult for a low-incidence state such as Colorado to provide the assistance required to a small rural county and maintain all program functions.

The patient completed 6 months of directly observed therapy for culture-confirmed and drug-susceptible Mycobacterium tuberculosis on November 5, 2004. She exhibited severe joint and muscle pain at times while on treatment, although this did not interrupt her therapy. The patient was determined to complete her therapy regardless of side effects. The public health nurse offered encouragement to the patient and arranged appointments with the patient’s private care provider for evaluation of symptoms and follow-up. As treatment continued, the patient regained 20 pounds of her weight loss and other TB symptoms resolved. She was extremely thankful for the treatment and care she received from the public health nursing service. She refused HIV testing though it was offered several times. Her reasoning was that she could not handle any additional bad news and would refuse treatment even if the test proved positive. The patient recounted knowing others who had died of HIV/AIDS in Uganda.

Contact Investigation. Owing to the length of time the case was misdiagnosed and to the patient’s work and living environment, an extensive contact investigation was performed. It quickly became apparent that the patient had become very involved in the community since her arrival.  The investigation included the work site, on-site housing, work site day care, high-risk patients from the clinic waiting room, the patient’s church, and a Girl Scout troop. The public health nurse began tuberculin testing of the contacts; however, the need for support was soon recognized. As the numbers of contacts and sites increased, the state TB program offered assistance. Several CDPHE TB program staff assisted, as did a communicable disease epidemiologist.

The CDPHE TB program nurse consultant’s visits to the county provided opportunities for additional education to those who needed it, including local public health staff, contacts, providers, and community members. Being on site was invaluable in understanding the anxiety created as the numbers of sites and contacts grew. It also provided the opportunity to assess new problems as they arose, make quick decisions, and give directions. The CDPHE TB program nurse consultant was able to obtain immediate guidance while on site from the expert physicians at Denver Public Health when needed.

A total of 321 people were initially tested, and a list of 267 true contacts was developed for the follow-up testing. A large number of the contacts were foreign-born persons, coming from many countries around the world, including high-incidence countries. This added confusion to the task of determining transmission and controlling the scope of the investigation.

Local clinicians were contacted and given recommendations regarding follow-up of their patients who were named as contacts. Questions and discussion were encouraged. 

Results of the contact investigation identified one additional person with active TB. She was treated by DOT with 4 months of therapy since she had a negative culture but clinical improvement. This patient was also from Uganda and traveled with the index case.

There were 56 contacts identified with latent TB infection (LTBI), of which 38 were started on treatment with INH; 39 of these contacts were foreign-born persons. To date, 30 contacts continue their therapy. Several patients returned to their home countries during the investigation. Referrals were made where possible.

BT Exercise

The local public health nursing director requested assistance from the bioterrorism (BT) program in conducting the contact investigation. The bioterrorism (BT) program felt the follow-up tuberculin testing would be an excellent opportunity to carry out a response exercise. Testing was accomplished at several clinics set up at the sites where contacts were identified. The BT program and rural public health agency gained experience in putting a plan together, initiating the plan, and making calls for assistance from the community, the surrounding counties, and the State TB and BT Programs. Public health nurses as well as support staff from many surrounding counties and the state responded to help with the testing clinics. 

The nurses who responded not only received updated information on tuberculosis and testing procedures, but also were able to fulfill many objectives related to bioterrorism grant funding. The responders gained experience in how an actual event could evolve and a response would occur. The community and surrounding counties were able to practice the ability to put a plan together and modify it as the event progressed. The members of the BT exercise planning team gained experience in working together. It was beneficial for all involved to appreciate the effectiveness of program and regional collaborations.

One caveat or limitation of the TB/BT collaboration was that participating in the planning, initiation, and execution of the exercise increased the workload of both the CDPHE TB Program and the local public health agency. Those responders who were assigned to place and read skin tests were trained appropriately and monitored, with adjustments in assignments made as needed. The local public health nurse was responsible for arranging the clinics and making staffing assignments as responders volunteered. The public health nurse, who was assigned the role of incident commander, was responsible for the adjustment of staff before and during the clinics.

The participants in the event came away with new skills, new associates, and a sense of collaboration within public health and the community.

Submitted by Gayle M. Schack, RN,
Nurse Consultant and
Juli Bettridge, Health Professional III
Colorado Department of Public Health and Environment


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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