Uncommon presentations of pulmonary tuberculosis in adults

Outbreak of tuberculosis among regular patrons of a neighborhood bar

BACKGROUND

Outbreaks of tuberculosis have been reported in prisons, nursing homes, urban homeless shelters, and other crowded settings. We report a nonresidential outbreak of tuberculosis that originated in a neighborhood bar.

METHODS

A homeless patient with highly infectious pulmonary tuberculosis was a regular patron of a neighborhood bar during a long symptomatic interval before diagnosis. We investigated 97 other regular customers and employees of the bar through interviews, tuberculin skin testing, and chest roentgenography. We performed DNA fingerprinting on isolates from the index patient and 11 other patients.

RESULTS

The index patient apparently infected 41 of 97 contacts (42 percent), resulting in 14 cases of active tuberculosis and 27 cases of infection but no disease (indicated by positive tuberculin skin tests). Four other cases of active tuberculosis occurred among regular customers of the bar who were missed by the contact investigation. There were also two secondary cases. Radiographic findings in active cases included upper-lobe disease in seven cases (three cavitary) and negative chest films at the time of diagnosis in four cases. All 12 culture isolates we tested had the same chromosomal-DNA restriction pattern.

CONCLUSIONS

The spread of tuberculosis in a neighborhood bar can be a major public health problem. The high rate of infection and disease among the contacts was unexpected and was not due to coinfection with the human immunodeficiency virus. Possible explanations include heavy alcohol use among the contacts, high infectivity of the index case, or both. Sputum cultures must be performed in tuberculin-positive contacts who have symptoms, even if the chest films are normal.