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Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 174-177

Another hazard to laboratory workers

Department of Internal Medicine, King Fahad Hospital of the University, College of Medicine, University of Dammam, Dammam, Kingdom of Saudi Arabia

Date of Web Publication6-May-2015

Correspondence Address:
Huda A Bukharie
Department of Internal Medicine, King Fahd Hospital of the University, University of Dammam, P.O. Box 2208, Al-Khobar 31952
Kingdom of Saudi Arabia
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DOI: 10.4103/1658-631X.156440

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Needle-stick injuries, unfortunately, are a common occurrence during blood extraction and handling of specimens in the laboratory, which often lead to the contraction of blood-borne viral diseases. Mycobacterium tuberculosis infection also poses a threat to healthcare workers, especially laboratory workers in areas with endemic levels of tuberculosis infections. We present in this report, a case of primary inoculation of tuberculosis of the skin transmitted following a needle-stick injury, which was successfully treated. Reports of such an occurrence are few, and our report further underlines the need to take greater precautions against these accidents. In addition, our case draws attention to the possibility of prophylactic anti-tuberculous treatment in high-risk patients to prevent the progression of an overt illness.

  Abstract in Arabic 

ملخص البحث :

تعتبر إصابات الوخز بإبرة الحقن من الأمور الشائعة أثناء سحب عينات الدم من المرضى والتعامل معها في المختبر مما قد يؤدي إلى الإصابة بالأمراض الفيروسية والبكتيرية المنقولة بالدم. تشكل العدوى ببكتيرا الدرن تهديدًا للعاملين بالمختبرات في المناطق التي يستوطن فيها المرض. يعرض الباحثان حالة للدرن الجلدي بعد وخزة بإبرة الحقن، وقد تم علاجها بنجاح. يندر حدوث مثل هذه الحالات. ويؤكد عرض هذه الحالة أهمية التدابير الوقائية حيال هذه الحوادث كما تلفت هذه الحالة النظر إلى إمكانية المعالجة الوقائية لمرض الدرن في المناطق الأكثر تعرضا لمنع تطور المرض.

Keywords: Cutaneous tuberculosis, needle-stick injury, primary inoculation tuberculosis, tuberculosis prophylaxis

How to cite this article:
Ghanbar MI, Bukharie HA. Another hazard to laboratory workers. Saudi J Med Med Sci 2015;3:174-7

How to cite this URL:
Ghanbar MI, Bukharie HA. Another hazard to laboratory workers. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Jan 28];3:174-7. Available from: https://www.sjmms.net/text.asp?2015/3/2/174/156440

  Introduction Top

Laboratory accidents causing self-inoculation of disease are somewhat under-reported. [1] Moreover, the infections commonly of concern are those of blood-borne viruses such as hepatitis B and C, and human immunodeficiency virus (HIV). However, Mycobacterium tuberculosis (TB) still poses a significant public health risk with an estimated incidence of 8.6 million cases in 2012 by the World Health Organization. [2] This precludes regular exposure to fluid and tissue material from suspected infected individuals among health care workers, creating a serious risk for infection to health care personnel, particularly microbiology laboratory staff. [3] It has been estimated that the annual risk of TB attributed to nosocomial exposure ranges from 25 to 5,361/100,000, [4] which underscores the significance of this threat.

Cutaneous TB is largely a rare disorder, [3] which mainly presents in health professionals following an interruption in the skin's integrity, as a number of reports have outlined. [5],[6],[7],[8] We present here a case of primary cutaneous TB following its direct inoculation in a finger of a microbiology laboratory worker from an accidental needle-stick injury.

  Case report Top

A 34-year-old, very healthy female medical laboratory technologist was aspirating liquid culture media from a positive mycobacteria growth indicator tube to perform dilutions for sensitivity testing. The positive culture belonged to a patient who had been diagnosed with TB lymphadenopathy and was being treated at our facility.

She was using a 1 ml syringe to measure and transfer the liquid culture media when the phone rang. The noise startled her, resulting in her accidentally pricking her left index finger with the syringe. Even though, she was wearing vinyl examination gloves, the syringe broke through both barriers of glove and skin and penetrated her flesh.

She washed her hand with running water and squeezed the site of the prick. She then reported the incident to her supervisor and to the Infection Control Department, and was instructed to perform serological testing as per hospital protocol. Since she was inoculated with culture media that had undergone digestion, decontamination and concentration, the main concern was TB rather than any blood-borne viruses. She was therefore, instructed to report whenever she noticed any symptoms of TB, such as fever or night sweats and any swelling at the prick site or any other site.

Three weeks later, she started to complain of pain and there was a swelling at the site of the injury as well as subjective fever, night sweats and uncomfortable sensation in her left axilla. She, however, denied any cough, shortness of breath or any other systemic upset. Examination only revealed a hot swelling between the left distal interphalangeal and proximal interphalangeal joints suggestive of a collection measuring about 1/1 cm with a small ulcer at the site of needle entry [Figure 1], [Figure 2] and [Figure 3]. Multiple left-sided axillary lymphadenopathy, the largest measuring about 3 by 2 cm was also noted. However, the remaining systemic examination was normal. As the suspicion of TB was high, the collection was aspirated and sent for microbiological evaluation to identify any acid fast bacilli (AFB).
Figure 1: Ulcer at site of needle stick injury adjacent to swelling

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Figure 2: Correlation between site of inoculation and swelling

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Figure 3: Swelling occupying the palmar space between the proximal
and distal interphalangeal joints

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Blood-work including complete cell count, liver and renal functions were within the normal range apart from an albumin level of 3.2 mg/dL (normal range: 3.5-5 mg/dL). Her erythrocyte sedimentation rate was 68 mm (normal range: 0-20 mm in 1 st h) in 1 st h with a quantitative C-reactive protein of 2.8 mg/dL (normal range: 0-0.3 mg/dL). Her chest roentography was normal and a contrast enhanced computer tomography scan of her finger and axilla revealed a swelling at the second digit extending to the lumbricals with prominent axillary and supraclavicular lymphadenopathy, the largest of which measured 3.5 by 2.8 cm with central necrosis. Her aspirate was positive for AFB stain and she was consequently started on anti-TB treatment with rifampicin, isonizide, ethambutol and pyrazinamide as the original culture sensitivity was yet to be released. She underwent an unremarkable course of rapid recovery and resolution of all her symptoms and signs after a 9 months course of treatment. She has maintained follow-up after cessation of treatment with no relapse or new symptoms after 1½ years.

  Discussion Top

The skin acts as a barrier against the development of TB and a break is necessary for an infection to take place. [9] Usually, primary cutaneous TB affects the face and extremities, where scratch marks or chronic skin disorders may exist. Once the skin is infected, a TB chancre, TB verrucosa cutis or in minor cases lupus vulgaris develops within 3 weeks. This is followed by the development of a non-tender regional lymphadenopathy that becomes prominent at around 3-6 weeks producing a lymphocutaneous complex which resembles that of a Ghon's complex in its pulmonary infection counterpart. The initial lesion usually heals with scarring within 3 months, but it can occasionally progress to TB verrucosa cutis or lupus vulgaris. Cutaneous TB occurs after direct inoculation of the Mycobacterium organism into the skin, spread from a source of infiltration within an organ, or by its dissemination from blood and lymphatics. [10]

Direct inoculation of the skin with TB is relatively rare and usually occurs as a result of the penetration of the skin with an infected instrument following circumcision, [11] tattooing, [12] ear piercing [13] or intramuscular injection. [14] Contamination during autopsy of infected cadavers have also been well-documented and are referred to as prosector's wart or paronychia. [15] The resurgence of TB [16] together with the HIV epidemic, which has led to even higher rates of TB in the community, [17] has the potential of increasing the hazard of the contraction of TB by health care workers, especially laboratory staff. The consequence of such a transmission is even more serious in an era of multidrug resistance species of TB. [18] Therefore, stringent infection control measures should be put in place and laboratory safety precautions adhered to in order to reduce this significant threat.

Our case demonstrated a typical sequence of events regarding primary inoculation of TB with a classic reactive lymphadenopathy resembling that of a Ghon's complex which completely resolved posttreatment. Moreover, although our patient did not develop a classic skin reaction postinoculation, the timeframe was characteristic and the secretions were positive for AFB that grew mycobacterial colonies in culture proving that the lesion developed post a needle-stick injury. In addition, the location of the lesion corresponded to the point of entry of the needle, and the culture was similar to that grown from the patient, proving the cause-effect relationship.

With evidence supporting the higher risk of TB infection amongst laboratory workers, [19] and a suggested 35-50 fold higher incidence amongst health care workers, [20] greater care should be taken in these environments. The handling of such hazardous material with the emergence of multidrug resistance TB should provoke stringent procedural precautions. One option may be that to direct that staff to manipulate any test tubes in the rack, rather than in their hand, in an attempt to minimize the risk of self-injury. [7] Media transfer could also be attempted with blunt objects when possible to reduce the possible risk of self-injury. Unfortunately, data on healthcare accidents appear to be inadequate for an accurate estimate of the risk. [21] Better reporting and surveillance is required worldwide in order to tackle this problem appropriately.

  Conclusion Top

Our case is an excellent example of how laboratory workers may contract TB easily and its associated morbidity. Although with adequate management there were no permanent sequelae to her accident, we should remain stringent regarding adherence to occupational hazard regulations to minimize similar future risks. This case report emphasizes the importance of adequate training and compliance with health and safety measures in laboratories. Besides, it makes a case for the advocacy of the use of prophylactic therapy against TB in high risk situations such as this, and thereby avoid the progression to overt disease and its associated morbidity.

  References Top

Pike RM. Laboratory-associated infections: Incidence, fatalities, causes, and prevention. Annu Rev Microbiol 1979;33:41-66.  Back to cited text no. 1
Global Tuberculosis Report 2013. World Health Organization; 2013:1.  Back to cited text no. 2
Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol 2007;25:173-80.  Back to cited text no. 3
Menzies D, Joshi R, Pai M. Risk of tuberculosis infection and disease associated with work in health care settings. Int J Tuberc Lung Dis 2007;11:593-605.  Back to cited text no. 4
Kramer F, Sasse SA, Simms JC, Leedom JM. Primary cutaneous tuberculosis after a needlestick injury from a patient with AIDS and undiagnosed tuberculosis. Ann Intern Med 1993;119:594-5.  Back to cited text no. 5
Chandramukhi A, Manjunath MV, Veenakumari HB, Mahadevan A, Shivaraja G, Buggi S. Tuberculous skin ulcer following needle-prick injury in a health care professional. J Assoc Physicians India 2005;53:825-6.  Back to cited text no. 6
Belchior I, Seabra B, Duarte R. Primary inoculation skin tuberculosis by accidental needle stick. BMJ Case Rep 2011;bcr1120103496.  Back to cited text no. 7
Huang D, Yin H. Primary inoculation tuberculosis after an accidental scalpel injury. Infection 2013;41:841-4.  Back to cited text no. 8
O'Leary PA, Harrison MW. Inoculation tuberculosis. Arch Derm Syphilol 1941;44:371-90.  Back to cited text no. 9
Beyt BE Jr, Ortbals DW, Santa Cruz DJ, Kobayashi GS, Eisen AZ, Medoff G. Cutaneous mycobacteriosis: Analysis of 34 cases with a new classification of the disease. Medicine (Baltimore) 1981;60:95-109.  Back to cited text no. 10
Holt LE. Tuberculosis acquired through ritual circumcision. JAMA 1913;61:99-102.  Back to cited text no. 11
Dennie CC. Primary tuberculosis complex of the skin. Arch Derm Syphilol 1945;51:316-24.  Back to cited text no. 12
Michelson HE. The primary complex of tuberculosis of the skin. Arch Derm Syphilol 1935;32:589-601.  Back to cited text no. 13
Heycock JB, Noble TC. Four cases of syringe-transmitted tuberculosis. Tubercle 1961;42:25-7.  Back to cited text no. 14
Goette DK, Jacobson KW, Doty RD. Primary inoculation tuberculosis of the skin. Prosector's paronychia,. Arch Dermatol 1978;114:567-9.  Back to cited text no. 15
Tenover FC, Crawford JT, Huebner RE, Geiter LJ, Horsburgh CR Jr, Good RC. The resurgence of tuberculosis: Is your laboratory ready? J Clin Microbiol 1993;31:767-70.  Back to cited text no. 16
Barnes PF, Bloch AB, Davidson PT, Snider DE Jr. Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 1991;324:1644-50.  Back to cited text no. 17
Pearson ML, Jereb JA, Frieden TR, Crawford JT, Davis BJ, Dooley SW, et al. Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis. A risk to patients and health care workers. Ann Intern Med 1992;117:191-6.  Back to cited text no. 18
Seidler A, Nienhaus A, Diel R. Review of epidemiological studies on the occupational risk of tuberculosis in low-incidence areas. Respiration 2005;72:431-46.  Back to cited text no. 19
Sepkowitz KA. Tuberculosis and the health care worker: A historical perspective. Ann Intern Med 1994;120:71-9.  Back to cited text no. 20
Walker D, Campbell D. A survey of infections in United Kingdom laboratories, 1994-1995. J Clin Pathol 1999;52:415-8.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3]

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