Tuberculosis Meningitis on a Fishing Boat: A Hawaii Case, 2016–2017

In December 2016, U.S. Customs and Border Protection alerted CDC's Honolulu Quarantine Station to a crewman from a commercial fishing vessel who was in a Hawaii hospital with suspected tuberculosis (TB). Erin K. Imada of CDC and colleagues, with the Hawaii Department of Health, reported the case.

The patient

The crewman, in his mid-30s, came from a Pacific country with a high burden of TB. By the time CDC was notified he was unconscious and on a ventilator. He had been admitted nine days earlier after a month of headache, fever, night sweats, chills, fatigue, weight loss, breathing trouble and cough, followed by abdominal pain, vomiting, dizziness and blurred vision.

• Brain scans showed lesions deep in the brain; a chest scan showed lung lesions with hollowed-out centers.
• A lung biopsy found Mycobacterium tuberculosis, susceptible to all first-line drugs.
• Spinal fluid had low sugar, high protein and many white blood cells — consistent with TB meningitis.
• He tested negative for HIV and had no other medical conditions.

He received standard four-drug TB treatment, regained consciousness and came off the ventilator, but remained neurologically incapacitated. He completed 12 months of treatment and, after 426 days, was sent home.

Checking the crew

Once infectious TB was confirmed, Customs and Border Protection and the Hawaii Harbor Police called the vessel into port. The Quarantine Station and state health department screened seven contacts: the U.S. captain, five crew members from the patient's country, and a U.S. NOAA fisheries observer. None had symptoms of active TB. Four crew members had positive skin tests and normal chest X-rays — latent TB infection — and were offered treatment, but all four declined.

Why it matters

• Meningeal TB is the most severe form of TB. Even in wealthy countries, 5%–24% of patients suffer lasting harm — stroke, seizures, fluid on the brain, vision or hearing loss — and 10%–20% die. It happens when TB spreads from the lungs through the blood to the brain, and complications are worst when diagnosis is delayed.
• Think TB. Clinicians should suspect meningeal TB in people from high-TB countries who have TB symptoms (fever, chills, night sweats) plus neurologic ones (headache, blurred vision, dizziness) with no better explanation — and check for lung disease once TB outside the lungs is confirmed.
• Crews at sea are vulnerable. This patient went more than a month before seeing a clinician. Commercial crews are often far from care, without medical resources on board, and may not be allowed ashore at the nearest port; close living and working quarters raise their risk of catching infections from each other.
• Latent TB is hard to treat in mobile populations. Obstacles include confusion between latent and active TB, access, long treatment, cost and side effects, patients' willingness, and clinicians' worry about losing track of patients. About 4%–6% of people with untreated latent TB go on to develop infectious TB.

Even so, the investigation showed that TB contacts can be found and evaluated successfully in difficult settings.

Sources

Based on Imada EK, Roberson EK, Goswami ND, Brostrom RJ, Moser K, Tardivel K, "Notes from the Field: Meningeal and Pulmonary Tuberculosis on a Commercial Fishing Vessel — Hawaii, 2017," MMWR, Centers for Disease Control and Prevention; a work of the United States government in the public domain.