We report a case of severe hepatotoxicity associated with rifampin-pyrazinamide preventative therapy that required liver transplantation in a closely monitored, human immunodeficiency virus-uninfected individual who had no risk for hepatotoxicity. Because hepatotoxicity associated with this treatment appears to be idiosyncratic, we recommend closer monitoring of liver enzyme levels than do the Centers for Disease Control and Prevention guidelines, as well as at least temporary interruption of treatment during any elevation of liver enzyme levels greater than the normal value.

One of the most useful strategies to control the spread of tuberculosis is treating latent tuberculosis infections. Certain populations at higher risk for tuberculosis infection, such as homeless individuals, are also at increased risk for treatment nonadherence. This article describes the treatment completion rate for latent tuberculosis infections at a health clinic in Edmonton, Alberta, including an assessment of the correlates of noncompletion as well as potential means to improve treatment adherence.

I n low TB incidence countries such as Canada, TB disease remains concentrated in urban settings with outbreaks involving homeless and under-housed populations that continue to challenge TB control programs. While the incidence of TB in Canada declined to 4.7/100,000 in 2009, the burden of TB cases continues to be diagnosed among foreign-born (FB) individuals. 1 In Alberta, the rate of TB among the FB is 17.7/100,000, compared to the Canadian-born (CB) population at 1.7/100,000. 1 Other descriptions of homeless and under-housed populations in Canadian urban centres have reported that disease remains concentrated among CB-Aboriginal (CB-AB) populations, 2 though the rise in the proportion of FB cases among homeless populations has been noted. 3 Although cases of TB in the FB represent the majority of cases in Alberta, there had previously been little documented transmission to other FB or to CB individuals. 4 The objective of this study is to describe the transmission of TB from FB populations to CB populations through shelterbased locations in the inner city of Edmonton, Alberta. METHODS Study population Edmonton is a northern Canadian city with a population of 1,024,820; 18.5% of the population are immigrants. 5 The homeless population is estimated to be 3,079 and is concentrated in the inner city of Edmonton. 6 All cases of TB in the province are centrally reported to TB Services. Between May 2008 and December 2009, 103 cases of active TB were reported within Edmonton (mean annual rate for 2008 and 2009 was 7.9/100,000); 19 cases were linked to three locations (one apartment building and three homeless shelters) within a one-block area of the inner city. Demographic and clinical characteristics A retrospective review of these 19 cases was completed by extracting demographic, clinical, treatment and contact tracing data from iPHIS. All TB cases were culture-confirmed at the Provincial Laboratory for Public Health (Edmonton, Alberta). Contacts were identified through social networking interviews and through resident lists of shared communal-living locations. Contact investigation was limited to chest x-ray (CXR), sputum for acid-fast bacilli (AFB) analysis and symptom inquiry.

BACKGROUND: The correctional setting presents an opportunity for latent TB infection (LTBI) screening in an otherwise difficult to reach demographic. We evaluate factors associated with the fidelity of the tuberculin skin test (TST) and interferon-gamma release assay (IGRA), specifically the QuantiFERON®-TB Gold In-Tube assay (QFT-GIT), explain factors associated with discordance, and report LTBI treatment outcomes.METHODS: We describe the association between demographic and clinical variables, and predictors of concordance with IGRA using univariate logistic regression in a population of TST-positive inmates. We report outcomes among those offered LTBI treatment.RESULTS: We observed concordance between TST and QFT-GIT in 90 of 306 (29.4%) inmates. Persons with TST+/QFT-GIT+ results were less likely to be male (OR 3.94, 95% CI 1.73–8.97) or have a BCG vaccination history (OR 0.34, 95% CI 0.12–0.95), and more likely to be foreign-born (P < 0.001). Of the 108 inmates offered LTBI treatment, 65 (60.1%) accepted and 51 (78.0%) completed. TST/QFT-GIT discordance has not been associated with disease during follow-up.CONCLUSION: Our findings suggest that TST/QFT-GIT discordance in Canadian federal inmates is common; however, low-risk of disease progression in those with discordance suggests that a shift towards IGRA-based screening is warranted and feasible.