Mycobacterium bovis Bacillus Calmette-Guérin Cross-Contamination in the Operating Room: A Case Report

• Authors: Jasmine K Aqua, Emory University; Jill Holdsworth, Emory University; Eileen Burd, Emory University; Jesse Jacob, Emory University; Susan Ray, Emory University; Marcos Schechter, Emory University
• Journal Title: Journal of Investigative Medicine High Impact Case Reports
• Volume: Volume 9
• Publisher: American Federation for Medical Research | 2021-12-01, Pages 23247096211066287-23247096211066287
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1177/23247096211066287
• Subjects: Health Sciences, Epidemiology; Health Sciences, Public Health
• Keywords: BCG; Mycobacterium bovis; Mycobacterium tuberculosis; cross-contamination; false-positive; tuberculosis; Administration, Intravesical; BCG Vaccine; Equipment Contamination; False Positive Reactions; Humans; Mycobacterium bovis; Operating Rooms

Abstract

Mycobacterium tuberculosis complex (MTBC) false-positive cultures are commonly attributed to laboratory cross-contamination, but cross-contamination in the operating room (OR) is seldom reported. We report an investigation of cross-contamination in the OR for our case patient, who underwent surgical intervention for a chronic, left-sided breast lesion. Although the case patient had never received Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccine or chemotherapy, a subsequent surgical sample culture was identified as MTBC by high-performance liquid chromatography and M. bovis BCG-type by genotyping. A collaborative false-positive investigation was initiated, and we discovered a cross-contamination event in the OR from a source case who received BCG intravesical instillation. Clinicians, public health, and infection control staff should be aware that MTBC cross-contamination in the OR is rare, but possible, and should recognize the importance of conducting thorough false-positive investigations.