Patient 4 was a 38 year old black female with a history of AIDS and a CD4 count of 250. She worked as a cleaner and was involved in the disinfection of the hospital room where Patient 1 died, which was performed wearing a scrub gown, surgical mask, plastic visor and surgical latex gloves. No specific exposures to blood or bodily fluids were reported.
Patient 4 fell ill on September 27 (ID-1), 13 days after cleaning Patient 1's room. Initial complaints included headache, dry cough, rhinitis, sore throat, myalgias and left sided chest pain. She visited her general primary care practitioner where a fever of 38.5 C was recorded and amoxicillin and diclofenac were prescribed. Five days later (ID-6), she presented to the infectious disease clinic at her local hospital. On the basis of fevers, sweating and an abnormal chest radiograph, outpatient therapy for tuberculosis was started. However, her condition continued to deteriorate and she was admitted to her local hospital on ID-8. At this point, the contact tracing team had located her and she was transferred to a tertiary academic hospital where she was noted to be confused with photophobia, nausea and vomiting. Physical exam showed candidiasis and generalized lymphadenopathy. Lumbar puncture and cerebrospinal fluid analysis showed five neutrophils and no lymphocytes, markedly elevated protein (>5 g/dl) and elevated glucose (7 mmol/L), which were considered consistent with a diagnosis of tuberculous meningitis. Clinical laboratory analysis revealed thrombocytopenia (23,000/microL), elevated transaminases (AST 549 IU/L, ALT 237 IU/L), mild renal dysfunction, a high anion gap metabolic acidosis, and a positive hepatitis B surface antigen. The patient's confusion worsened and fatal cardiac arrest occurred on ID-10.