ABSTRACT
Tuberculosis was initially unrecognized in a pregnant 26-year-old woman from Mexico. The diagnosis was first considered in this mother 24 days postpartum, when her newborn was admitted in shock with congenital tuberculosis. Had a high index of suspicion for tuberculosis been present during the early course of the patient's care or had she been tested on a routine basis because she was a member of a high-risk group, the continued exposure of 7 family members and the acute exposure of 293 healthcare workers and newborns in three tertiary-care centers could have been minimized or avoided entirely. We wish to emphasize the often elusive features of this diagnostic setting and the public health consequences of delayed recognition resulting in a massive recall effort. Unfortunately, only two thirds of the exposed infants were successfully recalled and skin tested. We identified one skin test conversion in a health-care worker.
