10 - Tuberculosis Flashcards
2nd leading cause of infection of the world?
TB
22 countries that account for 80% of TB?
Slide 4
Top 7 countries that account for the maj of US cases?
Mexico Philippines Vietnam India China Haiti Guatemala
Asians are the most cases
Untreated fatality rate for TB?
50%
Social, economic and medical factors make this worse
Risk groups for TB?
Close contact w TB Foreign born No medicine/income Elderly Long term care facilities IV drugs Occupational exposure
Who is the reservior host for M. Tuberculosis’?
Humans
How is TB spread?
Airborne droplet nuclei transmission
- can be fewer than 10 bacilli
Lab words for TB?
Acid-fast
Non-motile
Non-spore forming
Non-encapsulated
How does infection occur?
Airborne droplet nuclei transmisison
Deposit w/in terminal airspaces
Macrophages ingest
- transport to regional lymph n
What is a common concomitant infection with TB?
HIV
What makes you more likely to go from latent to active TB?
- HIV - 100x more
- DM - 3x more
- Substance abuse (IV)
- Recent TB (w/in 2 yrs)
- CXR w previous TB w no Tx
- Low body weight (<10%)
- Immunosuppressive therapy
- Silicosis
- Gastroectomy
HIV to active TB incidence?
7-10% increase each year
HIV pts also need to worry about?
Extrapulmonary TB
S/S of TB (typical)
Pulmonary TB
- productive cough
- fever
- wt loss
- hemoptysis
- chest pain
- anorexia
- fatigue
- night sweats
Types of non-respiratory TB?
TB meningitis Skeletal TB Genitourinary TB Cutaneous TB Gastorintestinal TB
Miliary
Who is prone to non-respiratory TB?
Immunocompromised
Elderly
TB meningitis S/S
HA(intermittent or persistent)
Mental status change
Coma
Fever (low/absent)
Skeletal TB S/S?
Spine
- Potts disease
- back pain/stiffness
- extremity paralysis
Arthritis
- 1 joint
- any joint
MC skeletal TB?
Spine
Genitourinary TB S/S?
- flank pain
- dysuria
- frequency
- epididymitis
- scrotal mass
- PID
Tb induced PID accounts for?
10% of sterility worldwide
Cutaneous TB s/s?
Ulcer
Wart like lesion
Gastrointestinal TB s/s?
- Any site
- non-healing ulcers
- esophageal disease
- peptic ulcer disease
- malabsorption
- diarrhea
- hematochezia
Miliary TB s/s?
Widespread (hematogenous) dissemination
- weakness/fatigue
- wt loss
- HA
- fever
- cough
- generalized lymphadenopathy
- hepatomegaly
- splenomegaly
- pancreatitis
- multi-organ dysfunction
- adrenal insufficiency
Who gets miliary tb?
Immunocompromised
Mortality rate for miliary TB?
Close to 100%
Pulmonary TB physical exam findings?
Abnormal breath sounds
- especially over upper lobes
Exgrapulmonary TB physical exam findings?
tissue dependent
But common ones are
- confusion
- neurolgic deficit
- lymphadenopathy
- coma
- chorioretinitis
- cutaneous lesion
Tests for TB?
PPD
Sputum
Biopsy
Blood cultures
Cornerstone for Latent TB diagnosis?
PPD
Sputum collection?
For smear and culture
- early morning
- 3 days in a row
Alternates for sputum collection?
- Gastric aspirate
- Transbronchial biopsy
- Fiberoptic bronchoscopy
- Bronchial washings
Blood cultures for TB?
QTF-G (quantiferon gold)
RNA probes
PCR
Line probe assay
Screening labs for TB tx?
CBC Chem (AST/ALT) Alkaling phosphate Total bilirubin Uric acid Creatinine Obtain HIV serology
Radiology findings for primary progressive TB?
Central apical portion
- left lower lobe infiltrate
Pleural effusions
CXR reactivation findings?
Cavity formation
Noncalcified round infiltrates
Ranke complex
Hemogenously calcified nodules/tuberculomas
What are ranke complexes?
Ghon lesion - Calcified peripheral nodule
Calcified hilar nodes
If you see homogeneously calcified nodules or tuberculomas it means?
Its an old disease
What will an x ray show for miliary TB?
Millet seeds
What is the empiric tx for TB?
6 months of 4-drug regimen
- INH (isoniazid)
- Pyrazinamine
- Rifampin
- Ethambutol
Treatment progression of TB?
Start with empiric
Once the isolate is know DC ethambutol
After 2 months only INH + rifampin
Special considerations?
If they are INH resistant
- rifampin
- pyrazinamide
- ethambutol
X 6 months
What type of mask do you need for TB protection?
N-95 particulate respirator
Complications of pulmonary TB?
Relapse
Aspergilloma
Carcinoma
Differentials for TB?
- FOUO
- histoplasmosis
- lung abscess
- lung cancer (non small cell)
- other mycobacterium infection
What is the only latent TB (LTBI) test available?
PPD or TST
(Mantoux test)
TST (tuberculin skin testing)
How is PPD/TST given?
5 tuberculin units of PPD
Measure response in 48-72 hrs
What is a pos PPD?
Size of induration is diagnostic
Not erythemia
All pos PPD get?
CXR
A PPD larger than 5mm is pos for:
- close contacts to TB
- HIV
- organ transplants
- long term steroids
- fibrotic lesions on CXR
(Not granulomas)
SHE SAID TO STARR THIS SLIDE
A PPD larger than 10mm is pos for:
High risk pts
Recent converters
Kids <4 yrs w adult TB exposure
Residents/employees of high risk facilities (prisons, hospitals, military)
Who are “high risk” pts (10mm is pos)
- DM
- Hematologic malignancies
- head/neck carcinoma
- jejunoileal bypass
- IV drug use
- HIV pos
- ESRD
- silicosis
- malnutrition
- gastrectomy
What is a “recent converter”?
10mm increase in past 2 yrs
Recent immigrants from high prevalence country
Normal “pos PPD”
?
> /= 15mm
What will cause false positives?
Infection w other mycobacterium
Vaccination w bacille calmett-guerin
- BCG (given in other countries)
BCG is effective in?
Effective in kids but not in adults
What about false neg?
10-25% of pts with TB are negative on PPD
How long do we wait to check PPD?
72hrs
Who gets LFT’s when on INH?
Everybody every month
What is two step testing?
A complicated way to test that avoids using QTF-G for confirmation
Its on slide 45
What is the LBTI prevention therapy?
Isoniazid (INH, Lanizaid) 300mg PO x 9 months
CDC recommend
What should be added to INH therapy?
Pyridoxine PO QD
To prevent peripheral neuropathy
What is the alternate drug for LTBI tx?
rifampin
If they are INH resistant or unable to tolerate INH
What is the new MMWR tx for LTBI?
LTBI DOT tx
- INH
- rifampentinn (priftin)
Weekly x 3 mo DOT
TB tx options and regimens?
Slide 48
Though we should do AST/ALT on all TB pts in the military who else is high risk and needs liver tests?
- 35yrs
- other drugs
- ETOH
- chronic liver
- hx of peripheral neuropathies
- conditions predisposing to neuropathy
- pregnancy
- IV drug users
Get monthly AST/ALT
INH side effects?
Hepatocellular disease
Peripheral neuropathy
Interactions w phenytoin
- increases concentrations of both
Rifampin s/e?
Thrombocytopenia
Accelerated clearance of drugs
Decrease effectiveness of OCP
Ethambutol SE?
Change in visual acuity
Pyrazinamide SE?
Hyperuricemia
- asymptomatic hyperuricemia
NOT an indication for discontinuing
with age comes skills
Its called multi-tasking
I can laugh, cough, sneeze and pee all at the same
