Highlights

Question 1

Whose responsibility is it to report diseases?

Answer 1

The provider’s (NOT the pt’s)

Question 2

What is necessary to contract TB?

Answer 2

Someone w. active, pulmonary TB must cough on you

Question 3

1) Which immune response is activated by TB?
2) What specific cells are involved?
3) What cells does HIV attack?

Answer 3

1) Cellular immune response
2) CD4 and CD8 T cells
3) T cells

Question 4

After you contract TB, one of what two things happens?

Answer 4

1) Latent TB: in Granulomas
OR
2) Active TB (spreads)

Question 5

1) What type of mycobacterium tuberculosis infection can be asymptomatic or symptomatic?
2) What kind is related to prior containment?
3) What kind is inactive and non-communicable?

Answer 5

1) Primary
2) Reactivation
3) Latent

Question 6

90% of the time, primary infection results in __________- infection

Answer 6

latent

Question 7

The primary mechanism the immune system has for controlling TB is walling it off in granulomas, primarily because of what response?

Answer 7

healthy CD4 and CD8 T-cell

Question 8

1) Describe caseating granulomas
2) Define granuloma

Answer 8

1) Their areas of caseation are areas of necrosis with complete loss of tissue architecture
2) A rim of healthy macrophages and T cells that are walling off

Question 9

Latent TB can progress to Active TB. This is called ____________

Answer 9

reactivation.

Question 10

What are 3 symptoms that are pretty unique to TB?

Answer 10

1) Coughing up blood
2) Unintended weight loss
3) Night sweats

Question 11

If a pt with no symptoms is from somewhere w high rates of TB, has a high risk of reactivation (immunosuppressed), should you test for TB?

Answer 11

Yes

Question 12

Reading TB test results:
1) When is 5mm of induration positive? (3 groups)
2) What about 10mm? (6 groups)
3) What abt 15mm?

Answer 12

1) HIV+, organ transplant, other immunosuppressed people
2) Recent immigrants from areas with high TB incidence, health care workers, the homeless, and people
with hematologic or head/neck malignancies, renal failure, or diabetes
3) People with no known risk factors

Question 13

What do TB blood tests measure to estimate T cell activity?

Answer 13

Interferon gamma

Question 14

What causes interferon gamma production in a positive TB blood test tube?

Answer 14

Effector T cells are present and re-encountering TB antigen

Question 15

1) Cavitation on a CXR can be a sign of what infectious disease?
2) What can cavitation cause?

Answer 15

1) TB
2) Hemoptysis

Question 16

What do TST and IGRA TB tests have in common?

Answer 16

A negative rxn doesn’t exclude the Dx of LTBI or TB

Question 17

1) BCG vaccination doesnotcause
false-positive result with what TB test?
2) Infection with most nontuberculous mycobacteria doesnotcause false-positive result with which TB test?

Answer 17

1) IGRA
2) IGRA

Question 18

Which type of TB test can NOT cause a boosted rxn?

Answer 18

IGRA

Question 19

True or false: you should always rule out active TB before starting treatment for latent TB, b/c if you give a latent TB regimen (monotherapy) to someone with active TB, you risk development of drug resistant TB

Answer 19

True

Question 20

Describe TB drug action:
1) Which drug is the most early bactericidal?
2) Which is the best for long term sterilizing (bacilli w short metabolism periods)?
3) Which is best for resistance prevention? (actively growing bacilli)

Answer 20

1) INH (> EMB > RIF > PZA)
2) RIF (> PZA > INH > EMB)
3) INH (> RIF > EMB > PZA)

Question 21

What are the two exceptions to the general active TB treatment plan?

Answer 21

1) 7 months of cont. phase in patients with cavitary pulmonary TB and ongoing M. Tb in sputum samples at 2 months
2) In extrapulmonary TB, continuation phase is 9-12 months

Question 22

What two labs are specific to HIV?

Answer 22

1) CD4 Cell Count
2) Viral Load

Question 23

True or false: Yeasts, molds, and dimorphics are all examples of fungi

Answer 23

True

Question 24

What is an example of a budding yeast that forms pseudo-hyphae?

Answer 24

Candida

Question 25

What is an example of a species that is common normal flora, but also an opportunistic pathogen?

Answer 25

Candida

Question 26

1) What is Candida endocarditis?
2) Who is it typically found in?
3) What are the symptoms?
4) How is it Dx’d?
5) How is it managed?

Answer 26

1) Most serious manifestation of candidiasis & most common cause of fungal endocarditis, results from candidemia
2) Prosthetic heart valves, IV drug users, CV catheters, prolonged funguria
3) Fever, changing or new murmurs, S/Sx heart failure; possible visual loss
4) Persistent candidemia (blood Cx), vegetation (echocardiography)
5) 3-5mg/kg/day Amphotericin B (or high-dose echinocandin) & valve replacement

Question 27

1) What family is the most common cause of fungal meningitis? What is it an example of?
2) What type of fungus is this family?
3) How is it contracted? Where?

Answer 27

1) Cryptococcus; an invasive fungal infection primarily of lungs & CNS
2) Encapsulated yeast
3) Inhalation of C. neoformans & C. gattii (encapsulated yeasts); found in soil & dried pigeon & chicken dung

Question 28

1) Describe subclinical cryptococcus infection
2) What presentation is seen most often in immunodeficiency?
3) What does the presentation of cryptococcus infection range from?

Answer 28

1) Common, mostly asymptomatic (incidental)
2) Progressive lung disease & dissemination
3) Range from simple nodules to widespread infiltrates leading to respiratory failure

Question 29

1) Describe the most common imaging findings for a cryptococcus infection
2) What are some other imaging findings?

Answer 29

1) Solitary or few well-defined, noncalcified nodules that are often pleural based.
2) Lobar infiltrates, hilar and mediastinal adenopathy, and pleural effusions.

Question 30

What is it called when Cryptococcus spreads to the CNS? What can also be involved?

Answer 30

Cryptococcal meningitis; skin and bones
(most common cause of fungal meningitis)

Question 31

What are the two tests for cryptococcus infection? Describe their sensitivities and specificities

Answer 31

1) Cryptococcal antigen test aka CrAg:
-93-99% sensitive, 93-98% specific, and fast.
2) India Ink Staining
-Traditional but not as sensitive

Question 32

What are the lumbar puncture CSF values for a Cryptococcal meningitis infection? (glucose, protein, WBC, & opening pressure)

Answer 32

Glucose: normal
Protein: Mildly Elevated
WBC: Less than 20
Opening Pressure: Increased

Question 33

What 3 things do you use to treat cryptococcal meningitis?

Answer 33

1&2) Amphotericin B 3-4mg/kg/day IV x 2-8 weeks
AND
Flucytosine 100mg/kg/day x 2-8 weeks
3) Followed by Fluconazole 400mg/day PO x 12 months

Question 34

How do you treat Cryptococcus if no CNS involvement and pt is immunocompetent?

Answer 34

Fluconazole 400mg PO x 6-12 months

Question 35

1) What is the etiology of histoplasmosis?
2) What type of fungus is histoplasmosis? Explain.

Answer 35

1) Inhalation of conidia spores from soil contaminated by bird & bat droppings.
2) Dimorphic endemic fungus
-Exist as a mold in the soil and “narrow based budding yeast” in the body

Question 36

Describe the clinical features (most cases asymptomatic or mild) of histoplasmosis:
1) What is indicative of past infection?
2) What is most common?
3) What is a complication of pulmonary histoplasmosis?
4) What are some other features?

Answer 36

1) Incidental pulmonary & splenic calcifications
2) Acute pulmonary histoplasmosis
3) Progressive disseminated histoplasmosis
4) Cough, fever, myalgias

Question 37

1) ______% of histoplasmosis infection are subclinical, but it can form __________ and be latent / reactivate
2) It’s more severe in __________________ hosts
3) Where is it endemic to?

Answer 37

1) 90%; granulomas
2) immunocompromised
3) Mississippi River Valley area

Question 38

1) What does acute histoplasmosis infection mimic?
2) What can a CXR have?
3) How is it diagnosed? Desc. the sensitivity and specificity of this test.

Answer 38

1) Pneumonia
2) Diffuse infiltrates and conspicuous hilar adenopathy
3) Urine histo antigen:
~70-85% sensitive, but false-positive from blastomycosis, aspergillus, and a few others

Question 39

1) Chronic pulmonary histoplasmosis is seen in what groups the most often?
2) What is it characterized by?
3) What does it show on a CXR/ CT?
4) What does serology show?
5) How do you differentiate it from TB?

Answer 39

1) Older pts with chronic lung disease, smokers
2) Productive cough, dyspnea, CP, fatigue, fever, sweats
3) Complex apical cavities, infiltrates, nodules (TB?)
4) Usually positive
5) Sputum or BAL fluid Cx or lung Bx

Question 40

1) Progressive disseminated histoplasmosis makes 1 in ____________ pts with acute infection.
2) Who is most likely to get a progressive disseminated infection?

Answer 40

1) 2000
2) HIV, immunosuppressive disorders & meds (TNFa-I, steroids, anti-rejection meds)

Question 41

What are the two types of progressive disseminated histoplasmosis? Describe the symptoms/ locations of each, and who each was most common in

Answer 41

1) Acute (infants, immunocompromised): fever, fatigue, hepatosplenomegaly, pancytopenia
2) Chronic (older pts, men): pancytopenia, hepatosplenomegaly, transaminitis, oropharyngeal or GI lesions
-Other sites: skin, brain, adrenal glands

Question 42

How is mild-to moderate Histoplasmosis treated?
2) What about disseminated histoplasmosis?
3) What may be needed after initial therapy? For who?

Answer 42

1) Itraconazole 100-200 mg/day PO BID for weeks to months
2) Amphotericin B 3mg/kg/day
3) Suppressive therapy for AIDS patient or itraconazole after initial therapy

Question 43

1) What is Coccidiomycosis also called? What is its etiology?
2) Where is it endemic to? Why is it expanding?

Answer 43

1) “Valley fever”; Mold in the soil, yeast in the body
(Coccidioides immitis, C. posadasii)
2): Endemic to the Southwest United States, Mexico, central America and South America (42.6 cases per 100,000 in endemic regions)
-Has increased 7 fold in the past 13 years
-Expanding territory/warming climate