HIV + TB Flashcards
What is the estimated worldwide prevalence of people with TB co-infected with HIV?
8%
What proportion of people who died with TB are co-infected with HIV?
1/6
There was a drop in TB incidence in PLW HIV in the UK between 2008-2011, what was the change in incidence?
17.5/1000
to
4.4/1000
Why was there an apparent reduction in incidence of TB + HIV co-infection between 2008-2011?
reduced HIV diagnosis in people from sub-Saharan Africa
increased total number of people living with HIV
What is the current proportion of people with TB with HIV co-infection?
3%
What is the impact of HIV on risk of developing TB?
risk of TB 26-31 times greater
Is HIV testing mandatory in TB infection?
YES
What impact does HIV have on the investigation findings for TB?
ATYPICAL
NORMAL CXR
Sputum SMEAR NEGATIVE, culture positive
What are the FIVE aims of TB treatment (as per WHO)?
CURE patient and restore QoL
PREVENT DEATH from active TB or complications
prevent RELAPSE
REDUCE TRANSMISSION
prevent development and transmission of RESISTANCE
Molecular diagnostic tests for TB identify what?
early identification of MYCOBACTERIUM
genotypic DRUG SUSCEPTIBILITY
Which mutations confer rifampicin resistance in TB?
rpoB
What is the limitation of the Xpert MTB/RIF molecular test for TB?
REDUCED SENSITIVITY if smear NEGATIVE
How does the sensitivity of TB molecular testing differ for smear POSITIVE and smear NEGATIVE samples?
98% smear POSITIVE
c/w
67% smear NEGATIVE
In addition to molecular testing for TB what additional investigation must be done?
CULTURE
Why must culture for TB be done in addition to molecular testing?
to increase SENSITIVITY
to identify full DRUG-SUSCEPTIBILITY
What is the sensitivity and specificity of IGRA in PLW HIV in active TB?
SUBOPTIMAL
What culture medium provides quicker results for TB culture?
LIQUID culture
c/w
solid culture
What is the most common presentation of CNS TB?
tuberculous MENINGITIS
What is the proportion of mortality in TB meningitis?
20-50%
What are the FOUR presentations of CNS TB?
MENINGITIS (most common)
ENCEPHALITIS
intracranial TUBERCULOMAS
brain ABSCESS
What are the non-specific symptoms of TB MENINGITIS?
Fever
headache
Vomiting
What is the timing of TB MENINGITIS?
gradual onset
often progressing over weeks
What are the TWO main investigations for TB MENINGITIS?
imaging MRI
Lumbar puncture
What is the typical finding on CSF in TB meningitis?
mononucleate cell pleocytosis (LYMPHOCYTIC predominant)
WCC 100-500cells/mm3
low GLUCOSE <2.5mml/L
high PROTEIN 1-5g/L
What impact does HIV have on CSF of a person with TB meningitis?
ACELLULAR (ie no raised WCC)
What is the sensitivity of Ziehl-Neelsen staining for AFB in CNS TB?
10-60%
What is the sensitivity of culture from CSF of TB in CNS TB?
10-60%
What increases the sensitivity of CSF culture for TB?
Large volume of CSF >6mL
Which molecular test is recommended for diagnosing TB meningitis?
Xpert MTB/RIF ULTRA
What is the most common cause of lymphatic pleural effusion in PLW HIV?
TB (if HIV endemic)
In addition to analysis of pleural effusion what other samples are required if TB pleural effusion is likely?
PULMONARY samples for culture
sputum or BAL
What is the yield of sputum culture for TB in induced sputum for people with pleural effusion but no evidence of parenchymal lung disease of TB?
55%
What impact does CD4 cell count have on the microscopy yield of AFB in TB pleural disease?
INCREASED yield in lower CD4 count
What additional test of pleural fluid can help diagnose TB disease?
raised adenosine deaminase (ADA)
+
lymphocyte predominant exudative pleural effusion
What point of care test is used for diagnosis of extrapulmonary TB disease?
URINE lateral flow lipoarabinomannan (LF-LAM)
What impact dose CD4 cell count have on the sensitivity of point of care urine lateral flow for TB?
INCREASED
In addition to urine lateral flow what investigation would be useful To diagnose disseminated TB?
mycobacterial BLOOD CULTURE
What CYTOPATHOLOGICAL features are present in TB eg samples from lymph node, lung aspirate, focal lesions?
Macrophage GRANULOMAS +/- necrosis
AFB on ZN staining
What HISTOPATHOLOGICAL features are present in TB eg samples from lymph node, lung aspirate, focal lesions?
epithelioid cell GRANULOMAS +/- Langhans giant cells
CASEATION
NECROSIS
AFB on ZN staining
What additional microbes should be tested for on HISTOPATHOLOGICAL suspicious for TB?
FUNGAL staining (HISTOPLASMOSIS)
If TB is diagnosed histopathologically but standard treatment is ineffective what must be considered?
consider NON-TB mycobacterial infection
What differential diagnoses can mimic TB?
SARCOIDOSIS HISTOPLASMOSIS NOCARDIOSIS LEISHMANIASIS GRANULOMATOUS reaction to local tumour CVID VASCULITIS AUTOIMMUED disease GRAM NEGATIVE infection (BRUCELLOSIS, MELIOIDOSIS)
What is the definition of MDR-TB?
resistance to at least ISONIAZID and RIFAMPICIN
What is the definition of pre-XDR-TB?
pre-EXTENSIVELY DRUG RESISTANT TB resistance to ISONIAZID+RIFAMPICIN and FLUOROQUINOLONE or 2nd line INJECTABLE (not both)
What is the definition of XDR-TB?
resistance to
SONIAZID+RIFAMPICIN+FLUOROQUINOLONE
and
at least one 2nd line INJECTABLE (eg amikacin)
What proportion of people with TB have MDR-TB in the UK?
1.6%
What proportion of PLW HIV + TB have resistance to RIFAMPICIN only?
1.3%
What proportion of PLW HIV + TB have resistance to ISONIAZID only?
4%
List SIX(6) risk factors for drug-resistant TB?
1) PREVIOUS TB treatment
2) CONTACT with MDR/XDR-TB
3) birth, travel or work in settings with VERY HIGH MDR/XDR-TB
4) POOR ADHERENCE to past TB treatment
5) No clinical improvement, or smear/culture POSITIVE 3 months into treatment
6) HOMELESSNESS/HOSTEL LIVING/INCARCERATION
What factors increase the risk of people with latent TB developing active TB?
recent ACQUISITION of TB
IMMUNOSUPPRESSED
What is the incidence of TB in PLW HIV in the UK?
0.6/1000
What is the incidence of TB in the general UK population?
0.13/1000
Is the incidence of TB higher or lower in PLWHIV c/w UK general population?
HIGHER
What is the definition of HIGH TB incidence?
> 151/100 000
What is the definition of MEDIUM TB incidence?
4-150/100 000
Over what time period is the risk of progression to active TB from latent TB highest?
2-3 years
What is the definition of latent TB?
positive IGRA
+
no clinical or radiological evidence of active TB
How does the NICE guideline differ from BHIVA guideline on how to diagnose latent TB?
NICE - recommends both IGRA and TST
BHIVA - recommends only IGRA
Why is only IGRA and not TST recommended for diagnosis of latent TB in PLW HIV?
TST reduced sensitivity in low CD4
and
false positive if past BCG vaccination
What additional risk factors should prompt testing for latent TB, even if PLW HIV is from a country of low incidence?
EXPOSURE to TB TRAVEL to higher incidence countries WORKING in MEDICAL settings with high incidence TB IDU CKD Diabetes CHEMOTHERAPY IMMUNOSUPPRESSION BIOLOGICAL DISEASE MODIFIERS
If latent TB is identified in a pregnant women with HIV, should they be offered treatment in pregnancy?
YES
Which group of PLW HIV should be screened for TB?
People from HIGH and MEDIUM TB incidence
Why should latent TB be treated in PLW HIV?
PROTECTIVE effect
What is the first line recommended treatment for latent TB?
ISONIAZID (with PYRIDOXINE) daily
6 months
What TWO alternative regimens can be used for treatment for latent TB?
ISONIAZID (with PYRIDOXINE) + RIFAMPICIN 3 months or ISONIAZID + RIFAMPICIN (with PYRIDOXINE) TWICE WEEKLY 3 months
What drug shows promise in SHORTER regimens for latent TB?
RIFAPENTINE
What RIFAPENTINE-containing regimens have been shown to be effective for latent TB?
ISONIAZID (900mg) + RIFAPENTINE (900mg) WEEKLY 12 weeks or ISONIAZID (300mg) + RIFAPENTINE (450-600mg) DAILY 1 month
What effect does ISONIAZID have on liver function?
Mild rise aminotransferases
Not generally clinically relevant
RARE symptomatic hepatotoxicity
What risk factors increase the risk of severe HEPATOTOXICITY with ISONIAZID?
excessive ALCOHOL
OLDER age >65yrs
slow ACETYLATOR
LIVER DISEASE
What impact does ART have on the risk of TB disease?
PROTECTS against TB
What is the recommended first line treatment for active TB?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Which TWO drugs are the CONTINUATION phase of TB treatment?
Rifampicin
Isoniazid
How long is the INTENSIVE phase and the CONTINUATION phase of TB treatment?
2 months
then
4 months
What is the treatment duration for CNS TB?
6-12 months
What RIFAPENTINE-containing regimen appears to be an effective shorter regimen for active TB?
Pyrazinamide Rifapentine Isoniazid Moxifloxacin 8 weeks then 9 weeks DUAL
What is the benefit of RIFABUTIN for PLW HIV + TB?
can co-administer with RITONAVIR boosted PIs
Which group with TB + HIV should receive cortosteroids as part of TB treatment?
TB MENINGITIS
severe IRIS
What is the risk of giving corticosteroids to people with TB + HIV?
in non-CNS TB
- increased risk of HIV-associated disease
KS
CMV
How might mycobacterium avid (MAC) be differentiated from mycobacterium tuberculous (TB)?
Smear AFB positive
Negative molecular test
What dose of RIFAMPICIN should be used in the INDUCTION phase for treatment of TB in people with CD4 <100?
HIGHER dose 15mg/kg
vs
10mg/kg (higher CD4)
If the clinical picture suggests disseminated MAC, what should be added to the TB regimen whilst awaiting results?
RIFABUTIN (instead of rifampicin)
MACROLIDE (clarithromycin or azithromycin)
How should a TREATMENT INTERRUPTION be managed - INTENSIVE phase, LESS than 14 days since last dose?
CONTINUE
COMPLETE planned total doses
How should a TREATMENT INTERRUPTION be managed - INTENSIVE phase, GREATER than 14 days since last dose?
RESTART treatment
How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, >80% doses + SMEAR NEGATIVE in pulmonary disease?
TREATMENT can stop
How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, >80% doses + SMEAR POSITIVE or EXTRAPULMONARY disease?
CONTINUE ALL DOSES
How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, <80% doses + cumulative lapse <3 months, consecutive lapse <2 months?
CONTINUE ALL DOSES
How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, <80% doses + cumulative lapse >3 months?
RESTART treatment (include INTENSIVE)
Within what time frame must ALL doses in the INTENSIVE phase of TB treatment be complete?
3 months
Within what time frame must ALL doses in the CONTINUATION phase of TB treatment be complete?
6 months
What tests of vision are required before TB treatment?
VISUAL ACUITY (Snellen chart) COLOUR vision (Ishihara plate)
Why does visual ACUITY and COLOUR vision need to be checked before TB treatment?
ETHAMBUTOL can affect both
Why should hepatitis B & C be checked prior to TB treatment for PLW HIV?
PLW HIV have higher risk of viral hepatitis
TB treatment can cause hepatotoxicity
For patients with liver disease how often should they be monitored after starting TB treatment?
2 weekly
What is the definition of treatment FAILURE in TB?
smear or culture POSITIVE 5 months into treatment
What is the definition of RELAPSE in TB treatment?
previous treatment for TB completed
New episode of TB
What is the definition of TREATMENT AFTER FAILURE in TB treatment?
previous treatment for TB whose treatment failed at the end of most recent course
What proportion of people with PULMONARY TB treated with multi drug therapy will be culture/smear NEGATIVE at 3 months?
98%
What is the main reason for TB treatment failure?
poor adherence
What impact does ART have on TB developing drug resistance?
reduces acquired RIFAMYCIN resistance
What should be tested for in TB treatment failure or relapse?
Drug susceptibility
Whilst awaiting drug susceptibility results what NEW regimen could be considered for relapsed or treatment failure in TB?
RIFAMPICIN \+ FLUROQUINOLONE \+ CLOFAZIMINE or LINEZOLID
What proportion of PLW HIV + TB have ISOLATED isoniazid resistance?
6%
What TB regimen should be given to people with isolated isoniazid resistance?
Rifampicin
Levofloxacin
Pyrazinamide
Ethambutol
What class of drugs is substituted for isoniazid in isoniazid resistant TB?
FLUROQUINOLONES
Which parts of the world have a high risk for MDR-TB?
RUSSIA
EASTERN EUROPE
How is treatment for MDR-TB given?
ALL-ORAL shorter regimen
What is the all-oral shorter regimen for MDR-TB?
BEDAQUILINE LEVOFLOXACIN ETHIONAMIDE CLOFAZIME ISONIAZID PYRAZINAMIDE ETHAMBUTOL
Is surgical management useful for TB treatment?
selected cases of PULMONARY MDR-TB
BEDAQUILINE is used as part of a regimen to treat what TB?
rifampicin resistant (RR)/MDR-TB
What is the action of bedaquiline?
INHIBITS mycobacterial ATP synthase
What effect can bedaquiline have on QTc?
PROLONGATION
Which other TB antimicrobials may cause QTc prolongation other than bedaquiline?
QUINOLONES
CLOFAZIME
What is the action of DELAMANID?
inhibits MTB CELL WALL synthesis
What properties of PRETOMANID make it a potential part of TB treatment in the future?
activity on actively REPLICATING and SLOWLY dividing mycobacteria
What has PRETOMANID been combined with for treatment of XDR-TB?
BEDAQUILINE
LINEZOLID
Which patient groups may benefit from direct observed therapy (DOT) for TB?
MIGRANTS PRISONERS users of DRUGS HOMELESS MENTAL ILLNESS
When should ART be started within 2 weeks in PLW HIV and TB?
CD4 <50 cells
Other than at low CD4 count when should ART be started in context of HIV and TB?
after INDUCTION phase
unless patient keen to start sooner
What is the preferred ART of choice for HIV + TB co-infection?
TDF/FTC + EFAVIRENZ
What dosing adjustment should be made to RALTEGRAVIR is used as ART in HIV + TB co-infection?
TWICE daily dosing
DOUBLE dose
800mg BD
What dosing adjustment should be made to DOLUTEGRAVIR is used as ART in HIV + TB co-infection?
TWICE daily dosing
50mg BD
In what RARE circumstances might ART interruption be required for a person on established ART and starting TB treatment?
Failing ART due to poor ADHERENCE
may be best to stop ART whilst established on TB treatment
Is there any dosing adjustment required for efavirenz when used alongside rifampicin?
NO
(traditionally there was)
STANDARD dose 600mg DAILY
unless high BMI
Can NEVIRAPINE be used alongside RIFAMPICIN?
Yes - If patient STABLE on nevirapine
do not start nevirapine
What effect does RIFAMYCINS have on metabolism of CORTICOSTEROIDS?
ACCELERATED
need to increase dose of steroid
What effect does RIFAMPICIN have on metabolism of METHADONE?
INCREASED elimination
risk of symtomatic WITHDRAWAL
If a PLW HIV is co-infected with TB and hepatitis C how should this be managed?
Treat TB FIRST
then hepatitis C
When might therapeutic drug monitoring be considered in the treatment of both HIV and TB?
ADHERENCE concerns
VIRAEMIA
RIFABUTIN 150mg 3x/week + COBICISTAT
In addition to poor adherence what else should be considered if HIV viraemia or poor response to TB treatment?
MALABSORPTION
What increases risk of MALABSORPTION for PLW HIV?
low CD4 count
HIV ENTEROPATHY or other HIV-related GI disease
What common side effects may occur as a result of either ART or TB treatment?
FEVER
RASH
HEPATOTOXICITY
What is the definition of drug-induced liver injury (DILI)?
AST or ALT >3x ULN + SYMPTOMS
or
AST or ALT >5 ULN, NO symptoms
What is the ACUTE management of drug-induced liver injury in PLW HIV and on TB treatment?
1) STOP hepatotoxic medication
eg isoniazid, rifampicin, pyraxinamide, co-trimoxazole
2) VIRAL HEPATITIS serology
3) Other HEPATOTOXINS eg alcohol
When can TB medication be re-introduced following cessation for drug-induced liver injury?
AST/ALT < 2x ULN
Rank these anti-TB drugs in order of risk of HEPATOTOXICITY in context of pre-existing liver disease - rifampicin, isoniazid, pyrazinamide?
PYRAZINAMIDE>
ISONIAZID>
RIFAMPICIN
How should LFTs be interpreted if deranged due to pre-exisiting liver disease prior to TB treatment?
pre-treatment LFT is ‘BASELINE’
threshold 2-3x upper limit of ‘baseline’
What symptoms should patients be aware of that suggest liver injury in TB treatment?
ANOREXIA NAUSEA VOMITING ABDOMINAL PAIN JAUNDICE
What common GI side effects are experienced with TB treatment?
EPIGASTRIC pain
NAUSEA
VOMITING
What recommendations can be made to support people on anti-TB treatment manage GI side effects?
Take meds with MEALS
change dose TIMING
SWITCH regimen
Why is PYRIDOXINE use alongside ISONIAZID?
To reduce PERIPHERAL NEUROPATHY
If PERIPHERAL NEUROPATHY is experienced with ISONIAZID what can be done?
increase PYRIDOXINE
What dose adjustment of PYRIDOXINE can be made if PERIPHERAL NEUROPATHY develops with ISONIAZID?
INCREASE to 50mg DAILY (from 10mg)
Which anti-TB treatment most commonly causes a RASH?
ETHAMBUTOL
If drug-induced liver injury or rash occurs after re-introduction of ALL anti-TB drugs how should this be managed?
re-introduce SEQUENTIALLY
ETHAMBUTOL then ISONIAZID then RIFAMPICIN
What is it called when a person gets an exacerbation of symptoms after starting antiTB treatment?
PARADOXICAL reaction
Immune reconstitution disease or inflammatory syndrome (IRIS)
What is the presumed pathophysiology of IRIS in people with ART and TB treatment?
abnormal immune response to
tubercle ANTIGENS
released by dead or dying BACILLI
What are the TWO manifestations of IRIS in HIV?
PARADOXICAL - worsening of symptoms of known disease
UNMASKING - occult opportunistic infection becomes apparent after ART started
What other factors need to be excluded before diagnosing IRIS during TB treatment?
TB treatment FAILURE
Drug HYPERSENSITIVITY
OI
MALIGNANCY
What proportion of patients started on ART and TB treatment develop IRIS?
15.7%
What TWO presentations are most common in TB-IRIS?
FEVER
LYMPHADENOPATHY
What is the clinical presentation of TB-IRIS, other than fever or lymphadenopathy?
PULMONARY lesions PLEURAL or PERICARDIAL lesions ASCITES PSOAS abscess CUTANEOUS lesions TUBERCULOMAS Granulomatous HEPATITIS
What dose of corticosteroid should be used in TB-IRIS?
1-1.5mg/kg for 1-2 weeks then reduce
What happens to corticosteroid metabolism if administered with rifampicin?
INCREASED
reduced effect
What viral infections can be induced by high dose corticosteroid?
CMV retinitis
Kaposi sarcoma
What potential impact does corticosteroid have on TB-IRIS if started with ART?
reduced IRIS
reduced need for STEROID
well TOLERATED
Should corticosteroid be given to prevent TB-IRIS?
No (not currently recommended)
What is the potential complication if TB lymph node or abscess spontaneously ruptures?
SINUS formation
SCARRING
What can be done to manage swollen, tense lymph nodes or abscesses due to TB?
recurrent needle ASPIRATION
Through what mechanism might MONTELUKAST be useful in TB-IRIS?
Leukotriene activity implicated in IRIS
What other therapies may be useful for TB-IRIS other than steroid or montelukast?
THALIDOMIDE/LENALIDOMIDE TOCILIZUMAB Interleukin-2 INFLIXIMAB HYDROXYCHLOROQUINE
When should women who are pregnant and have TB infection be treated?
As soon as possible if ACTIVE TB
In pregnancy
What is the treatment regimen for TB treatment in women who are pregnant?
STANDARD first line treatment
RIPE
What impact does PREGNANCY have on the risk of developing peripheral NEUROPATHY with ISONIAZID?
INCREASED risk
Which alternative TB antimicrobials are CONTRAINDICATED in PREGNANCY?
STREPTOMYCIN AMIKACIN KANAMYCIN PROTHIONAMIDE ETHIONAMIDE
Which alternative TB antimicrobials can cause CONGENITAL DEAFNESS in PREGNANCY?
STREPTOMYCIN
AMIKACIN
KANAMYCIN
Which alternative TB antimicrobial is TERATOGENIC?
PROTHIONAMIDE
Which new TB treatment could be considered but has limited data on use in pregnancy?
BEDAQUILINE
When should a women with HIV be tested for latent TB?
same guidance as for non-pregnant PLW HIV
What risk is there to the women if active TB is not treated during pregnancy?
HAEMATOGENOUS spread via PLACENTA and DISSEMINATED TB
What factor should be considered when deciding when to treat LATENT TB in a woman who is PREGNANT?
RECENT ACQUISITION - requires treatment in pregnancy
In LATENT TB, if a pregnant woman has recently acquired it what impact does it have on timing of treatment?
RECENT - treat in pregnancy to reduce risk of haematogenous spread
HISTORICAL - otherwise delay until after pregnancy
For babies born to mothers treat for TB in pregnancy what impact does it have on birth outcomes?
LOW BIRTH WEIGHT
What is the recommendation for women of childbearing age who are undergoing treatment for TB?
use CONTRACEPTION
especially if MDR-TB
What impact does TB treatment have on BREASTFEEDING?
NO impact
Possible low dose antibiotic in breast milk
When should a person who is being treated for PULMONARY TB be admitted to hospital?
only if CLINICAL or PUBLIC HEALTH need
If a person is admitted to hospital with PULMONARY TB, what type of room should the be nursed in?
NEGATIVE pressure room
How should close contacts of people with pulmonary or laryngeal TB be managed?
SCREEN for TB
What is an alternative management of people in close contact with MDR-TB other than preventive treatment?
OBSERVE and MONITOR for development of ACTIVE TB
Is TB a notifiable disease?
YES
What are the potential causes of DEATH in TB/HIV co-infection?
Active PROGRESSIVE TB
SECONDARY effects of TB ie lung haemorrhage
IRIS affecting critical ORGANS
AntiTB DRUG TOXICITY
HIV or non-HIV related COMORBIDITY
Othe FATAL disease not related to TB or HIV
What are the potential clinical presentations or syndromes that lead to DEATH from ACTIVE progressive TB?
CRITICAL ORGAN FAILURE
SYSTEMIC SEPTIC SHOCK
What are the potential clinical presentations or syndromes that lead to DEATH that are secondary effects of TB?
Lung HAEMORRHAGE
MENINGOVASCULAR obstruction
STROKE
If person with TB dies what samples should routinely be sent from autopsy and why?
TUBERCULOUS TISSUE
for CULTURE and DRUG SENSITIVITY
What impact does HIV have on molecular testing sensitivity for TB?
REDUCED SENSITIVITY
79% PLW HIV vs 86% no HIV
What is the potential utility of lateral flow urine LAM assay in diagnosing TB?
in people DIFFICULTY producing SPUTUM or EXTRAPULMONARY TB or DISSEMINATED TB
What is the LIMITATION of lateral flow urine LAM assay in diagnosing TB?
less SENSITIVE
CROSS-REACTIVITY = FALSE POSITIVES
What does an IGRA measure?
Interferon-Gamma Release from Cells after STIMULATION with ANTIGENS specific to MTB
What is the MAJOR criteria for diagnosing TB - PARADOXICAL IRIS?
1) New, enlarging or abscess LYMPH NODES New or worsening 2) RADIOLOGY 3) CNS TB signs 4) SEROSITIS (pleural, pericardial, ascites, arthritis)
What is the MINOR criteria for diagnosing TB - PARADOXICAL IRIS?
new or worsening
1) CONSTITUTIONAL symptoms
2) RESPIRATORY symptoms
3) ABDOMINAL pain
4) in RETROSPECT, RESOLVING symptoms without changing TB therapy
What combination of MAJOR and MINOR criteria must be met to make a diagnosis on TB - PARADOXICAL IRIS?
ONE major
or
TWO minor
What is the MAJOR criteria for diagnosing TB - UNMASKING IRIS?
NO treatment when ART is started
and
ACTIVE TB within 3 months of ART start
What is the MINOR criteria for diagnosing TB - UNMASKING IRIS?
1) heightened INTENSITY of clinical MANIFESTATIONS with evidence of marked INFLAMMATORY component
2) PARADOXICAL reaction once on TB treatment
What combination of MAJOR and MINOR criteria must be met to make a diagnosis on TB - UNMASKING IRIS?
ONE major
+
ONE minor
Within what timeframe does the majority of IRIS occur after starting ART?
60 days
What is the MEDIAN timeframe for IRIS after starting ART?
15 days
DDIs - AMINOGLYCOSIDES and ART-what monitoring?
RENAL
DDIs - FLUROQUINOLONES and ART-what monitoring?
QTC
Which antiTB agent is an essential component of SHORT course (6 month) TB treatment?
PYRAZINAMIDE
extend TB treatment to 9 months if cannot give
If PYRAZINAMIDE cannot be given as part of SHORT course (6 month) TB treatment how should the regimen be altered?
extend TB treatment to 9 months if cannot give
What factor predicts increased relapse after completion of TB treatment?
SMEAR positive at end of treament
If smear POSITIVE at end of TB treatment what should be done?
check ADHERENCE
EXTEND TB treatment to 9 months
