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DipHIV > HIV + TB > Flashcards

HIV + TB Flashcards

1
Q

What is the estimated worldwide prevalence of people with TB co-infected with HIV?

A

8%

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2
Q

What proportion of people who died with TB are co-infected with HIV?

A

1/6

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3
Q

There was a drop in TB incidence in PLW HIV in the UK between 2008-2011, what was the change in incidence?

A

17.5/1000
to
4.4/1000

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4
Q

Why was there an apparent reduction in incidence of TB + HIV co-infection between 2008-2011?

A

reduced HIV diagnosis in people from sub-Saharan Africa

increased total number of people living with HIV

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5
Q

What is the current proportion of people with TB with HIV co-infection?

A

3%

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6
Q

What is the impact of HIV on risk of developing TB?

A

risk of TB 26-31 times greater

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7
Q

Is HIV testing mandatory in TB infection?

A

YES

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8
Q

What impact does HIV have on the investigation findings for TB?

A

ATYPICAL
NORMAL CXR
Sputum SMEAR NEGATIVE, culture positive

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9
Q

What are the FIVE aims of TB treatment (as per WHO)?

A

CURE patient and restore QoL
PREVENT DEATH from active TB or complications
prevent RELAPSE
REDUCE TRANSMISSION
prevent development and transmission of RESISTANCE

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10
Q

Molecular diagnostic tests for TB identify what?

A

early identification of MYCOBACTERIUM

genotypic DRUG SUSCEPTIBILITY

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11
Q

Which mutations confer rifampicin resistance in TB?

A

rpoB

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12
Q

What is the limitation of the Xpert MTB/RIF molecular test for TB?

A

REDUCED SENSITIVITY if smear NEGATIVE

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13
Q

How does the sensitivity of TB molecular testing differ for smear POSITIVE and smear NEGATIVE samples?

A

98% smear POSITIVE
c/w
67% smear NEGATIVE

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14
Q

In addition to molecular testing for TB what additional investigation must be done?

A

CULTURE

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15
Q

Why must culture for TB be done in addition to molecular testing?

A

to increase SENSITIVITY

to identify full DRUG-SUSCEPTIBILITY

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16
Q

What is the sensitivity and specificity of IGRA in PLW HIV in active TB?

A

SUBOPTIMAL

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17
Q

What culture medium provides quicker results for TB culture?

A

LIQUID culture
c/w
solid culture

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18
Q

What is the most common presentation of CNS TB?

A

tuberculous MENINGITIS

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19
Q

What is the proportion of mortality in TB meningitis?

A

20-50%

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20
Q

What are the FOUR presentations of CNS TB?

A

MENINGITIS (most common)
ENCEPHALITIS
intracranial TUBERCULOMAS
brain ABSCESS

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21
Q

What are the non-specific symptoms of TB MENINGITIS?

A

Fever
headache
Vomiting

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22
Q

What is the timing of TB MENINGITIS?

A

gradual onset

often progressing over weeks

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23
Q

What are the TWO main investigations for TB MENINGITIS?

A

imaging MRI

Lumbar puncture

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24
Q

What is the typical finding on CSF in TB meningitis?

A

mononucleate cell pleocytosis (LYMPHOCYTIC predominant)
WCC 100-500cells/mm3
low GLUCOSE <2.5mml/L
high PROTEIN 1-5g/L

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25
Q

What impact does HIV have on CSF of a person with TB meningitis?

A

ACELLULAR (ie no raised WCC)

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26
Q

What is the sensitivity of Ziehl-Neelsen staining for AFB in CNS TB?

A

10-60%

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27
Q

What is the sensitivity of culture from CSF of TB in CNS TB?

A

10-60%

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28
Q

What increases the sensitivity of CSF culture for TB?

A

Large volume of CSF >6mL

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29
Q

Which molecular test is recommended for diagnosing TB meningitis?

A

Xpert MTB/RIF ULTRA

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30
Q

What is the most common cause of lymphatic pleural effusion in PLW HIV?

A

TB (if HIV endemic)

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31
Q

In addition to analysis of pleural effusion what other samples are required if TB pleural effusion is likely?

A

PULMONARY samples for culture

sputum or BAL

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32
Q

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?

A

55%

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33
Q

What impact does CD4 cell count have on the microscopy yield of AFB in TB pleural disease?

A

INCREASED yield in lower CD4 count

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34
Q

What additional test of pleural fluid can help diagnose TB disease?

A

raised adenosine deaminase (ADA)
+
lymphocyte predominant exudative pleural effusion

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35
Q

What point of care test is used for diagnosis of extrapulmonary TB disease?

A

URINE lateral flow lipoarabinomannan (LF-LAM)

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36
Q

What impact dose CD4 cell count have on the sensitivity of point of care urine lateral flow for TB?

A

INCREASED

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37
Q

In addition to urine lateral flow what investigation would be useful To diagnose disseminated TB?

A

mycobacterial BLOOD CULTURE

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38
Q

What CYTOPATHOLOGICAL features are present in TB eg samples from lymph node, lung aspirate, focal lesions?

A

Macrophage GRANULOMAS +/- necrosis

AFB on ZN staining

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39
Q

What HISTOPATHOLOGICAL features are present in TB eg samples from lymph node, lung aspirate, focal lesions?

A

epithelioid cell GRANULOMAS +/- Langhans giant cells
CASEATION
NECROSIS
AFB on ZN staining

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40
Q

What additional microbes should be tested for on HISTOPATHOLOGICAL suspicious for TB?

A

FUNGAL staining (HISTOPLASMOSIS)

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41
Q

If TB is diagnosed histopathologically but standard treatment is ineffective what must be considered?

A

consider NON-TB mycobacterial infection

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42
Q

What differential diagnoses can mimic TB?

A 
SARCOIDOSIS
HISTOPLASMOSIS
NOCARDIOSIS
LEISHMANIASIS
GRANULOMATOUS reaction to local tumour
CVID
VASCULITIS
AUTOIMMUED disease
GRAM NEGATIVE infection (BRUCELLOSIS, MELIOIDOSIS)
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43
Q

What is the definition of MDR-TB?

A

resistance to at least ISONIAZID and RIFAMPICIN

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44
Q

What is the definition of pre-XDR-TB?

A 
pre-EXTENSIVELY DRUG RESISTANT TB
resistance to 
ISONIAZID+RIFAMPICIN
and
FLUOROQUINOLONE or 2nd line INJECTABLE (not both)
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45
Q

What is the definition of XDR-TB?

A

resistance to
SONIAZID+RIFAMPICIN+FLUOROQUINOLONE
and
at least one 2nd line INJECTABLE (eg amikacin)

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46
Q

What proportion of people with TB have MDR-TB in the UK?

A

1.6%

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47
Q

What proportion of PLW HIV + TB have resistance to RIFAMPICIN only?

A

1.3%

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48
Q

What proportion of PLW HIV + TB have resistance to ISONIAZID only?

A

4%

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49
Q

List SIX(6) risk factors for drug-resistant TB?

A

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

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50
Q

What factors increase the risk of people with latent TB developing active TB?

A

recent ACQUISITION of TB

IMMUNOSUPPRESSED

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51
Q

What is the incidence of TB in PLW HIV in the UK?

A

0.6/1000

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52
Q

What is the incidence of TB in the general UK population?

A

0.13/1000

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53
Q

Is the incidence of TB higher or lower in PLWHIV c/w UK general population?

A

HIGHER

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54
Q

What is the definition of HIGH TB incidence?

A

> 151/100 000

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55
Q

What is the definition of MEDIUM TB incidence?

A

4-150/100 000

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56
Q

Over what time period is the risk of progression to active TB from latent TB highest?

A

2-3 years

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57
Q

What is the definition of latent TB?

A

positive IGRA
+
no clinical or radiological evidence of active TB

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58
Q

How does the NICE guideline differ from BHIVA guideline on how to diagnose latent TB?

A

NICE - recommends both IGRA and TST

BHIVA - recommends only IGRA

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59
Q

Why is only IGRA and not TST recommended for diagnosis of latent TB in PLW HIV?

A

TST reduced sensitivity in low CD4
and
false positive if past BCG vaccination

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60
Q

What additional risk factors should prompt testing for latent TB, even if PLW HIV is from a country of low incidence?

A 
EXPOSURE to TB
TRAVEL to higher incidence countries
WORKING in MEDICAL settings with high incidence TB
IDU
CKD
Diabetes
CHEMOTHERAPY
IMMUNOSUPPRESSION
BIOLOGICAL DISEASE MODIFIERS
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61
Q

If latent TB is identified in a pregnant women with HIV, should they be offered treatment in pregnancy?

A

YES

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62
Q

Which group of PLW HIV should be screened for TB?

A

People from HIGH and MEDIUM TB incidence

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63
Q

Why should latent TB be treated in PLW HIV?

A

PROTECTIVE effect

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64
Q

What is the first line recommended treatment for latent TB?

A

ISONIAZID (with PYRIDOXINE) daily

6 months

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65
Q

What TWO alternative regimens can be used for treatment for latent TB?

A 
ISONIAZID (with PYRIDOXINE) + RIFAMPICIN
3 months
or
ISONIAZID + RIFAMPICIN (with PYRIDOXINE) 
TWICE WEEKLY
3 months
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66
Q

What drug shows promise in SHORTER regimens for latent TB?

A

RIFAPENTINE

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67
Q

What RIFAPENTINE-containing regimens have been shown to be effective for latent TB?

A 
ISONIAZID (900mg) + RIFAPENTINE (900mg)
WEEKLY
12 weeks
or
ISONIAZID (300mg) + RIFAPENTINE (450-600mg)
DAILY
1 month
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68
Q

What effect does ISONIAZID have on liver function?

A

Mild rise aminotransferases
Not generally clinically relevant
RARE symptomatic hepatotoxicity

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69
Q

What risk factors increase the risk of severe HEPATOTOXICITY with ISONIAZID?

A

excessive ALCOHOL
OLDER age >65yrs
slow ACETYLATOR
LIVER DISEASE

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70
Q

What impact does ART have on the risk of TB disease?

A

PROTECTS against TB

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71
Q

What is the recommended first line treatment for active TB?

A

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

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72
Q

Which TWO drugs are the CONTINUATION phase of TB treatment?

A

Rifampicin

Isoniazid

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73
Q

How long is the INTENSIVE phase and the CONTINUATION phase of TB treatment?

A

2 months
then
4 months

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74
Q

What is the treatment duration for CNS TB?

A

6-12 months

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75
Q

What RIFAPENTINE-containing regimen appears to be an effective shorter regimen for active TB?

A 
Pyrazinamide
Rifapentine
Isoniazid
Moxifloxacin
8 weeks
then 
9 weeks DUAL
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76
Q

What is the benefit of RIFABUTIN for PLW HIV + TB?

A

can co-administer with RITONAVIR boosted PIs

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77
Q

Which group with TB + HIV should receive cortosteroids as part of TB treatment?

A

TB MENINGITIS

severe IRIS

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78
Q

What is the risk of giving corticosteroids to people with TB + HIV?

A

in non-CNS TB
- increased risk of HIV-associated disease
KS
CMV

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79
Q

How might mycobacterium avid (MAC) be differentiated from mycobacterium tuberculous (TB)?

A

Smear AFB positive

Negative molecular test

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80
Q

What dose of RIFAMPICIN should be used in the INDUCTION phase for treatment of TB in people with CD4 <100?

A

HIGHER dose 15mg/kg
vs
10mg/kg (higher CD4)

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81
Q

If the clinical picture suggests disseminated MAC, what should be added to the TB regimen whilst awaiting results?

A

RIFABUTIN (instead of rifampicin)

MACROLIDE (clarithromycin or azithromycin)

82
Q

How should a TREATMENT INTERRUPTION be managed - INTENSIVE phase, LESS than 14 days since last dose?

A

CONTINUE

COMPLETE planned total doses

83
Q

How should a TREATMENT INTERRUPTION be managed - INTENSIVE phase, GREATER than 14 days since last dose?

A

RESTART treatment

84
Q

How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, >80% doses + SMEAR NEGATIVE in pulmonary disease?

A

TREATMENT can stop

85
Q

How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, >80% doses + SMEAR POSITIVE or EXTRAPULMONARY disease?

A

CONTINUE ALL DOSES

86
Q

How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, <80% doses + cumulative lapse <3 months, consecutive lapse <2 months?

A

CONTINUE ALL DOSES

87
Q

How should a TREATMENT INTERRUPTION be managed - CONTINUATION phase, <80% doses + cumulative lapse >3 months?

A

RESTART treatment (include INTENSIVE)

88
Q

Within what time frame must ALL doses in the INTENSIVE phase of TB treatment be complete?

A

3 months

89
Q

Within what time frame must ALL doses in the CONTINUATION phase of TB treatment be complete?

A

6 months

90
Q

What tests of vision are required before TB treatment?

A 
VISUAL ACUITY (Snellen chart)
COLOUR vision (Ishihara plate)
91
Q

Why does visual ACUITY and COLOUR vision need to be checked before TB treatment?

A

ETHAMBUTOL can affect both

92
Q

Why should hepatitis B & C be checked prior to TB treatment for PLW HIV?

A

PLW HIV have higher risk of viral hepatitis

TB treatment can cause hepatotoxicity

93
Q

For patients with liver disease how often should they be monitored after starting TB treatment?

A

2 weekly

94
Q

What is the definition of treatment FAILURE in TB?

A

smear or culture POSITIVE 5 months into treatment

95
Q

What is the definition of RELAPSE in TB treatment?

A

previous treatment for TB completed

New episode of TB

96
Q

What is the definition of TREATMENT AFTER FAILURE in TB treatment?

A

previous treatment for TB whose treatment failed at the end of most recent course

97
Q

What proportion of people with PULMONARY TB treated with multi drug therapy will be culture/smear NEGATIVE at 3 months?

A

98%

98
Q

What is the main reason for TB treatment failure?

A

poor adherence

99
Q

What impact does ART have on TB developing drug resistance?

A

reduces acquired RIFAMYCIN resistance

100
Q

What should be tested for in TB treatment failure or relapse?

A

Drug susceptibility

101
Q

Whilst awaiting drug susceptibility results what NEW regimen could be considered for relapsed or treatment failure in TB?

A 
RIFAMPICIN
\+
FLUROQUINOLONE
\+ 
CLOFAZIMINE or LINEZOLID
102
Q

What proportion of PLW HIV + TB have ISOLATED isoniazid resistance?

A

6%

103
Q

What TB regimen should be given to people with isolated isoniazid resistance?

A

Rifampicin
Levofloxacin
Pyrazinamide
Ethambutol

104
Q

What class of drugs is substituted for isoniazid in isoniazid resistant TB?

A

FLUROQUINOLONES

105
Q

Which parts of the world have a high risk for MDR-TB?

A

RUSSIA

EASTERN EUROPE

106
Q

How is treatment for MDR-TB given?

A

ALL-ORAL shorter regimen

107
Q

What is the all-oral shorter regimen for MDR-TB?

A 
BEDAQUILINE
LEVOFLOXACIN
ETHIONAMIDE
CLOFAZIME
ISONIAZID
PYRAZINAMIDE
ETHAMBUTOL
108
Q

Is surgical management useful for TB treatment?

A

selected cases of PULMONARY MDR-TB

109
Q

BEDAQUILINE is used as part of a regimen to treat what TB?

A

rifampicin resistant (RR)/MDR-TB

110
Q

What is the action of bedaquiline?

A

INHIBITS mycobacterial ATP synthase

111
Q

What effect can bedaquiline have on QTc?

A

PROLONGATION

112
Q

Which other TB antimicrobials may cause QTc prolongation other than bedaquiline?

A

QUINOLONES

CLOFAZIME

113
Q

What is the action of DELAMANID?

A

inhibits MTB CELL WALL synthesis

114
Q

What properties of PRETOMANID make it a potential part of TB treatment in the future?

A

activity on actively REPLICATING and SLOWLY dividing mycobacteria

115
Q

What has PRETOMANID been combined with for treatment of XDR-TB?

A

BEDAQUILINE

LINEZOLID

116
Q

Which patient groups may benefit from direct observed therapy (DOT) for TB?

A 
MIGRANTS
PRISONERS
users of DRUGS
HOMELESS
MENTAL ILLNESS
117
Q

When should ART be started within 2 weeks in PLW HIV and TB?

A

CD4 <50 cells

118
Q

Other than at low CD4 count when should ART be started in context of HIV and TB?

A

after INDUCTION phase

unless patient keen to start sooner

119
Q

What is the preferred ART of choice for HIV + TB co-infection?

A

TDF/FTC + EFAVIRENZ

120
Q

What dosing adjustment should be made to RALTEGRAVIR is used as ART in HIV + TB co-infection?

A

TWICE daily dosing
DOUBLE dose
800mg BD

121
Q

What dosing adjustment should be made to DOLUTEGRAVIR is used as ART in HIV + TB co-infection?

A

TWICE daily dosing

50mg BD

122
Q

In what RARE circumstances might ART interruption be required for a person on established ART and starting TB treatment?

A

Failing ART due to poor ADHERENCE

may be best to stop ART whilst established on TB treatment

123
Q

Is there any dosing adjustment required for efavirenz when used alongside rifampicin?

A

NO
(traditionally there was)
STANDARD dose 600mg DAILY
unless high BMI

124
Q

Can NEVIRAPINE be used alongside RIFAMPICIN?

A

Yes - If patient STABLE on nevirapine

do not start nevirapine

125
Q

What effect does RIFAMYCINS have on metabolism of CORTICOSTEROIDS?

A

ACCELERATED

need to increase dose of steroid

126
Q

What effect does RIFAMPICIN have on metabolism of METHADONE?

A

INCREASED elimination

risk of symtomatic WITHDRAWAL

127
Q

If a PLW HIV is co-infected with TB and hepatitis C how should this be managed?

A

Treat TB FIRST

then hepatitis C

128
Q

When might therapeutic drug monitoring be considered in the treatment of both HIV and TB?

A

ADHERENCE concerns
VIRAEMIA
RIFABUTIN 150mg 3x/week + COBICISTAT

129
Q

In addition to poor adherence what else should be considered if HIV viraemia or poor response to TB treatment?

A

MALABSORPTION

130
Q

What increases risk of MALABSORPTION for PLW HIV?

A

low CD4 count

HIV ENTEROPATHY or other HIV-related GI disease

131
Q

What common side effects may occur as a result of either ART or TB treatment?

A

FEVER
RASH
HEPATOTOXICITY

132
Q

What is the definition of drug-induced liver injury (DILI)?

A

AST or ALT >3x ULN + SYMPTOMS
or
AST or ALT >5 ULN, NO symptoms

133
Q

What is the ACUTE management of drug-induced liver injury in PLW HIV and on TB treatment?

A

1) STOP hepatotoxic medication
eg isoniazid, rifampicin, pyraxinamide, co-trimoxazole
2) VIRAL HEPATITIS serology
3) Other HEPATOTOXINS eg alcohol

134
Q

When can TB medication be re-introduced following cessation for drug-induced liver injury?

A

AST/ALT < 2x ULN

135
Q

Rank these anti-TB drugs in order of risk of HEPATOTOXICITY in context of pre-existing liver disease - rifampicin, isoniazid, pyrazinamide?

A

PYRAZINAMIDE>
ISONIAZID>
RIFAMPICIN

136
Q

How should LFTs be interpreted if deranged due to pre-exisiting liver disease prior to TB treatment?

A

pre-treatment LFT is ‘BASELINE’

threshold 2-3x upper limit of ‘baseline’

137
Q

What symptoms should patients be aware of that suggest liver injury in TB treatment?

A 
ANOREXIA
NAUSEA
VOMITING
ABDOMINAL PAIN
JAUNDICE
138
Q

What common GI side effects are experienced with TB treatment?

A

EPIGASTRIC pain
NAUSEA
VOMITING

139
Q

What recommendations can be made to support people on anti-TB treatment manage GI side effects?

A

Take meds with MEALS
change dose TIMING
SWITCH regimen

140
Q

Why is PYRIDOXINE use alongside ISONIAZID?

A

To reduce PERIPHERAL NEUROPATHY

141
Q

If PERIPHERAL NEUROPATHY is experienced with ISONIAZID what can be done?

A

increase PYRIDOXINE

142
Q

What dose adjustment of PYRIDOXINE can be made if PERIPHERAL NEUROPATHY develops with ISONIAZID?

A

INCREASE to 50mg DAILY (from 10mg)

143
Q

Which anti-TB treatment most commonly causes a RASH?

A

ETHAMBUTOL

144
Q

If drug-induced liver injury or rash occurs after re-introduction of ALL anti-TB drugs how should this be managed?

A

re-introduce SEQUENTIALLY

ETHAMBUTOL then ISONIAZID then RIFAMPICIN

145
Q

What is it called when a person gets an exacerbation of symptoms after starting antiTB treatment?

A

PARADOXICAL reaction

Immune reconstitution disease or inflammatory syndrome (IRIS)

146
Q

What is the presumed pathophysiology of IRIS in people with ART and TB treatment?

A

abnormal immune response to
tubercle ANTIGENS
released by dead or dying BACILLI

147
Q

What are the TWO manifestations of IRIS in HIV?

A

PARADOXICAL - worsening of symptoms of known disease

UNMASKING - occult opportunistic infection becomes apparent after ART started

148
Q

What other factors need to be excluded before diagnosing IRIS during TB treatment?

A

TB treatment FAILURE
Drug HYPERSENSITIVITY
OI
MALIGNANCY

149
Q

What proportion of patients started on ART and TB treatment develop IRIS?

A

15.7%

150
Q

What TWO presentations are most common in TB-IRIS?

A

FEVER

LYMPHADENOPATHY

151
Q

What is the clinical presentation of TB-IRIS, other than fever or lymphadenopathy?

A 
PULMONARY lesions
PLEURAL or PERICARDIAL lesions
ASCITES
PSOAS abscess
CUTANEOUS lesions
TUBERCULOMAS
Granulomatous HEPATITIS
152
Q

What dose of corticosteroid should be used in TB-IRIS?

A

1-1.5mg/kg for 1-2 weeks then reduce

153
Q

What happens to corticosteroid metabolism if administered with rifampicin?

A

INCREASED

reduced effect

154
Q

What viral infections can be induced by high dose corticosteroid?

A

CMV retinitis

Kaposi sarcoma

155
Q

What potential impact does corticosteroid have on TB-IRIS if started with ART?

A

reduced IRIS
reduced need for STEROID
well TOLERATED

156
Q

Should corticosteroid be given to prevent TB-IRIS?

A

No (not currently recommended)

157
Q

What is the potential complication if TB lymph node or abscess spontaneously ruptures?

A

SINUS formation

SCARRING

158
Q

What can be done to manage swollen, tense lymph nodes or abscesses due to TB?

A

recurrent needle ASPIRATION

159
Q

Through what mechanism might MONTELUKAST be useful in TB-IRIS?

A

Leukotriene activity implicated in IRIS

160
Q

What other therapies may be useful for TB-IRIS other than steroid or montelukast?

A 
THALIDOMIDE/LENALIDOMIDE
TOCILIZUMAB
Interleukin-2
INFLIXIMAB
HYDROXYCHLOROQUINE
161
Q

When should women who are pregnant and have TB infection be treated?

A

As soon as possible if ACTIVE TB

In pregnancy

162
Q

What is the treatment regimen for TB treatment in women who are pregnant?

A

STANDARD first line treatment

RIPE

163
Q

What impact does PREGNANCY have on the risk of developing peripheral NEUROPATHY with ISONIAZID?

A

INCREASED risk

164
Q

Which alternative TB antimicrobials are CONTRAINDICATED in PREGNANCY?

A 
STREPTOMYCIN
AMIKACIN
KANAMYCIN
PROTHIONAMIDE
ETHIONAMIDE
165
Q

Which alternative TB antimicrobials can cause CONGENITAL DEAFNESS in PREGNANCY?

A

STREPTOMYCIN
AMIKACIN
KANAMYCIN

166
Q

Which alternative TB antimicrobial is TERATOGENIC?

A

PROTHIONAMIDE

167
Q

Which new TB treatment could be considered but has limited data on use in pregnancy?

A

BEDAQUILINE

168
Q

When should a women with HIV be tested for latent TB?

A

same guidance as for non-pregnant PLW HIV

169
Q

What risk is there to the women if active TB is not treated during pregnancy?

A

HAEMATOGENOUS spread via PLACENTA and DISSEMINATED TB

170
Q

What factor should be considered when deciding when to treat LATENT TB in a woman who is PREGNANT?

A

RECENT ACQUISITION - requires treatment in pregnancy

171
Q

In LATENT TB, if a pregnant woman has recently acquired it what impact does it have on timing of treatment?

A

RECENT - treat in pregnancy to reduce risk of haematogenous spread
HISTORICAL - otherwise delay until after pregnancy

172
Q

For babies born to mothers treat for TB in pregnancy what impact does it have on birth outcomes?

A

LOW BIRTH WEIGHT

173
Q

What is the recommendation for women of childbearing age who are undergoing treatment for TB?

A

use CONTRACEPTION

especially if MDR-TB

174
Q

What impact does TB treatment have on BREASTFEEDING?

A

NO impact

Possible low dose antibiotic in breast milk

175
Q

When should a person who is being treated for PULMONARY TB be admitted to hospital?

A

only if CLINICAL or PUBLIC HEALTH need

176
Q

If a person is admitted to hospital with PULMONARY TB, what type of room should the be nursed in?

A

NEGATIVE pressure room

177
Q

How should close contacts of people with pulmonary or laryngeal TB be managed?

A

SCREEN for TB

178
Q

What is an alternative management of people in close contact with MDR-TB other than preventive treatment?

A

OBSERVE and MONITOR for development of ACTIVE TB

179
Q

Is TB a notifiable disease?

A

YES

180
Q

What are the potential causes of DEATH in TB/HIV co-infection?

A

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

181
Q

What are the potential clinical presentations or syndromes that lead to DEATH from ACTIVE progressive TB?

A

CRITICAL ORGAN FAILURE

SYSTEMIC SEPTIC SHOCK

182
Q

What are the potential clinical presentations or syndromes that lead to DEATH that are secondary effects of TB?

A

Lung HAEMORRHAGE
MENINGOVASCULAR obstruction
STROKE

183
Q

If person with TB dies what samples should routinely be sent from autopsy and why?

A

TUBERCULOUS TISSUE

for CULTURE and DRUG SENSITIVITY

184
Q

What impact does HIV have on molecular testing sensitivity for TB?

A

REDUCED SENSITIVITY

79% PLW HIV vs 86% no HIV

185
Q

What is the potential utility of lateral flow urine LAM assay in diagnosing TB?

A 
in people DIFFICULTY producing SPUTUM
or
EXTRAPULMONARY TB
or
DISSEMINATED TB
186
Q

What is the LIMITATION of lateral flow urine LAM assay in diagnosing TB?

A

less SENSITIVE

CROSS-REACTIVITY = FALSE POSITIVES

187
Q

What does an IGRA measure?

A

Interferon-Gamma Release from Cells after STIMULATION with ANTIGENS specific to MTB

188
Q

What is the MAJOR criteria for diagnosing TB - PARADOXICAL IRIS?

A 
1) New, enlarging or abscess LYMPH NODES
New or worsening
2)  RADIOLOGY
3) CNS TB signs
4) SEROSITIS (pleural, pericardial, ascites, arthritis)
189
Q

What is the MINOR criteria for diagnosing TB - PARADOXICAL IRIS?

A

new or worsening

1) CONSTITUTIONAL symptoms
2) RESPIRATORY symptoms
3) ABDOMINAL pain
4) in RETROSPECT, RESOLVING symptoms without changing TB therapy

190
Q

What combination of MAJOR and MINOR criteria must be met to make a diagnosis on TB - PARADOXICAL IRIS?

A

ONE major
or
TWO minor

191
Q

What is the MAJOR criteria for diagnosing TB - UNMASKING IRIS?

A

NO treatment when ART is started
and
ACTIVE TB within 3 months of ART start

192
Q

What is the MINOR criteria for diagnosing TB - UNMASKING IRIS?

A

1) heightened INTENSITY of clinical MANIFESTATIONS with evidence of marked INFLAMMATORY component
2) PARADOXICAL reaction once on TB treatment

193
Q

What combination of MAJOR and MINOR criteria must be met to make a diagnosis on TB - UNMASKING IRIS?

A

ONE major
+
ONE minor

194
Q

Within what timeframe does the majority of IRIS occur after starting ART?

A

60 days

195
Q

What is the MEDIAN timeframe for IRIS after starting ART?

A

15 days

196
Q

DDIs - AMINOGLYCOSIDES and ART-what monitoring?

A

RENAL

197
Q

DDIs - FLUROQUINOLONES and ART-what monitoring?

A

QTC

198
Q

Which antiTB agent is an essential component of SHORT course (6 month) TB treatment?

A

PYRAZINAMIDE

extend TB treatment to 9 months if cannot give

199
Q

If PYRAZINAMIDE cannot be given as part of SHORT course (6 month) TB treatment how should the regimen be altered?

A

extend TB treatment to 9 months if cannot give

200
Q

What factor predicts increased relapse after completion of TB treatment?

A

SMEAR positive at end of treament

201
Q

If smear POSITIVE at end of TB treatment what should be done?

A

check ADHERENCE

EXTEND TB treatment to 9 months

DipHIV (14 decks)

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