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Unit 2 Clin Med II > L15: TB+cocci > Flashcards

L15: TB+cocci Flashcards

1
Q

how is TB spread?

A

must have active TB to spread infection

Transmission by prolonged exposure to airborne droplet nuclei→ inhaled nuclei reach alveoli

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2
Q

primary TB

A

skin test conversion in 6-8 weeks→ spontaneous healing in 6 months→ latent TB

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3
Q

latent TB risk of progressing to reactivated TB

A

5% progress by 2 years
5% progress after 2 years
90% don’t progress
But HIV patients have a 10% risk/year of progression

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4
Q

latent TB

A

No symptoms, not contagious
Macrophages ingest tubercle bacilli→ barrier shell: granuloma
Can activate to disease state if immunocompromised→ granuloma breakdown

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5
Q

MDR-TB

A

does not respond to INH or RIF

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6
Q

XDR-TB

A

does not respond to INH, RIF, fluoroquinolones

→ surgery to remove necrotic tissue

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7
Q

Treatment for active TB

A

Isolated, negative pressure inpatient hospital room

RIPE: rifampin (RIF) + isoniazid (INH) + pyrazinamide (PZA) + ethambutol (EMB)

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8
Q

Treatment for active TB lengths

A

Initially 4 meds daily x 2 months→ 56 doses→ repeat CXR, AFB smear, culture
Continuation: RIF + INH for 4 months daily or twice weekly→126/36 doses sputum culture→ +/- phase extended

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9
Q

completion of TB treatment is based on

A

total doses, not duration of treatment

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10
Q

Treatment of TB in HIV+

A

9-12 months with intermittent dosing

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11
Q

Treatment of TB in children

A

no ethambutol, extend tx

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12
Q

Treatment of TB if pregnant

A

no pyrazinamide
INH+RPT contraindicated
INH: risk of fatal hepatitis

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13
Q

Side effects of rifampin

A

orange tears, sweat, urine

skin sensitivity

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14
Q

Side effects of isoniazid

A

hepatotoxicity→ monitor LFTs

peripheral neuropathy→ give vitamin B6

→fatal hepatitis: esp in pregnant women

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15
Q

Side effects of pyrazinamide

A

Hepatotoxicity, hyperuricemia

→ contraindicated in pregnancy

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16
Q

Side effects of ethambutol

A

Optic neuritis→ test visual acuity/color vision

→ contraindicated in children

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17
Q

when is TB in treatment considered noninfectious

A

after 2 weeks+3 (-) sputum smears symptoms improve

:

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18
Q

Going home while still infectious

A

no travel, DOT, no children <5 or immunocompromised in home

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19
Q

Latent TB treatment options

A
  1. INH 9 months 300 mg daily or 900 mg twice weekly
    Preferred therapy for pregnant women and children 2-11 years old
  2. INH+Rifapentine (RPT)
    12 weekly doses DOT
    Newly preferred in 2018 for adults and children >12 years, otherwise healthy patients with HIV
    Contraindicated in pregnancy
  3. Rifampin
    4 months daily→ 120 daily
    If cannot tolerate INH
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20
Q

INH + RPT contraindication

A

less than 12 years old

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21
Q

high risk for TB

A

Immunocompromised: HIV, <5 years, DM, silicosis, malnutrition, substance abuse, immunosuppressants
Immigrants
IVDU
Close living quarters

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22
Q

TB symptoms

A

Fever, cough (3+ weeks), pleuritic/retrosternal chest pain

+/- weakness, weight loss, anorexia, chills, night sweats, dyspnea

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23
Q

TB physical exam

A

+/- normal

+/- posttussive crackles (classic), LAD, pleural thickening→ dullness/decreased fremitus, clubbing (severe)

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24
Q

TB buzzwords:

A

Exam:
Fever, cough
posttussive crackles
dullness/decreased fremitus

CXR:
apical/posterior upper lobes
miliary pattern
hilar LAD

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25
Q

preferred monotherapy for latent TB

A

INH
Rifampin if can’t tolerate
new guidelines: INH + RPT: no longer monotherapy but suggested bc only 12 doses

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26
Q

Bacille Calmette-Guerin (BCG) Vaccine

A

Intradermal live strain vaccine→ single dose at birth→ protects against severe consequences: meningitis, disseminated TB

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27
Q

Bacille Calmette-Guerin (BCG) Vaccine is recommended for

A

(-) TST and continual exposure

high risk MDR-TB healthcare workers

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28
Q

Bacille Calmette-Guerin (BCG) Vaccine is contraindicated in

A

immunosuppressed, children, HIV+ children

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29
Q

Mantoux tuberculin skin test

A

Forearm intradermal wheel with .1 ml purified protein derivative (PPD)
Read for induration in mm at 48-72 hours
False negatives: 2-8 weeks following exposure

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30
Q

> 15 mm: positive if:

A

Positive for everyone

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31
Q

> 10 mm: positive if:

A

Intermediate risk: recent immigrants, HIV(-) IVDU, mycobacteriology lab personnel, health care providers, high risk medical conditions, <4 years old, children and adolescents exposed to adults at high risk

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32
Q

> 5 mm: positive if:

A

High risk: HIV, recent contact, +CXR, immunosuppressed (steroids), organ transplant

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33
Q

2 step TB skin test (PPD)

A

recommended as initial test for health care workers and individuals requiring periodic retesting. Repeat test in 1-3 weeks, if (+) on 2nd test→ boosted response due to past exposure: TB infection

False positives: Bacillus Calmette-Guerin vaccine→ test with IGRA

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34
Q

Interferon Gamma Release Assays (IGRA): Quantiferon TB Gold and T-Spot TB:

A

measures immune response in blood to TB antigen: IFN-g concentration
Cannot distinguish disease from latent infection

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35
Q

how to collect sputum for TB testing

A

3 specimens 8-24 hours apart with at least 1 in the morning

36
Q

acid fast smear is

A

supportive but nonspecific

37
Q

nucleic acid amplification test is

A

supportive, can’t confirm TB

38
Q

presumed TB, empirically treat while waiting for results of culture

A

both AFB and NAA positive

39
Q

gold standard for TB diagnosis

A 
culture
If (+), do drug susceptibility testing
40
Q

if your patient has a negative TB culture but you remain suspicious

A

treat and monitor response to treatment

41
Q

Confirmed and suspected cases:

A

Report within 24 hours

identify contacts

42
Q

Hallmark of TB on biopsy

A

necrotizing/caseating granulomas

43
Q

Xpert MTB/RIF assay:

A

Automated NAA testing using disposable cartridges, takes 2 hours
→ identifies M tuberculosis DNA and rifampin resistance
Does not replace AFB smear or culture

44
Q

CXR for TB in general

A

Can rule out TB, but cannot determine active vs. latent or rule out other causes

Abnormalities usually seen in apical/posterior upper lobes or superior areas of lower lobe

HIV→ atypical presentation

CT more sensitive (2nd line)

45
Q

abnormalities on CXR of TB are seen in

A

apical/posterior upper lobes

46
Q

CXR of Primary active TB:

A

+/ hilar LAD→ pleural effusions/infiltrates→ cavities

Miliary pattern

47
Q

CXR of Latent TB:

A

Dense nodules/lesions +/-calcification

48
Q

CXR of Reactivation of latent TB:

A

Cavities, infiltrates, possible adenopathy

49
Q

Ranke complex

A

Healed primary pulmonary TB:

  1. Ghon lesion/Focus: calcified parenchymal granuloma (tuberculoma)
  2. Ipsilateral calcified hilar lymph node
50
Q

Histoplasma Capsulatum

A

soil contaminated with bird/bat droppings→ inhalation of fungal spores→ convert to yeast at body temp
Midwestern states, Ohio and mississippi river valleys, Central and South America

51
Q

Histoplasma Capsulatum incubation

A

Incubation: 3-17 days

52
Q

Asymptomatic primary histoplasmosis

A

90%

asymptomatic/mild flu like→ resolve in few weeks/month

53
Q

symptomatic pulmonary histoplasmosis

A

Fever, marked fatigue, few respiratory sx for 6 months

Mild symptoms typically self limited

54
Q

Progressive disseminatedhistoplasmosis

A

Immunocompromised→ fever, marked fatigue, cough, dyspnea, weight loss, multi-organ involvement, fatal within 6 weeks

55
Q

Chronic pulmonary histoplasmosis

A

Older COPD pts→ progressive lung changes→ apical cavities

56
Q

Who to suspect histoplasmosis in

A

pneumonia with mediastinal/hilar LAD, mediastinal/hilar mass, pulmonary nodule, cavitary lung disease, pulmonary symptoms with rheumatologic arthritis/arthralgia and erythema nodosum, dysphagia with esophageal swallowing

57
Q

CXR of histoplasmosis

A

Hilar adenopathy, patchy or nodular infiltrates in lower lobes

Asymptomatic: residual granuloma
Chronic pulmonary: apical cavities

58
Q

Immunodiffusion of histoplasmosis

A

detects acute and chronic

59
Q

complement fixation of histoplasmosis

A

more sensitive, less specific that ID, takes 6 weeks

60
Q

antibody detection of histoplasmosis

A

Enzyme immunoassay (EIA) of urine/serum

61
Q

culture of histoplasmosis

A

severe or chronic disease, takes 6 weeks

62
Q

coccidioidomycosis aka

A

valley fever

63
Q

valley fever causes

A

Coccidioides immitis, coccidioides posadasii
Contaminated soil→ inhalation of spores
Outbreaks: dust storms, earthquakes

Lower deserts of western hemisphere: Southwest US, Mexico, Central and South America

64
Q

histoplasmosis treatment

A

Amphotericin B

Methylprednisolone (respiratory complications)

65
Q

valley fever treatment

A

Typically not required

High risk/serious illness→ azoles
→ no ketoconazole due to side effects
→ teratogenic

Pregnant or severe→ amphotericin B

66
Q

your otherwise healthy patient has valley fever, what’s the treatment of choice

A

nothing, will resolve on its own

67
Q

the only azole you shouldn’t use bc of side effects

A

ketoconazole

68
Q

pregnant+valley fever

A

ampho B

69
Q

pregnant+histoplasmosis

A

gonna guess ampho B is fine since it’s okay for valley fever

70
Q

valley fever follow up

A

every 2-4 weeks for 1 year w/o therapy, 2 years if therapy needed

71
Q

valley fever incubation

A

1-3 weeks

72
Q

% of valley fever which is asymptomatic

A

60%

73
Q

high risk of valley fever, more likely to have disease progress

A

More severe presentation: immunocompromised, DM, pregnant, african, filipino

74
Q

Subacute valley fever

A

mild respiratory symptoms, self limited, weeks to months
Protective from future disease
→ +/- progression

75
Q

Primary infection valley fever presentation

A

CAP 7-21 days after exposure
Fever, cough, pleuritic chest pain, marked fatigue, HA, arthralgia (desert rheumatism), rash: erythema multiforme, erythema nodosum

76
Q

Disseminated disease valley fever

A

Lungs (more pronounced lesions), bone lesions, brain
LAD, meningitis
More likely in high risk group

77
Q

CXR of valley fever

A

+/- hilar adenopathy, patchy nodular pulmonary infiltrates, miliary infiltrates, thin wall cavities

Asymptomatic: residual granuloma

Chronic pulmonary disease:
Residual lung nodules with thin walled cavities→ disappear within 2 years
Chronic cavitary lesions with infiltrates

78
Q

finding of valley fever that can mimic TB on CXR

A

Chronic cavitary lesions with infiltrates

if you see this buzzword look closely at the history

79
Q

Enzyme immunoassay (EIA) for valley fever

A

more sensitive that ID

80
Q

Immunodiffusion (ID) for valley fever

A

more specific, used following a positive EIA

Detects IgM antibodies: recent/active infection

81
Q

Complement fixation (CF) for valley fever

A

Detects IgG antibodies→ assess disease severity

82
Q

Immunodiffusion vs Complement fixation: antibodies, assesses

A

Immunodiffusion: IgM antibodies, recent/active infection

Complement fixation: IgG antibodies, disease severity

83
Q

labs of valley fever

A

eosinophilia with slight leukocytosis

84
Q

Valley fever skin testing

A

Coccidioidin or spherulin

lifelong reactivity, can’t indicate when exposed, not diagnostic

85
Q

sputum culture for valley fever

A

difficult to obtain due to dry cough

Unit 2 Clin Med II (7 decks)

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