Mycobacterial

Question 1

Which species of mycobacterium are associated with lymphadenitis in immunocompetent children?

Answer 1

Mycobacterium avium complex (MAC), and Mycobacterium scrofulaceum

Question 2

What are mycobacterial diseminated infections usually associated with?

Answer 2

HIV infection

Question 3

What value is associated with disseminated MAC disease?

Answer 3

Low CD4+ lymphocyte count

Question 4

What is Lady Windermere syndrome?

Answer 4

voluntary cough suppression that results in stagnation of secretions which is great for the growth of organisms.

Question 5

What is the most common presentation of atypical mycobacteria in immunocompetent pediatric host.

Answer 5

Suppurative cervical or sumbandibular lymphadenoptahy.

Question 6

What is the most common presentation of atypical mycobacteria in children with HIV?

Answer 6

Recurrent and persistent fever and chronic anemia

Question 7

Presentation of Atypical Mycobacteria?

Answer 7

Chronic pulmonary dz resembling TB (adults)
Cervical adenopathy/lymphadenitis in children
Tenosynovitis, bursae, bone and joint infections
Osteomyelitis of the sternum
Disseminated dz in immunocompromised

Question 8

What is the unique MAC syndrome with AIDS?

Answer 8

in the first 1-2 mos. post HAART-Fever and focal MAC Lymphadenitis.
–the immune systems starts to recover the then responds to previously acquired opportunistic infection w/ overwhelming inflam. response

Question 9

W/U for atypical mycobacteria?

Answer 9

Culture-blood or BX, bone marrow on routine media. Better on selective mycobacterial media.
Nucleic acid hybrid probes
PCR
CXR-immunocompetent pt’s mimic TB
CT lung-Bronchiectasis
CT abd-Large retroperitoneal and mesenteric lymph nodes
FNA-confirms

Question 10

What is the best diagnostic tool to use when diagnosing disseminated MAC?

Answer 10

culture of blood and bone marrow or other normally sterile tissues or bf.

Question 11

Surgical Tx. for atypical mycobacteria?

Answer 11

excision of infected nodes recommended for immunocompetent children
I+D of fluctuant abscesses often lead to drinage sinus lasting mos. or years
*“that won’t look pretty on a date”

Question 12

Medical tx. for atypical mycobacteria?

Answer 12

Send to ID
tx includes at least 2 drugs
1st line-Clarithromycin, or Azithromycin
2nd drug Ethambutol preferred

Question 13

TB Pathology?

Answer 13

Mycobacterium tuberculosis

Question 14

What is MDR-TB defined as?

Answer 14

Multi-drug resistant TB-resistance to the 2 most effective first line meds: Isoniazid and rifampin

Question 15

What is definition of XDR-TB

Answer 15

Extensive drug resistant TB is resistant to Isoniazid, rifampin, and second line drugs as well.

Question 16

How is M TB usually contracted?

Answer 16

aerosol exposure through the lungs or mucous membranes

Question 17

What response in the body allows M TB reactivation?

Answer 17

decreased immune response

Disease results from direct bacterial effects and inappropriate host immune response to tubercular antigens

Question 18

Presentation for TB?

Answer 18

Pulm complaints
Infected end organs (kidney, bone, meninges,)
TB lesions-are epithelioid granuloma w/ central caseation necrosis

Question 19

R/f for TB:

Answer 19

HIV
Hx of + PPD
prior TB tx.
Travel
Homlessness

Question 20

Features of active TB:

Answer 20

Cough
Wt. loss/ anorexia
Fever
Night sweats 
Hemoptysis
Chest pain
extrapulmonary involvement

Question 21

Presentation of tuberculous meningitis?

Answer 21

Intermittent/persistent HA for 2-3 weeks
Subtle mental status changes may progress to acme
Fever minimal or absent

Question 22

Skeletal TB presentation

Answer 22

Spine MC site (Pott dz) back pain/stiffness; lower ext. paralysis up to 50% w/ undiagnosed Pott dz.
TB arthritis involves on 1 joint
Rad. changes may not be present for weeks/months

Question 23

Genetourinary TB presentation

Answer 23

Symptoms include flank pain, dysuria and frequency
In men, epidymitis or a scrotal mass
In women - PID, infertility

Question 24

GI TB presentation?

Answer 24

Nonhealing ulcers in mouth or anus
Diffuclty swallowing
Abd pain mimicking pep ulcer dz
malabsorption
pain, diarrhea, hematochezia

Question 25

W/U TB-LABS

Answer 25

sputum-acid fast
CBC
Chem-ALT, AST
Alk phos
Total bili
Uric acid
Creat.
HIV serology 
HCG
HIV screeing

Question 26

W/U TB-RAD

Answer 26

CXR

Question 27

PPD test for TB parameters

Answer 27

• (+) > 15cm in healthy

- (+) > 5cm in immunocompromised

Question 28

What other test is available, albeit more expensive than PPD for testing for presence of TB?

Answer 28

IGRA

Question 29

What are the 3 basic principles for tx of TB?

Answer 29

1. Any regimen must use multiple drugs to which M TB is susceptible
2. Therapy must be taken regularly
3. Therapy must continue for a period sufficient to resolve the illness

Question 30

What 4 drugs are used in new tx of TB?

Answer 30

Isoniazid
Rifampin
Pyrazinamide
ethambutol (or streptomycin)

Question 31

tx protocol for pretreatment of TB?

Answer 31

Should initially receive at least 5 drugs-including:
Isoniazid,
Rifampin
at least 2 new drugs to which the pt has not been exposed.

Question 32

tx of MDR TB?

Answer 32

Initiate tx w/ 3-5 previously used drugs.
Never add single new drug to a failing regimen
Do not use intermittent tx
Surgery
Low threshold for referral to TB centers