PPS COMPILED SAMPLEX [PART 5 OF 5] - 652 items total with Rationale

Question 1

“Steroids can be used in TB EXCEPT

a. Pleural thickening in pleural effusion
b. TB meningitis in HIV negative
c. TB pericarditis
d. Miliary TB”

Answer 1

A

“TBIC 2016 p157
The benefit of corticosteroids has been evaluated in the following forms of complicated tuberculosis
1. TB meningitis - reduces vasculitis, inflammation, and intracranial pressure, which may then lead to improved circulation of chemotherapeutic drugs through the brain
2. TB pericarditis - recommended as adjunctive therapy during the first 11 weeks of treatment
3. TB pleural effusion - insufficient data to support routine use. Although steroids do not appear to reduce the development of residual pleural thickening, some studies showed a significantly more rapid resolution of symptoms
4. Endobronchial TB - enlarged mediastinal lymph nodes cause respiratory difficulty or a severe collapse-consolidation lesion, steroids have benefit in reducing the size of the lymph nodes
5. Miliary TB - dramatic improvement with corticosteroid therapy if the inflammatory reaction is so severe that alveocapillary block is present”

Question 2

“Baby was born to a mother with TB.(+) hepatosplenomegaly. On xray, 2-3 mm… Given antibiotic but no response.

a. Congenital TB
b. CMV
c. Bacterial sepsis
d. Toxoplasmosis”

Answer 2

A

“TBIC 2016 p61
Criteria for congenital TB - any infant with a TB lesion and one or more of the following criteria:

1. Present within the first week of life
2. A primary hepatic complex or caseating hepatic granuloma
3. TB infection of the placenta or endometrial TB in the mother or exclusion of the possiblity of postnatal transmission by excluding TB in other contacts

TBIC 2016 p62
A few important clues to the possibility of congenital TB include: unresponsive or worsening pneumonia, an infant born to a mother diagnosed with TB, an infant with high lymphocyte counts in CSF without identified bacterial pathogen or fever/hepatosplenomegaly.

The most common signs and symptoms are: respiratory distress, hepatomegaly and splenomegaly, failure to thrive, prematurity, and low birth weight”

Question 3

“Diagnostic test of choice for child less than 5 years old & immunocompromised?

a. TST
b. NAAT
c. AFB”

Answer 3

A

“TBIC 2016 p184. Approach to TB diagnosis in pediatric HIV
The cornerstone of diagnostic methods for LTBI is the TST, administered by Mantoux test. Because children with HIV infection are at high risk for TB, annual skin testing is recommended to diagnose LTBI. Induration of >=5 mm is considered positive if the child is living with HIV “

Question 4

“Multidrug therapy with ocular disturbance after 4 weeks

a. lsoniazid
b. Rifampicin
c. Pyrazinamide
d. Ethambutol”

Answer 4

D

”"”TBIC 2016 p141-142
Adverse effects of first-line anti-TB drugs

1. Isoniazid
   - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis among G6PD patients
   - inhibits drug metabolizing enzymes, leading to increased risk of phenytoin, ethosuximide, carbamazepine toxicity
2. Rifampicin
   - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thromocytopenia in patients given high dose intermittent therapy), orange discoloration of body fluids
   - induces drug metabolizing enzymes, resulting in decreased plasma levels of some drugs (AEDS, anti-infectives, hormonal therapy agents, corticosteroids, etc)
3. Pyrazinamide
   - nausea, vomiting, most common cause of hepatotoxicity in regimens also containing isoniazid and rifampicin, hypersensitivity reactions, polyarthralgia
4. Ethambutol
   - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision) “””

Question 5

“Skin finding in cutaneous TB?

a. Choroid tubercle
b. Papulonecrotic tuberculids
c. Both of the above
d. None of the above”

Answer 5

B

“TBIC 2016 p58 Table 6.2. Classification of skin tuberculosis in children

Primary - tuberculous chancre, miliary tuberculosis
Secondary - lupus vulgaris, scrofuloderma, tuberculous verrucosa cutis, tuberculous gumma (metastatic abscess), orificial tuberculosis
Tuberculids - micropapular lichen, scrofuloderma, papular-papulonecrotic tuberculis, nodular-nodular tuberculid (erythema induratum)

TBIC 2017 p59
Scrofuloderma is the most common form of childhood cutaneous TB “

Question 6

"Corticosteroids is given in miliary TB for?
A. Prevent strictures
B. Prevent microalveolar block
C. Resorption of pleural fluid
D. None of the above"

Answer 6

B

”"”TBIC 2016 p157
The benefit of corticosteroids has been evaluated in the following forms of complicated tuberculosis
1. TB meningitis - reduces vasculitis, inflammation, and intracranial pressure, which may then lead to improved circulation of chemotherapeutic drugs through the brain
2. TB pericarditis - recommended as adjunctive therapy during the first 11 weeks of treatment
3. TB pleural effusion - insufficient data to support routine use. Although steroids do not appear to reduce the development of residual pleural thickening, some studies showed a significantly more rapid resolution of symptoms
4. Endobronchial TB - enlarged mediastinal lymph nodes cause respiratory difficulty or a severe collapse-consolidation lesion, steroids have benefit in reducing the size of the lymph nodes
5. Miliary TB - dramatic improvement with corticosteroid therapy if the inflammatory reaction is so severe that alveocapillary block is present”””

Question 7

"Highest risk of conversion from infection to active disease?
A. Neonate
B. Infant
C. Toddler 
D.None"

Answer 7

A

“TBIC 2016 p35
There is relative immaturity of the immune system of young children. Those under age 1 year are particularly susceptible to develop tuberculosis, and are at increased risk of developing disseminated disease. Innate and adaptive responses of young children are comparatively weaker, allowing for more serious, advanced disease states.”

Question 8

“Adverse effect of pyrazinamide
A. Arthralgia
B. Leukopenia
C. Cataract”

Answer 8

A

“TBIC 2016 p141-142
Adverse effects of first-line anti-TB drugs

1. Isoniazid
   - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis among G6PD patients
   - inhibits drug metabolizing enzymes, leading to increased risk of phenytoin, ethosuximide, carbamazepine toxicity
2. Rifampicin
   - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thromocytopenia in patients given high dose intermittent therapy), orange discoloration of body fluids
   - induces drug metabolizing enzymes, resulting in decreased plasma levels of some drugs (AEDS, anti-infectives, hormonal therapy agents, corticosteroids, etc)
3. Pyrazinamide
   - nausea, vomiting, most common cause of hepatotoxicity in regimens also containing isoniazid and rifampicin, hypersensitivity reactions, polyarthralgia
4. Ethambutol
   - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision) “

Question 9

“2 yr old diagnosed with TB. No known exposure. No other family member with cough and symptoms. Has a 20-month old cousin he plays with. What will you do with the cousin?
A. Do TST
B. Start INH preventive tx
C. Observe”

Answer 9

B

“TBIC 2016 p152
Isoniazid preventive therapy (isoniazid (10) x6mos) is recommended for:
1. All HIV positive individuals
2. Children < 5 years old who are household contacts of a bacteriologically confirmed TB case, regardless of the TST results
3. Children < 5 years old who are household contacts of a clinically diganosed TB case, if the TST result is positive

TBIC 2016 p153. Refer to algorithm for approach to prophylaxis “

Question 10

"Match with proper dose and max dose of Anti-Koch
A. lnh 10-15mkd/ max400mg/day
B. Rif 10-20mkd / max 600mg/day
C. Pyz 25-30 mkd /  max 2g/day 
D. Eth 20-30 mkd/ 2.5g daily"

Answer 10

B

”"”TBIC 2016 p141-142

Isoniazid (10) 10-15mkd / max 300mg/day
Rifampicin (15) 10-20mkd / max 600mg/day
Pyrazinamide (30) 20-40mkd / max 2g/day
Ethambutol (20) 15-25 mkd / max 1.2g/day”””””””

Question 11

"When will we repeat Xray after TBtreatment?
A.1 month
B. 2 months
C. 3 months
D. 4 months"

Answer 11

C

“TBIC 2016 p100
Duration of followup for patients with primary TB depends on the patient’s clinical status after therapy. Radiologists recommend followup study for as early as 3-6 months or sooner if the patient is not responding to treatment. If patient has a good clinical response, followup xray would be to the clinician’s discretion “

Question 12

“In extrapulmonary TB, which has the shortest interval between infection and clinical manifestation?

a) Meningeal
b) Endobronchial
c) Bones and joints
d) Renal”

Answer 12

A

“TBIC 2016 p43-44
The end of the initial asymptomatic incubation period, around 3-12 weeks after the primary infection, is characterized by hypersensitivity reactions such as fever, erythema nodosum, positive TST, and primary complex on chest xray

1-3 months after the primary infection, following the occult hematogenous spread during the incubation, is the highest risk for TB meningitis and disseminated miliary TB

3-7 months after the primary infection is the period of secondary airway involvement. Large reactive pleural effusions can also occur during this time but more often among children >5 years old

1-3 years after the primary infection is the period of osteoarticular TB in children under 5 years of age, and adult-type disease among adolescents

> 3 years after the primary infection, when calcification has completed, the highest risk period is said to have passed

5-25 years after the initial infection, renal TB may develop “

Question 13

“What is the definitive diagnosis for TB lymphadenitis?

a) CXR
b) Tuberculin skin test
c) Histologic studies through aspirate
d) Culture”

Answer 13

D

“Nelson 21st p1573
A definitive diagnosis of tuberculous adenitis usually requires histologic or bacteriologic confirmation, which is best accomplished by fine needle aspiration for culture, stain, and histology. If FNA is not successful in establishing a diagnosis, excision biopsy of the involved node is indicated. Culture of LN tissue yields the organism in only approximately 50% of cases. “

Question 14

“Which of the anti TB drugs is bacteriostatic?

a. Pyrazinamide
b. lsoniazid
c. Rifampicin
d. Ethambutol”

Answer 14

D

“TBIC 2016 p139
The most effective bactericidal drugs are isoniazid and rifampicin, which are active against all populations of TB bacilli. In addition to its bactericidal effect, rifampicin is also the most potent sterilizing drug available.

Pyrazinamide is only active in the acidic intracellular environment of machophages and in aras of acute inflammation, where it exerts its sterilizing effect. Ethambutol is used together with other drugs to prevent emergence of resistant bacilli “

Question 15

“Compared to XDR-TB, how do you define MDR tb?

a. Resistant to at least isoniazid and rifampicin
b. Resistant to isoniazid
c. Resi stant to isoniazid and rifampicin + 1 of the 3 injectable drugs”

Answer 15

A

”"”TBIC 2016 p72-73
Classification based on Drug Susceptibility Testing
1. Monoresistant TB - resistance to one first line anti-TB drug only
2. Polydrug resistant TB - resistance to more than one first line anti-TB drug (other than both isoniazid and rifampicin)
3. Multi-drug resistant TB - resistance to at least both isoniazid and rifampicin
4. Extensively drug-resistant TB (XDR-TB) - resistance to any fluouroquinolone and at least one of the three second-line injectable drug (capreomycin, kanamycin, and amikacin) in addition to multidrug-resistance
5. Rifampicin-resistant TB (RR-TB) - resistance to rifampicin, detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to rifampicin, whether monoresistance, multi-drug resistance, poly-drug resistance or extensive drug resistance”””

Question 16

“When will you see calcifications in the chest x- ray after treatment of primary TB?

a. 7- 12 months
b. 9-16 months
c. 4-6 months
d. 1-3 months”

Answer 16

A

“TBIC 2016 p100
In the small proportion of chidlren with radiological evidence of the disease, clearing usually occurs within 6 months to 2 years after the institution of therapy.

Calcifications, although not common, may also be found in TB. Calcifications on chest xray may be due to healed, healing, or quiescent infection, thus it should be correlated with the history of treatment”

Question 17

“Reactivity of TST with BCG vaccine wanes after?

a. 2-3 years
b. 5-10 years
c. Lifetime”

Answer 17

B

“TBIC 2016 p85
However, the tuberculin reaction believed to be affected by BCG wanes after 5 years from immunization. About 80%-90% of children who recieved BCG in their infancy ahve non reactive TST at 5 years of age. Studies have shown that infants, children, and adults from countries with intermediate and high TB rates have the same prevalence of significant tuberculin reactions, regardless of BCG status. “

Question 18

“Neonate with hepatomegaly, hilar and mediastinal adenopathies. Most important to consider congenital TB?

a. Maternal and family history of TB
b. Lymphadenopathy
c. TST”

Answer 18

A

“TBIC 2016 p61
A clinican relies on having a high index of suspicion and a detailed history and physical examination. A maternal history of unresolving pneumonia, possible contact with a member of the household with TB, a history of treatment for TB or infection with HIV must be sought. Other vital information include infertility, poor reproductive performance, recurrent abortions, stillbirth, premature rupture of membranes, and preterm labor, which are all established effects of TB in pregnancy. “

Question 19

“Most common site of TB?

a. Liver
b. Lungs
c. Brain”

Answer 19

B

PAG DI MO PA NASAGOT TO NG TAMA EWAN KO NALANG

Question 20

“TB predilection for upper lung due to?

a. High 02 tension and good lymphatic drainage
b. High 02 tension and poor lymphatic drainage
c. Low 02 tension and good lymphatic drainage
d. Low 02 tension and poor lymphatic drainage”

Answer 20

B

“TBIC 2016 p43
The lungs, particularly the apices, are most often affected due to higher oxygen tension and poor lymphatic drainage. “

Question 21

“Mother asymptomatic, + TST, + IGRA,exposure to relative with TB, Normal CXR. Treatment?

a. 6H
b. 9H
c. 10H”

Answer 21

B

“TBIC 2016 p178
Asymptomatic pregnant women with positive TST results, normal chest radiographic findings, and recent contact with a contagious person should be considered for isoniazid preventive therapy. The recommended duration is 9 months. Therapy in these circumstances should begin after the first trimester. However under WHO/DOH-NTP, the mother should be given isoniazid for at least 6 months immediately without delay with pyridoxine supplementation to diminish the risk of peripheral neuropathy. “

Question 22

“Child asymptomatic, with 10 mm induration on TST, negative chest xray and contact with a source case with active TB. Management?
a. 6H
b. 9H
C. 3H”

Answer 22

A

Child has latent TB infection. Treatment is isoniazid secondary prophylaxis for 6 months

Question 23

“Mother with abnormal x ray findings of infiltrates, cough for less than 2 weeks, other work up not indicative of TB (-) TST. What will you do?

a. Separate mother and baby
b. Treat mother as LTBI, no need to separate
c. Close observation of mother and infant.”

Answer 23

C

Mother does not fit the definition of presumptive TB with negative TST. Findings of infiltrates on xray + cough point to community acquired pnuemonia. Close observation of mother and infant is advised

Question 24

Primary defense against TB

Answer 24

MACROPHAGE AND T LYMPHOCYTES

“TBIC 2016 p32
Although there are differences betweeen murine models of TB and human TB disease, there is extensive agreement and experimental support for the following:
1. Macrophages and T lymphocytes are the primary defenses against TB;
2. Antibodies and B lymphocytes have little role, if any, in protecting one against TB
3. The role of neutrophils and NK cells is unclear”

Question 25

Feature of Ghon complex

Answer 25

PERIHILAR LYMPH NODES (and Ghon focus)

”"”TBIC 2016 p95
In primary TB, the following radiographic changes may be seen: parenchymal involvement (primary focus), lymphangitis, localized pleural effusion, and regional lymphadenitis. The primary complex is composed of all the above 4 findings. The most common radiologic finding is lymphadenopathy “””

Question 26

Spread of miliary TB:

Answer 26

LYMPHO-HEMATOGENOUS

“TBIC 2016 p49
Milary tuberculosis refers to clinical disease resulting from the hematogenous dissemination of Mycobacterium tuberculosis. It can arise as a result of progressive primary infection or via reactivation of latent form with subsequent spread. It is considered to be the most common clinically significant form of disseminated tuberculosis which occurs when massive numbers of tubercle bacilli are released into the bloodstream causing disease in two or more organs. “

Question 27

"A child treated with PTB medications for 6 months. Has weight gain, one episode of respiratory tract infection during treatment. CXR post-treatment showed calcification. What will you do?
A. Continue HR for 9 months
B. Discontinue treatment 
C. Repeat CXR
D. Do PPD"

Answer 27

B

Child is treated for TB with xray evidence of calcifications, weight gain, no progression of symptoms. Discontinue treatment

Question 28

“A child who has cough, denies exposure to TB, otherwise asymptomatic. Normal CXR findings, PPD of 12mm after 4 days. What will you do?
A. Start INH for 9 months
B. Observe
C. Start triple anti-Kochs therapy”

Answer 28

A

Child has latent TB infection. Treatment is isoniazid secondary prophylaxis for 6 months

Question 29

Which statement is untrue about PPD?

Answer 29

STRONGLY POSITIVE PPD READING AFTER 5 YEARS OF BCG

“TBIC 2016 p85
A history of BCG vaccine is not a contraindication for TST. Post BCG tuberculin reactions develop 6-12 weeks after administration. BCG and other NTM can bring about tuberculin raeactivity. Reaction sizes caused by NTM are usually <10mm induration.

The tuberculin reaction believed to be affected by BCG wanes after 5 years from immunization. “

Question 30

Which statement is false?

Answer 30

CHILD TO CHILD TRANSMISSION OF PTB

“Nelson 21st p1567-1568
Young children with tuberculosis rarely infect other children or adults. Tubercle bacilli are sparse in the endobronchial secretions of children with pulmonary tuberculosis, and cough is often absent or lacks the tussive force required to spread infectious particles of the correct size. Children and adolescents with adult-type cavitary or endobronchial pulmonary tuberculosis can transmit the organism. “

Question 31

"A newborn with mother treated for TB for 2 weeks. What will you do to the infant?
A. Start INH
B. Separate baby
C. Start HRZ
D. Observe"

Answer 31

A

”"”TBIC 2016 p152
Isoniazid preventive therapy (isoniazid (10) x6mos) is recommended for:
1. All HIV positive individuals
2. Children < 5 years old who are household contacts of a bacteriologically confirmed TB case, regardless of the TST results
3. Children < 5 years old who are household contacts of a clinically diganosed TB case, if the TST result is positive

TBIC 2016 p153. Refer to algorithm for approach to prophylaxis “””

Question 32

“TB drug with ototoxicity

a. lsoniazid
b. Rifampicin
c. Pyrazinamide
d. Streptomycin”

Answer 32

D

“Adverse effects of TB drugs

1. Isoniazid
   - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis among G6PD patients
   - inhibits drug metabolizing enzymes, leading to increased risk of phenytoin, ethosuximide, carbamazepine toxicity
2. Rifampicin
   - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thromocytopenia in patients given high dose intermittent therapy), orange discoloration of body fluids
   - induces drug metabolizing enzymes, resulting in decreased plasma levels of some drugs (AEDS, anti-infectives, hormonal therapy agents, corticosteroids, etc)
3. Pyrazinamide
   - nausea, vomiting, most common cause of hepatotoxicity in regimens also containing isoniazid and rifampicin, hypersensitivity reactions, polyarthralgia
4. Ethambutol
   - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision)
5. Streptomycin (second line TB drug)
   - nephrotoxicity and consequent electrolyte disorders, ototoxicity from CN 8 damage, neuromuscular blockade “

Question 33

“Tb drug which will cause dark urine

a. lsoniazid
b. Rifampicin
c. Pyrazinamide
d. Streptomycin”

Answer 33

B

”"”Adverse effects of TB drugs

1. Isoniazid
   - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis among G6PD patients
   - inhibits drug metabolizing enzymes, leading to increased risk of phenytoin, ethosuximide, carbamazepine toxicity
2. Rifampicin
   - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thromocytopenia in patients given high dose intermittent therapy), orange discoloration of body fluids
   - induces drug metabolizing enzymes, resulting in decreased plasma levels of some drugs (AEDS, anti-infectives, hormonal therapy agents, corticosteroids, etc)
3. Pyrazinamide
   - nausea, vomiting, most common cause of hepatotoxicity in regimens also containing isoniazid and rifampicin, hypersensitivity reactions, polyarthralgia
4. Ethambutol
   - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision)
5. Streptomycin (second line TB drug)
   - nephrotoxicity and consequent electrolyte disorders, ototoxicity from CN 8 damage, neuromuscular blockade “””

Question 34

“Maximum doses of TB drug

a. lsoniazid 10-lSmkd max 400mg
b. Rifampicin 10-20mkd max 500mg
c. Pyrazinamide 20-40mkd max 2g”

Answer 34

C

“TBIC 2016 p141-142

Isoniazid (10) 10-15mkd / max 300mg/day
Rifampicin (15) 10-20mkd / max 600mg/day
Pyrazinamide (30) 20-40mkd / max 2g/day
Ethambutol (20) 15-25 mkd / max 1.2g/day”””

Question 35

“Patient suspected to have TB disease, what examinations will support your diagnosis?

a. PPD 5mm induration, (-) CXR, no lymphadenopathy
b. PPD 5mm, (+) CXR, with lymphadenopathy
c. PPD 10mm induration, (-) CXR, no lymphadenopathy”

Answer 35

B

“TBIC p71 Table 7.1. Spectrum of TB exposure, infection, and pulmonary disease

TB exposure
(+) exposure
(-) signs and symptoms 
(-) TST/IGRA
(-) chext xray 
(-) direct sputum smear microscopy (AFB) 
(-) other diagnostics

TB infection
(+) exposure
(-) signs and symptoms 
(+) TST/IGRA
(-) chext xray 
(-) direct sputum smear microscopy (AFB) 
(-/+) other diagnostics

TB disease 
(+) exposure
(+) signs and symptoms 
(+) TST/IGRA
(-/+) chext xray 
(-/+) direct sputum smear microscopy (AFB) 
(-/+) other diagnostics"

Question 36

“Management of child compliant with TB treatment, asymptomatic, but still with chest x-ray findings

a. Stop treatment
b. Continue for more months
c. Do repeat PPD”

Answer 36

A

“Compliant with treatment and now asymptomatic, classified as treated even if with CXR findings since clearing occurs within 6 months to 2 years after the institution of threapy.

TBIC 2016 p100
In the small proportion of chidlren with radiological evidence of the disease, clearing usually occurs within 6 months to 2 years after the institution of therapy.

Calcifications, although not common, may also be found in TB. Calcifications on chest xray may be due to healed, healing, or quiescent infection, thus it should be correlated with the history of treatment”

Question 37

“On TB treatment with good compliance but with no response, what to do?

a. Do PPD
b. Do TB culture
c. Continue treatment”

Answer 37

B

Since with good compliance however no response to treatment, TB culture is indicated to identify possible drug-resistant TB

Question 38

"What cells are the primary defenses against TB
A. NK cells and macrophages
B. T Lymphocytes and Macrophages
C. B cell and T cell
D. B lymphocytes and NK cells"

Answer 38

B

”"”TBIC 2016 p32
Although there are differences betweeen murine models of TB and human TB disease, there is extensive agreement and experimental support for the following:
1. Macrophages and T lymphocytes are the primary defenses against TB;
2. Antibodies and B lymphocytes have little role, if any, in protecting one against TB
3. The role of neutrophils and NK cells is unclear”””

Question 39

"20 month old patient with TB negative culture. Minimal duration of treatment for MDRTB is
A. 6 months
B. 12 months
C. 18 months
D. 24 months"

Answer 39

C

“TBIC 2016 p171-172
A full treatment course can last for 20-24 months, although some patients are treated for less than 18 months after culture conversion “

Question 40

"MDRTB is active TB disease caused by bacteria that are resistant to
A. lsoniazid
B. Ethambutol
C. lsoniazid and Rifampicin
D. Pyrazinamide"

Answer 40

C

”"”TBIC 2016 p72-73
Classification based on Drug Susceptibility Testing
1. Monoresistant TB - resistance to one first line anti-TB drug only
2. Polydrug resistant TB - resistance to more than one first line anti-TB drug (other than both isoniazid and rifampicin)
3. Multi-drug resistant TB - resistance to at least both isoniazid and rifampicin
4. Extensively drug-resistant TB (XDR-TB) - resistance to any fluouroquinolone and at least one of the three second-line injectable drug (capreomycin, kanamycin, and amikacin) in addition to multidrug-resistance
5. Rifampicin-resistant TB (RR-TB) - resistance to rifampicin, detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to rifampicin, whether monoresistance, multi-drug resistance, poly-drug resistance or extensive drug resistance”””

Question 41

"Which of the following drugs are used in MDRTB prophylaxis
A. lsonizid, Rifampicin, Pyrazinamide
B. Pyrazinamide and Aminoglycoside
C. Pyrazinamide and Fluoroquinolone
D. Rifampicin and Pyrazinamide"

Answer 41

C

“MDR TB is resistant to at least both isoniazid and rifampicin, so these drugs should not be used for prophylaxis

TBIC 2016 p171. Basic principles in the treatment of MDR-TB
Whenever possible, it should have any first line drugs to which the strain is susceptible; it should include an injectable drug; it should also have a quinolone and must consider drug resistance data of an individual or area and the patient’s treatment history when designing a regimen. “

Question 42

“A 1-year old male came to the clinic with a history of exposure to a grandmother with PTB. The past medical history was
unremarkable. His chest x-ray was normal while the Mantoux test was unreactive. You should:
A. Request for gastric aspirate gene x-pert test.
B. Do not start any treatment but repeat the Mantoux test after 3 months .
C. Start H for 3 months followed by a repeat Mantoux test.
D. Observe him further”

Answer 42

C

TBIC 2016 p153. Refer to algorithm for approach to prophylaxis

Question 43

“A 5-year old female had a chest x-ray as part of the requirements for school. The x-ray showed hilar adenopathies & was read as primary tuberculosis. The past medical history was unremarkable. There was no history of exposure to an adult with active PTB. You should:
A. Do a TST.
B. Request for gastric aspirate gene x-pert t est.
C. Start HRZE for 2 months+ HR for 4 months.
D. Observe her further”

Answer 43

A

”
Only with radiologic evidence. Do TST as first line diagnostic.

TBIC 2016 p73
Criteria for the diagnosis of TB (three or more of the following criteria)
1. EPIDEMIOLOGIC - exposure to an adult/adolescent with active TB disease
2. CLINICAL - signs and symptoms suggestive of TB
3. IMMUNOLOGIC - positive tuberculin skin test
4. RADIOLOGIC - abnormal chest radiograph suggestive of TB
5. LABORATORY - laboratory findings suggestive of TB (histological, cytological, biochemical, immmunological and/or molecular) “

Question 44

“A 2-year old male had a TST for possible pulmonary tuberculosis. However, he returned for reading after 7 days. What should you do?
A. Read & interpret the test as is.
B. Repeat the skin test ASAP.
C. Repeat the skin test after 3 months.
D. Start H for 3 months & repeat the test.”

Answer 44

B

“Since patient is past the period of reading of TST, repeat the skin test ASAP

TBIC 2016 p84
The TST should be read between 48 to 72 hours after administration. Positive TST reactions can be measured accurately for up to 7 days, while negatvie TST reactions can be read accurately up to 72 hours only. “

Question 45

"A 15-month old male was scheduled for MMR immunization. His mother noted that his paternal grandfather was diagnosed with PTB during the past week. What should you do?
A. Give MMR & start H for 3 months.
B. Start H & give MMR after 3 months.
C. Give MMR & do a TST after a month.
D. Defer MMR & observe him further"

Answer 45

A

“TBIC 2016 p86
Live virus vaccines against polio, varicella, MMR, rotavirus, or typhoid may cause suppression of the tuberculin reaction. For this reason, the TST should be postponed at least 4 to 6 weeks from a live-vaccine administration. The TST however may be administered at the same time with a live vaccine provided they are injected on different anatomic sites.

It is recommended that the TST be delayed for 2 months after a bout of measles, mumps, varicella, or pertussis. In cases of generalized skin lesions (scabies, impetigo, atopic dermatitis), the TST shoould be delayed until lesions are completely healed.

TBIC 2016 p152
Isoniazid preventive therapy (isoniazid (10) x6mos) is recommended for:
1. All HIV positive individuals
2. Children < 5 years old who are household contacts of a bacteriologically confirmed TB case, regardless of the TST results
3. Children < 5 years old who are household contacts of a clinically diganosed TB case, if the TST result is positive

TBIC 2016 p153. Refer to algorithm for approach to prophylaxis “

Question 46

"Which of the following features is seen in latent tuberculosis?
A. TST induration of 5 mm
B. Hilar adenopathies on chest x-ray
C. Absence of suggestive signs/ symptoms
D. Positive AFB smear"

Answer 46

C

”"”TBIC p71 Table 7.1. Spectrum of TB exposure, infection, and pulmonary disease

TB exposure
(+) exposure
(-) signs and symptoms 
(-) TST/IGRA
(-) chext xray 
(-) direct sputum smear microscopy (AFB) 
(-) other diagnostics

TB infection
(+) exposure
(-) signs and symptoms 
(+) TST/IGRA
(-) chext xray 
(-) direct sputum smear microscopy (AFB) 
(-/+) other diagnostics

TB disease 
(+) exposure
(+) signs and symptoms 
(+) TST/IGRA
(-/+) chext xray 
(-/+) direct sputum smear microscopy (AFB) 
(-/+) other diagnostics"""

Question 47

"Which of the following features would make a presumptive diagnosis of PTB in a 16-year old male?
A. Cough >= 2 weeks
B. Unexplained fever >= 2 weeks
C. Failure to gain weight
D. Reduced activity/ lethargy"

Answer 47

A

“TBIC 2016 p74-75
For patients at least 15 years old and above, presumptive TB has any of the following:

1. Cough of at least 2 weeks duration with or without the following symptoms:
   - significant and unintentional weight loss
   - fever
   - hemoptysis
   - chest/back paints not referrable to any musculoskeletal disorders
   - easy fatigability or malaise
   - night sweats
   - shortness of breath or difficulty of breathing
2. Unexplained cough of any duration in:
   - close contact of a known active TB case
   - high risk clinical groups (ICC/HIV, immunosuppressed, etc)
   - high risk populations (elderly, urban poor, inmates, etc) “

Question 48

"A 30-year old mother was diagnosed with active PTB on the 3RD trimester of pregnancy. What is the appropriate management of her newborn who is apparently well at birth?
A. Do a TST.
B. Give BCG.
C. Request for a chest x-ray.
D. Start H for 3 months."

Answer 48

D

“TBIC 2016 p178-179
If the newborn is well, do not give BCG first. Instead give isoniazid preventive therapy for 3 months. After 3 months, do TST.

If TST is negative, stop IPT and give BCG

If TST is positive and the baby remains well, continue IPT for another 3 months. After 6 months of IPT and the baby remains well, give BCG

If TST is not available and the newborn is well, the newborn should recieve 6 months of IPT followed by BCG immunization.

The mother who has current TB disease but has undergone treatment for at least 2 weeks is presiumed to be no longer contagious at the time of delivery.

Separation is recommended for a mother who has active TB disease and has not recieved treatment. “

Question 49

"Which of the following drugs is NOT hepatotoxic?
A. lsoniazid
B. Rifampicin
C. Pyrazinamide
D. Ethambutol"

Answer 49

D

”"”Adverse effects of TB drugs

1. Isoniazid
   - hepatitis, peripheral neuropathy, allergic skin reactions, possible hemolysis among G6PD patients
   - inhibits drug metabolizing enzymes, leading to increased risk of phenytoin, ethosuximide, carbamazepine toxicity
2. Rifampicin
   - hepatitis, hypersensitivity reactions (including a systemic flu-like syndrome +/- thromocytopenia in patients given high dose intermittent therapy), orange discoloration of body fluids
   - induces drug metabolizing enzymes, resulting in decreased plasma levels of some drugs (AEDS, anti-infectives, hormonal therapy agents, corticosteroids, etc)
3. Pyrazinamide
   - nausea, vomiting, most common cause of hepatotoxicity in regimens also containing isoniazid and rifampicin, hypersensitivity reactions, polyarthralgia
4. Ethambutol
   - peripheral neuropathy and retrobulbar optic neuritis (impairment of visual acuity and red-green color vision)
5. Streptomycin (second line TB drug)
   - nephrotoxicity and consequent electrolyte disorders, ototoxicity from CN 8 damage, neuromuscular blockade “””

Question 50

"What is the recommended treatment for category la tuberculosis?
A. 2HRZ+4HR
B. 2HRZE + 4HR
C. 2HRZE + 10HR
D. 2HRZES + 1HRZE + 5HRE"

Answer 50

C

"TBIC 2016 p151
Cat I - 2HRZE / 4HR
Cat Ia - 2HRZE / 10HR
Cat II - 2HRZES / 1HRZE / 5HRE
Cat IIa - 2HRZES / 1HRZE / 9HRE "

Question 51

“A 5-year old female was diagnosed with PTB based on a positive TST, chronic cough, & suggestive radiologic findings. She was treated with 2HRZ + 4HR with good compliance. She had 2 episodes of URTI while on treatment. After 6 months, she gained
2.5 kg. Her repeat chest x-ray was unchanged. What should you do?
A. Request for culture & sensitivity studies.
B. Extend HR for 3 more months.
C. Start 2HRZE + 4HR.
D. Observe her further”

Answer 51

D

“Child is treated for TB Cat I with good compliance, noted, weight gain, no progression of symptoms, no chronic cough mentioned. Ideally discontinue treatment. Best answer is D

TBIC 2016 p100
In the small proportion of chidlren with radiological evidence of the disease, clearing usually occurs within 6 months to 2 years after the institution of therapy.

Calcifications, although not common, may also be found in TB. Calcifications on chest xray may be due to healed, healing, or quiescent infection, thus it should be correlated with the history of treatment”

Question 52

"The risk of TB disease among immune-competent children is highest if the primary infection was acquired at what age in years?
A. < 1
B. 1-2
C. 2-5
D. 5-10"

Answer 52

A

“TBIC 2016 p40
Age is the most important factor that determines the risk of progression to disease following primary infection among immunocompetent children. Infants are at greatest risk. The risk decreases but remains significant in the second year of life and is lowest in children 5-10 years old. “