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Clinical Medicine II > Pulm: Tb, Cocci, Etc. > Flashcards

Pulm: Tb, Cocci, Etc. Flashcards

1
Q

After initial transmission, primary tuberculosis can take ______ weeks to show as positive on PPD skin test…

A

6-8 weeks

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2
Q

In this stage of TB, macrophages ingest tubercle bacilli, creating a granuloma, rendering transmission unlikely

A

latent TB

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3
Q

Latent TB (LTBI) is present in what percent of TB cases?

A

95%

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4
Q

What percent of TB disease (active form) develops from latent TB?

A

5%

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5
Q

Patients with DM are ____ x more likely to develop TB

A

3x

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6
Q

What are 4 important lines of questioning to explore during hx in a potential TB case?

A
  1. immunocompromised?
  2. immigrant from high TB area?
  3. IVDU?
  4. close living quarters?
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7
Q

What are three major sxs of TB?

A

Fever, cough, CP

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8
Q

How long does the cough in TB persist, and what are two other features of the cough?

A

3+ weeks

+/- productive, hemoptysis

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9
Q

What might be heard on auscultation of the lungs in TB?

A

posttussive crackles

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10
Q

On PE, a patient presents with:

Dullness to percussion
decreased fremitus

This is concerning for…

A

TB

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11
Q

What 4 diagnostics are helpful in assessing TB

A
  1. TB testing (TST or IGRA)
  2. CXR
  3. Bacteriological exam
  4. Drug Susceptibility testing
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12
Q

Which TB diagnostic?

  • wheal created with 0.1ml PPD
  • read in 48-72 hours
  • may not present for 2-8 weeks following exposure
A

TST

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13
Q

The following groups are considered TB positive if induration is…

HIV
close contacts
Evidence on CXR
Immunosuppressed
Organ Transplant
A

5+ mm

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14
Q

The following groups are considered TB positive if induration is…

recent immigrants from high TB

IVDU

Mycobacteriology lab personnel

Healthcare workers

medical conditions

< 4yo

children/adolescents exposed to adults at high risk

A

10+ mm

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15
Q

A TB test is considered positive in anybody if it is greater than…

A

15mm

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16
Q

Who should receive 2 step TB testing?

A

healthcare workers

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17
Q

What vaccine may create false positives?

A

BCG

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18
Q

Which TB test measures immune response to TB in blood?

A

IGRA (quantiferon gold, T-Spot)

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19
Q

For the IGRA test, blood is incubated ______ and response is measured

A

TB antigen

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20
Q

When would IGRA be considered instead of TST?

A

compliance/return

BCG vaccination

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21
Q

Can IGRA differentiate between TB disease and latent TB?

A

no

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22
Q

What 4 features on CXR can help diagnose TB?

A
  1. hilar LAD
  2. effusion/infiltrate
  3. cavitation
  4. miliary pattern
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23
Q

Can CXR determine active vs inactive disease?

A

no

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24
Q

The following CXR finding indicates…

dense nodule/lesions with calcification

A

latent TB

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25
Q

The following CXR for TB finding indicates…

cavities
infiltrates
LAD

A

reactivation of latent TB

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26
Q

Where are abnormalities typically seen in the lungs in TB?

A

apical/posterior upper lobes

superior lower lobe

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27
Q

The following on CXR for TB indicates…

  1. calcified parenchymal granuloma
  2. ipsilateral calcified hilar lymph node
A

Healed primary pulmonary TB (Ranke Complex)

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28
Q

What is used for bacteriologic study in diagnosing TB?

A

sputum collection

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29
Q

What is the protocol for sputum collection in TB?

A

3 specimens 8-24 hr apart

1 sample in the morning

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30
Q

What type of bacteriologic study for TB?

Easy/quick
supports Dx, doesn’t confirm
smear

A

acid fast bacilli (AFB)

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31
Q

What type of bacteriologic study for TB?

supports dx, doesn’t confirm

used if high suspicion

cytology

A

Nucleic acid amplification (NAA)

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32
Q

What is the gold standard for diagnosis of TB, but takes weeks for results?

A

culture

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33
Q

You receive a positive AFB and NAA. What action occurs next?

A

begin treatment, presume TB

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34
Q

If culture is positive for TB, how do you proceed?

A

treatment and drug susceptibility testing

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35
Q

If culture is negative, but TB is still suspected, how do you proceed?

A

treat and monitor response

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36
Q

What is hallmark on biopsy for TB?

A

necrotizing granuloma

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37
Q

Which TB test has the following features?

  • automated NAA test
  • uses disposable cartridge
  • identifies TB DNA and rifampin resistane
A

Xpert MTB/RIF assay

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38
Q

What are the advantages to Xpert MTB/RIF assay?

A

2 hours

minimal training

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39
Q

What are the disadvantages for Xpert MTB/RIF assay?

A

cost

doesn’t replace AFB smear or cx

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40
Q

For whom is Xpert MTB/RIF assay indicated?

A

patients with < 3 days of therapy

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41
Q

TB must be reported within ______ hours

A

24 hours

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42
Q

What are the 4 first line drugs for TB?

A

Rifampin
isoniazid
pyrazinamide
ethambutol

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43
Q

What must be part of administering TB drugs?

A

direct observed treatment

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44
Q

Which of the 4 TB drugs has the following side effects?

skin sensitivity

45
Q

Which of the 4 TB drugs has the following side effects?

hepatotoxicity
peripheral neuropathy
fatal hepatitis

46
Q

Which of the 4 TB drugs has the following side effects?

hepatotoxicity
hyperuricemia

47
Q

Which of the 4 TB drugs has the following side effects?

optic neuritis

48
Q

What is the protocol for tx of TB in the initial phase?

A
  1. 4 meds daily x 2 mo

2. repeat CXR, AFB, Cx

49
Q

What is the protocol for tx of TB in the continuation phase?

A
  1. RIF and INH daily or 2x weekly for 4 months
50
Q

HIV extends treatment of TB for…

51
Q

What drug can’t be given to pregnant women?

52
Q

What drug shouldn’t be given to infants and children?

53
Q

What three criteria must be present to not be considered infectious with TB…

A

2 weeks of tx

3 negative sputum cultures

improved sxs

54
Q

Who isn’t allowed to go home while still infectious with TB?

A

if children < 5 or immunocompromised in home

55
Q

TB Tx completion is based on _______ not duration…

A

based on doses

56
Q

The initial phase of TB tx requires how many doses?

57
Q

The continuation phase requires how many doses of TB tx if daily or weekly?

A

126 if daily

36 if weekly

58
Q

What tx for latent TB?

  • preferred for adults/children 12+ yo
  • 12 weekly doses
  • not used in pregnancy
  • uncomplicated HIV
A

INH and Rifapentine

59
Q

What tx for latent TB?

  • 9 month regimen optimum
  • 300mg daily or 900 mg twice weekly
60
Q

What tx for latent TB?

4 month regimen

120 doses daily

given if pt. can’t tolerate INH

61
Q

Does latent TB require tx

62
Q

What 2 types of CP can be common with TB?

A

retrosternal or pleuritic

63
Q

This TB infx doesn’t respond to INH or RIF

64
Q

This TB infx responds to fewer drugs, including fluoroquinolones

65
Q

What tx is available for XDR-TB?

66
Q

What are 4 solutions to the MDR/XDR problem?

A
  1. cure TB 1st time
  2. access to diagnostics
  3. infection control
  4. use 2nd line meds
67
Q

Is the BCG vaccine live?

68
Q

Does BCG prevent TB?

A

no, protects against meningitis and disseminated TB

69
Q

What are 2 contraindications for the BCG vaccine?

A

immunocompromised

pregnancy

70
Q

For whom is BCG vaccine recommended?

A

negative TST, continual exposure

healthcare workers at risk of MDR

71
Q

Where is histoplasma most common?

A

OH and Mississippi river valleys

72
Q

Histoplasma is spread via…

A

bird or bat droppings

73
Q

What patient populations are most at-risk for histoplasma?

A

HIV/AIDS

immunocompromised

74
Q

90% of cases of histoplasma are ______ or flu-like

A

asymptomatic

75
Q

What type of histoplasma infx?

most common in healthy ppl

CXR showing residual granuloma

A

asymptomatic primary histoplasmosis

76
Q

What type of histoplasma infx?

Fever, fatigue, few respiratory sxs

sxs for 1 week to 6 mo

A

acute symptomatic pulmonary histoplasmosis

77
Q

What type of histoplasma infx?

immunocompromised

fatigue, fever, cough, dyspnea, weight loss

fatal w/in 6 weeks

multiple organ involvement

A

progressive disseminated histoplasmosis

78
Q

What type of histoplasma infx?

older COPD patients

progressive lung changes

apical cavity

A

chronic pulmonary histoplasmosis

79
Q

What two antibody tests are available for dx of histoplasmosis?

A

Immunodiffusion test

complement fixation test

80
Q

This Ab test monitors for acute and chronic infx of hisptoplasmosis

81
Q

This Ab test for histoplasmosis is more sensitive, but less specific and may take up to 6 weeks for results

82
Q

What is used in EIA testing for histoplasmosis?

A

urine or serum

83
Q

Besides serology, what other two diagnostics can be used in dx histoplasmosis?

A

biopsy

culture

84
Q

What can be seen on CXR of histoplasmosis?

A

hilar adenopathy

patchy or nodular infiltrates in lower lobes

85
Q

Tx for Acute pulmonary histoplasmosis: mild-moderate

A

< 4 weeks, no tx

4+ weeks Itraconazole PO x 6-12 weeks

86
Q

Tx for Acute pulmonary histoplasmosis: moderate-severe

A

amphotericin B IV x 1-2 weeks

THEN

itraconazole PO x 12 weeks

87
Q

what is added in Tx for Acute pulmonary histoplasmosis: moderate-severe with respiratory complications

A

methylprednisolone IV x 1-2 weeks

88
Q

Tx for progressive disseminated histoplasmosis…

A

amphotericin B IV x 1-2 weeks

THEN

Itraconazole PO x 12+ mo

89
Q

Tx for chronic histoplasmosis?

A

itraconazole PO x 12+ months

90
Q

Tx for HIV/AIDS histoplasmosis?

A

amphotericin B IV x 2 weeks + itraconazole PO maintenance therapy

91
Q

The following are suspicious of what pulmonary disorder?

  1. PNA w/ mediastinal or hilar LAD
  2. mediastinal or hilar mass
  3. pulmonary nodule
  4. cavitary lung disease
  5. pulmonary sx with RA/arthralgia and erythema nodosum
  6. dysphagia with esophageal narrowing
A

Histoplasmosis

92
Q

What percent of valley fever cases are asymptomatic?

93
Q

What 5 groups have the most severe presentation in valley fever?

A

immunocompromised

pregnant women

DM

African/filipino

94
Q

A patient presents with the following, which is concerning for…

Fever, cough, pleuritic CP

Marked Fatigue

erythema multiform/erythema nodosum

A

Cocci, valley fever

95
Q

Disseminated disease in valley fever affects what three tissues?

A

lungs
bones
brain

96
Q

A patient presents with positive cocci and the following sxs, this is concerning for what complication?

lung abscess

bone lesions

lymphadenitis, menigitis

A

disseminated disease

97
Q

What three serologic tests are available for cocci diagnosis?

A

Enzyme immunoassay

Immunodiffusion

Complement fixation

98
Q

which valley fever serology test has the following characteristics:

detects IgG
assess severity

A

complement fixation

99
Q

which valley fever serology test has the following characteristics:

more specific, used after a positive

detects IgM

A

Immunodiffusion

100
Q

This valley fever serology test is more sensative than the ID test…

A

enzyme immunoassay

101
Q

CBC in valley fever can show…

A

eosinophilia, slight leukocytosis

102
Q

What 4 findings on CXR can be present with cocci infx?

A

hilar adenopathy

patchy infiltrate

miliary infiltrate

thin wall cavity

103
Q

How long do thin wall cavities last in VF?

104
Q

What may mimic TB with VF infection?

A

cavitary lesion with infiltrate

105
Q

Who requires treatment for cocci?

A

high-risk/severe illness

106
Q

What is used to treat valley fever?

107
Q

What drug is used to treat cocci in pregnancy?

A

amphotericin B

108
Q

When is f/u required while treating cocci infx?

A

2-4 weeks while treatment, 3-6 mo after, then yearly

109
Q

Pulmonary complaints plus the 3 Es should make you think cocci… what are the 3 Es?

A

erythema nodosum

erythema multiforme

eosinophilia

Clinical Medicine II (31 decks)

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