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Tuberculosis > TB > Flashcards

TB Flashcards

1
Q

what are the radiologic findings in primary TB?

A

parenchymal involvement
lymphangitis
localized pleural effusion
regional lymphadenitis

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2
Q

what are the radiologic features seen in chronic pulmonary TB?

A 
local exudative TB- most common finding
focal, patch heterogenous consolidation
local fibroproductive TB
Cavitation- hallmark of TB reactivation
Tuberculoma
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3
Q

hallmark of TB reactivation

A

Cavitation

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4
Q

What are the radiologic findings in miliary TB?

A

stippling in both lungs –> coalesce –> richly stippled pattern (Snowstorm effect)

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5
Q

Advantages of IGRA vs TST

A 
IGRA is not affected by BCG
single patient visit
result available in 24hrs
booster phenomenon does not occur
TST used in children less than 5yo
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6
Q

what is most commonly affected in patients with musculoskeletal TB?

A

vertebral body

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7
Q

what are the 4 basic types of bone lesions in TB osteomyelitis?

A

cystic- most common in children
infiltrative
focal erosions
expansile lesions

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8
Q

TB of the joints are mostly

A

monoarticular; large, weight bearing joints

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9
Q

Triad of TB of the joints (phemister)

A

juxtaarticular osteoporosis
peripherally located osseous erosions
gradual narrowing of interosseous space

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10
Q

findings in TB meningitis (Imaging)

A

basal cistern hyperdensity (most specific finding)

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11
Q

most common complication of TB meningitis

A

communicating hydrocephalus

common complication: Ischemic infarct

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12
Q

most effective bactericidal drug

A

Isoniazid and Rifampicin

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13
Q

most potent sterilizing drug available

A

Rifampicin

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14
Q

active against rapidly multiplying TB

A

Pyrazinamide

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15
Q

used together with other drugs to prevent emergence of resistant bacili

A

Ethambutol

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16
Q

effective in reducing time to culture conversion in adults with MDR-TB

A

Bedaquilline

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17
Q

drug effective in increasing the proportion of patients achieving sputum culture concentration after 8 weeks treatment

A

Delamanid

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18
Q

inhibits mycelia acid synthesis

A

Isoniazid

may cause hepatitis
increased risk of hemolysis in G6PD
peripheral neuropathy
discontinue H&R if with ST/ALT >3x

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19
Q

inhibits DNA-dependent RNA polymerase

A

Rifampicin

may cause hepatitis, hypersensitivity, thrombocytopenia, orange discoloration of urine

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20
Q

causes disruption of membrane energy metabolism

A

Pyrazinamide

causes heptotoxicity
requires dose modification in renal toxicity

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21
Q

inhibits transference enzymes involved in cell wall synthesis

A

Ethambutol

causes peripheral neuropathy and optic neuritis

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22
Q

Fixed dose combinations

A

Intensive phase: Rifampicin 75mg + Isoniazid 50mg + Pyrazinamide 150mg

Continuation phase: Rifampicin 75mg + Isoniazid 50mg

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23
Q

mother has TB, can she breastfeed?

A

breastfeeding is encouraged

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24
Q

What to give in pregnant patients with TB

A

HRZE with pyridoxine (B6) at 25mg/day

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25
Q

pregnant LTBI at high risk of developing active TB

A

HIV positive

with contact history reveal tubercular conversion in 2yrs

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26
Q

Asymptomatic pregnant with TST positive result with chest xray

A

give IPT recommended for 9 months; Isoniazid for 6 months with pyridoxine

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27
Q

pregnant with TB disease

A

1st line drugs safe except Streptomycin, Capreomycin, Ethionamide, Fluoroquinolones, Cycloserine

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28
Q

Newborns of TB mothers:

Mother has LTBI

A

give BCG

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29
Q

Newborns of TB mothers:

mother has TB disease

A

if with treatment for 2 weeks or more still rule out congenital TB

If newborn is well, do not give BCG, give IPT x 3 months then perform TST
If TST negative, stop IPT then give BCG
If TST positive, give IPT for 3 months

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30
Q

if mother has EPTB

A

monitor infant for congenital TB

If suspected to have congenital TB: do TST, chest X-ray, lumbar puncture and appropriate
Even if negative, give treatment

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31
Q

Mother has current TB disease and no treatment received

A

Infant should be given Isoniazid
If TB isolate is Isoniazid-resistant: give Rifampicin

send placenta for AFB smear
evaluate for congenital TB
If initial TST is negative, repeat after 3 months
IF TST is positive but chest xray is negative, continue Isoniazid or Rifampicin to complete 6 months
If TST and chest xray are negative; completed treatment: give BCG, discontinue H & R

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32
Q

> /=5mm induration TST is positive in the ff:

A

close contact
chest xray findings suggestive of TB
clinical findings of PTB
immunocompromised state

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33
Q

standard treatment for pregnant women in intensive phase

A

Isoniazid, rifampicin, pyrazinamide, ethambutol (HRZE x 2mos)
Pyridoxine Vitamin B6 at 25mg/day
breastfeeding encouraged
advise mother to feed baby before taking anti-TB drugs

*streptomycin avoided due to ototoxicity

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34
Q

Treatment for asymptomatic pregnant women with positive TST results, normal chest radiographic findings, and recent contact with contagious person

A

Isoniazid Preventive Treatment (IPT)
recommended duration is 9 months
begin in the 1st trimester

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35
Q

management of newborn whose mother has latent TB infection (LTBI)

A

at birth, infant not separated from asymptomatic TST positive mother with negative chest xray; should be given BCG

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36
Q

management of a newborn whose mother has TB disease

A

IF with TB disease but has undergone treatment for 2 weeks or more, presumed to be no longer infectious.
Possibility of congenital TB should be ruled out
*if newborn is well, do not give BCG first, give IPT for 3 mos then do TST.

  • If TST is negative, stop IPT then give BCG
  • If TST is positive baby remains well, IPT for 3 mos
  • if after 6 mos of IPT, baby remains well give BCG
  • If TST is not available and newborn is well, give 6 mod IPT then BCG
  • if mother has not received any tx, give Isoniazid
  • If maternal TB isolate is Isoniazid-resistant, give Rifampicin instead
  • evaluate baby for congenital TB
  • if initial TST is negative, repeat after 3mos
  • if positive TST but chest xray is negative, Isoniazid or Rifampicin continued for 6 mos
  • If TST and chest xray of mother are negative and tx completed, BCG should be given and Isoniazid or Rifampicin discontinued
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37
Q

mother has extrapulmonary disease such as tubercluous meningitis, miliary, bone or joint TB or genitourinary TB

A

infant must be monitored closely for possible congenital TB

  • if suspected to have congenital TB, TST, Chest xray, LP, appropriate cultures
  • regardless of TST result, treatment should be initiated promptly
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38
Q

TB in children with liver disease

A

LFTs should be carried out before initiating anti-TB meds, monitor ALT 2x a week during the 1st 2 weeks
then on a weekly basis until end of second month
and monthly basis thereafter till the end of treatment

  • Isoniazid and Rifampicin are potentially hepatotoxic
  • total dose of Isoniazid should not be more than 10mg/kg/day
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39
Q

TB in children with drug-induced hepatitis

A
  • in children less than 5 yrs old with elevated transaminases less than 5x normal and asymptomatic, stopping drugs not warranted
  • if GI symptoms such as nausea, vomiting, abdominal pain or jaundice noted –>hepatotoxic first-line drugs should be discontinued or modified depending on levels of AST or ALT
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40
Q

Drug induced livery injury definition

A

AST level 3 or more times than upper limit of normal in presence of symptoms or 5x more than the upper limit in the absence of any symptoms

  • AST less than 5x normal = mild toxicity
  • AST of 5-10x more than normal is moderate
  • AST 10x or more than normal is severe
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41
Q

how can we restart giving of anti-TB meds for patients with drug-induced hepatitis

A

restarting done slowly
Rifampicin restarted first bec less likely to cause hepatotoxicity; least hepatotoxic
*if no increase in AST after 1 week, may restart Isoniazid
*if symptoms recur, last drug must be stopped
*if severe hepatitis, PZA must be discontinued and replaced by Ethambutol and INH and Rifampicin continued for 9 mos

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42
Q

TB in children with renal impairment

A

*recommended TB treatment for patients with renal failure or severe renal insufficiency; 2 months HRZE followed by 4 months HR

  • Ethambutol 80% cleared by kidney
  • streptomycin should be avoided in patients with renal failure
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43
Q

should be measured in all patients with renal disease prior to treatment

A

Creatinine clearance

  • timing of administration is important
  • Drugs administered after hemodialysis to prevent loss during dialysis
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44
Q

Antituberculosis drugs that are significantly dependent on renal clearance

A 
Ethambutol
Levofloxacin
Cycloserine
Kanamycin
Capreomycin
Amikacin
streptomycin

*metabolites of pyrazinamide may accumulate

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45
Q

In severe renal impairment with creatinine clearance less than 10ml/min

A
  • reduction of Isoniazid dose to 200mg is recommended

* Ethambutol is given 8hrs before dialysis at 25mg/kg 3x a week when creatinine clearance is between 50 to 100ml/min

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46
Q

cornerstone of diagnostic method for LTBI is

A

TST

*>5mm cut off for patients with HIV

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47
Q

primary diagnostic test in symptomatic people living with HIV

A

Xpert MTB/RIF assay

MTB culture remains a necessary diagnostic tool

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48
Q

Primary prophylaxis for TB in children living with HIV

A
  • Children with HIV more than 12 months of age ; unlikely to have TB disease on symptom based screening and have no contact with TB case:
  • should be offered 6 months of IPT
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49
Q

confirmed HIV-infected infant and children should receive CTX prophylaxis

A
  1. less than 1 year of age regardless of CD4 or clinical status
  2. children 1-5yrs old diagnosed with WHO stages 2, 3, 4 regardless of CD4 or any WHO stage and CD4 <25%
  3. less than 6 years diagnosed with any WHO clinical stage and CD4 <350
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50
Q

minor gastrointestinal upset, anorexia, nausea, abdominal pain

A

Pyrazinamide and Rifampicin

  • continue anti-TB drugs, check doses
  • Give drugs with small meal or just before going to bed
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51
Q

joint pains

A

Pyrazinamide

*NSAIDS

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52
Q

Burning sensation, numbness, tingling in the feet /hands

A

Isoniazid

*Pyridoxine 10mg per 100mg Isoniazid daily

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53
Q

Orange/red unrine

Discolored contact lenses

A

Rifampicin

*Reassurance

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54
Q

Itching, skin rash

A

Thioacetazone (streptomycin, Isoniazid, Rifampicin, Pyrazinamide)

*stop anti-TB drugs

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55
Q

deafness

A

Streptomycin

*stop streptomycin

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56
Q

dizziness, vertigo, nystagmus

A

Streptomycin

*stop streptomycin,, use ethambutol

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57
Q

jaundice

A

pyrazinamide, isoniazid, rifampicin

*stop anti-TB drugs

58
Q

confusion

A

most anti-TB drugs

*stop anti-TB drugs

59
Q

visual impairment

A

Ethambutol

*stop Ethambutol

60
Q

Shock, purpura, acute renal failure

A

Rifampicin

*stop rifampicin

61
Q

may cause petechial rash due to thrombocytopenia

A

Rifampicin

*check platelet count, stop RIF and monitor until it normalizes, RIF should not be restarted

62
Q

if patient taking anti-TB drugs develop rash and has healed, how do we reintroduce?

A

start with Isoniazid at low dose gradually increasing to normal dose within 3 days

63
Q

how to restart anti-TB meds in patients with hepatitis

A

restart with RIF bec it much less likely cause hepatotoxicity and is the most effective agent
*if no increase in ALT after 1 week then restart with INH then Pyrazinamide after 1 week

64
Q

patient taking anti-TB meds has jaundice, when do we resume medications?

A

anti-TB drugs be reintroduced 2 weeks after jaundice has disappeared

65
Q

most common cause of peripheral neuropathy

A

INH&raquo_space;>Ethambutol

*rarely occurs in children unless severe malnutrition is present

66
Q

common cause of optic neuritis

A

Ethambutol&raquo_space; INH

*blurred vision
*“spots” present in patient’s field of vision
red/green color blindness

67
Q

risk of progression from infection to active disease

A

age
time of exposure to initial infection
nutritional status
immunosuppression

68
Q

mycobacteria are

A

aerobic, non-motile and slightly curved or straight bacilli

69
Q

BCG is derived from

A

M. bovis

70
Q

virulence factors for M. tuberculosis

A 
trehalose dimycolate (cord factor) 
sulfatides

Man-LAM- dominant mycobacterial antigen; responsible for enhanced bacilli survival and entry into macrophages

71
Q

classic lesion in primary tuberculosis

A

Ghon focus

72
Q

granulomatous hilar LAD plus Ghon focus =

A

Ghon complex

73
Q

explain the Wallgren’s Timetable of Tuberculosis

A

1-3 months: highest risk for TB meningitis and disseminated and miliary TB
3-7 months: secondary airway involvement due to infected lymph nodes in children younger 5 yrs old
1-3yrs: osteoarticular TB in under 5yrs old
More than 3 yrs: calcification completed
5-25 yrs: renal involvement

74
Q

TB exposure

A

no signs and symptoms
negative TST
(+) exposure

75
Q

TB infection

A

no signs and symptoms

(+) TST

76
Q

TB disease

A

(+) signs and symptoms
(+)TST

classify:
Bacteriologically confirmed
Clinically diagnosed

Pulmonary TB: lung and tracheobronchial tree
Extrapulmonary TB: larynx, pleura, LN, abdomen, GUT, skin, joints and bones, meninges

77
Q

TB lymphadenitis in cervical region

A

Scrofula

78
Q

most severe form of EPTB

A

Tuberculous meningitis

  • subacute
  • high index of suspicion needed
79
Q

stages of TBM: first stage

A

personality changes, fever, irritability listlessness

80
Q

stages of TBM: second stage

A

after 1-2 weeks, increased ICP and cerebral damage appear: drowsiness, stiff neck, cranial nerve palsies, inequality of pupils, vomitig, tache cerebrale, absence of abdominal reflexes and convulsions that may be tonic or clonic, focal or generalized

81
Q

stages of TBM: third stage

A

coma, irregular pulse and respirations and rising fever

82
Q

what are the common neuroimaging findings in Tuberculous meningitis

A 
hydrocephalus (80%)
basal meningeal enhancement
hypodensities
cerebral edema
nodular enhancing lesions
83
Q

most important determinant of outcome in tuberculous meningitis

A

stage of illness

84
Q

most commonly affected in tuberculous spinal meningitis

A

dorsal cord–> lumbar –> cervical

85
Q

in TB of bones and joints, where does lesion usually start?

A

area of endarteritis in the metaphysis of long bones where blood supply is abundant

86
Q

most common skeletal site in TB of spine

A

vertebrae

hip and knee

87
Q

most common location of TB enteritis

A

ileocecal area with extension to mesenteric LN and peritoneum

88
Q

analysis of ascitic fluid with exudative features in TB peritonitis

A
  • elevated protein (25g/dl)
  • ascitic fluid- blood glucose ratio <0.96

*non-tuberculous ascitis >0.96

89
Q

a child is presumed to have active TB if 3 or more of the ff are present:

A

exposure to an adult/adolescent with active TB disease (Epidemiologic)
signs and symptoms suggestive of TB (Clinical)
positive TST (Immunologic)
abnormal chest radiograph suggestive of TB (Radiologic)
lab findings suggestive of TB (histological, cytological, biochemical, immunological and/or molecular) (Laboratory)

90
Q

treat as active TB if:

A

any 3 of the ff:

  1. (+) exposure
  2. (+) TST
  3. (+) s/sx
  4. abnormal chest xray
  5. laboratory findings suggestive of TB
91
Q

most important diagnostic tool in tuberculosis

A

Tuberculin test

92
Q

how do we do Mantoux test?

A

intradermal administration of 0.1 ml solution containing 0.1ug of 5TU of PPD-S or 2 TU of PPD-RT 23

93
Q

A positive TST can be measured accurately for up to

A

7 days

94
Q

negative TST can be read accurately up to

A

72 hours only

95
Q

post-BCG tuberculin reactions develop

A

six to 12 weeks after vaccination

96
Q

post-BCG tuberculin reactions develop

A

six to 12 weeks after vaccination

97
Q

risk factors for acquiring infection

A

household contact with a newly diagnosed smear (+) case
age less than 5 years
Immunocompromised state

98
Q

patient who has never had treatment for TB or who has taken anti-TB drugs for less than 1 month

A

New case

99
Q

patient who has been previously treated with anti-TB drugs for atleast 1 month in past

A

Retreatment case

100
Q

resistant to 1 1st line anti-TB drug only

A

mono-resistant TB

101
Q

resistant to more than 1 1st line anti-TB drug

A

polydrug-resistant TB

102
Q

resistant to at least both INH and RIF

A

Multidrug-resistant TB (MDR-TB)

103
Q

resistant to INH and RIF + any fluoroquinolone + 1 of 4 2nd line drugs

A

Extensively drug-resistant TB (XDR-TB)

104
Q

classic lesion of Primary tuberculosis

A

Ghon focus

105
Q

most common risk factors for progressive primary TB

A

immunossuppression and children <2yrs

106
Q

clinical disease resulting from hematogenous dissemination

A

Miliary tuberculosis

107
Q

most common clinically significant form of disseminated TB

A

Miliary tuberculosis

108
Q

presumptive TB

A

any person with signs and symptoms suggestive of TB
age cut-off: 15 years old
symptoms must last at least 2 weeks
any one with s/sx who is close contact of a know TB case
(+) CXR findings
presumptive extrapulmonary TB

109
Q

Most common EPTB

A

Scrofula/ TB adenitis

Location: anterior cervical space

110
Q

Most severe form of extrapulmonary PTB

A

Tuberculous meningitis

111
Q

A patient with both pulmonary and extrapulmonary TB should be classified as

A

Pulmonary TB

112
Q

What are the CSF findings in Tuberculous meningitis?

A

High opening pressure
50-100 WBC (early:luekocyte/ later: lymphocyte)
Low sugar
High protein (pedicle forms)

113
Q

In EPTB of the joints, where does lesion start?

A

Endarteritis in the metaphysis of long bones

114
Q

Pathognomonic of Pott’s disease

A

Calcification with the abscess

115
Q

Most common area involved in Intestinal TB

A

Ileocecal area

116
Q

Renal TB presents as

A

Painless sterile pyuria with hematuria and albuminuria

Occurs 15-20 years after primary infection

117
Q

Common site of genital TB in females

A

fallopian tubes

118
Q

TST should be postponed at least how many weeks after a live vaccine?

A

4-6 weeks from live vaccine

119
Q

After a bout of measles, mumps, varicella and whooping cough, how many weeks should we delay TST?

A

2 months or 8 weeks

120
Q

TST should be postponed at least how many weeks after a live vaccine?

A

4-6 weeks from live vaccine

121
Q

After a bout of measles, mumps, varicella and whooping cough, how many weeks should we delay TST?

A

2 months or 8 weeks

122
Q

Gold standard for diagnosing TB

A

TB culture

123
Q

In doing gastric lavage, how much sterile water should be injected through the stomach tube?

A

25-50ml

124
Q

Give dose of the 1st line anti-TB drugs

A 
isoniazid 10-15mkday 
Rifampicin 15 (10-20mkday) max 600mg
Pyrazinamide 30 (20-40mkday) 
Ethambutol 20 (15-25mkday)
125
Q

Once TB disease has been excluded, IPT is recommended for the ff:

A

All HIV positive individuals
Children less than 5 years old household contacts of BCTB regardless of TST result
Children less than 5 yrs old who are household contacts of CDTB, if TST is positive

6months course of INH at 10mkdose

126
Q

Prophylaxis for TB in HIV immunocompromised children

A

Less than 12 months: IPT if with household contact

more than 12 months: IPT x 6 months

127
Q

Treatment for TB in HIV children

A

2 HRZE/ 4 HR then additional 6 months of INH
Do not treat with intermittent regimens
Early start of ART
Pyridoxine supplementation

128
Q

Anti-TB drug that causes influenza syndrome

A

Rifampicin

1-2 hours after drug administration

129
Q

3 indications for IPT

A
  1. all children with HIV that was exposed
  2. less than 5yo and exposure with bacteriologically proven TB case regardless of TST result
  3. less than 5yo and exposure with clinically proven TB case after TST result is positive
130
Q

When a patient had TST for possible tuberculosis however returned for reading after 7 days, what should be done?

A

Repeat the skin test ASAP

131
Q

A 4 year old patient was given “window treatment” for Tuberculosis, what could this mean?

A

Negative TST + known exposure to a probably contagious relative

132
Q

What could explain the reason why children having TB disease are not as infectious as adults?

A

Nelson’s : 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 suspend infectious particles of the correct size.

133
Q

When will we repeat Xray after TB treatment?

A

2 months

134
Q

Usual duration of radiologic clearing in PTB

A

6-24 months

135
Q

Which clinical manifestation is most suggestive of childhood TB disease?

A

Recent weight loss

136
Q

What si Man-lam?

A

Enhanced bacilli survival and entry into macrophages

137
Q

Most common organ involve in EPTB

A

Meninges

138
Q

Findings in ascites of TB

A

Elevated protein (>25g/L)
Ascitic fluid to blood ratio <0.96
Non tuberculous: >0.96

139
Q

Criteria for congenital TB

A

One or more of the ff

Present within the 1st week of life
Primary hepatic complex or caseating hepatic granuloma
TB infection of the placenta or endometrial TB in the mother; or exclusion of the possibility of postnatal transmission by excluding TB in other contacts

140
Q

Clues to possibility of congenital TB

A

Unresponsive or worsening pneumonia
Infant born to a mother diagnosed with TB
Infant with high lymphocyte counts in the Csf without an identified bacterial pathogen or fever and hepatosplenomegaly

141
Q

What is presumptive TB in less than 15yo

A

At least 3 of the following:
Cough/wheeze of 2 weeks or more
Unexplained fever 2 weeks or more
Loss of weight or failure to gain weight
Failure to respond to 2 weeks of appropriate antibiotic therapy
Failure to regain previous state of health 2wks after viral infection
Fatigue, reduced playfulness or lethargy

142
Q

What is presumptive TB in 15 yo or older

A

Cough of at least 2 weeks duration with or without the following:
Significant and unintentional weight loss
Fever
Bloody sputum
Chest/back pains not relatable to any musculoskeletal disorders
Easy fatiguability/malaise
Night sweats
Shortness of breath or dob

Unexplained cough of any duration in
Close contact
High risk groups

Tuberculosis (1 decks)

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