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PPS - From Nelson's > TB > Flashcards

TB Flashcards

1
Q

Sixth leading cause of mortality in Philippines

A

TB

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2
Q

T or f

Most of mdr tb cases are new cases

A

False

Most are retreatment

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3
Q

indicated by negative skin test

caused by malnutrition, hiv, steroid, severe TB

A

anergy

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4
Q

TB gene xpert used for what tissues

A

sputum, gastric lavage, csf, lymph node

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5
Q

TB gene xpert not applicable for

A

stool, blood, urine

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6
Q

difference between th1 and th2 response

A

th1 protective role

th2 produce cytokines (humoral immunity)

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7
Q

factors that promote latency TB

A

low oxygen and nutrients

local production of TNF alpha and nitric oxide

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8
Q

key factors for getting TB

A

household contact with newly diagnosed smear +
age <5
immunocompromised state

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9
Q

age with lowest risk of TB

A

5-10 years

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10
Q

transmission of tb

A

droplet

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11
Q

how many bacilli necessary for successful infection

A

5 to 200

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12
Q

lung lesion primary tb

A

ghon focus

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13
Q

time period after primary tb infectioon is highest risk for disseminated tb

A

1 to 3 months

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14
Q

mortality rate of TST (+) versus (-)

A

3 times

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15
Q

classification according to bacteriological status

A

bacteriologically confirmed

clinically diagnosed

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16
Q

most common extrapulmonary sites

A

lymph nodes, bones, joints, liver

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17
Q

which lobe prone to obstruction and atelectasis/hyperaration

A

right middle lobe

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18
Q

most common extrapulmonary tb and most common cause of chronic lymphadenitis in kids

A

tuberculous lymphadenitis

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19
Q

most common location in CLAD

A

anteriro cervical

followed by axillary and supraclavicular

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20
Q

fistula in CLAD seen in

A

10%

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21
Q

most severe form of extrapulmonary tb

A

tuberculous meningitis

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22
Q

CSF in TB meningitis

A

clear, opalescent
5-500 WBC with PMNs first then lymphocytes later
glucose may be low normal in 2nd stage then very low on 3rd stage
protein may be normal initially but becomes high

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23
Q

what do you see if high protein in csf

A

pellicle forms

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24
Q

common findings on CT/MRI

A 
hydrocephalus
meningeal enhancement
hypodensities due too cerbral infarcts
cerebral edema
nodular enhancing lesion
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25
Q

most common location brain tuberculoma

A

infratentorial or at the base of the brain

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26
Q

why are children more prone to pott’s

A

have increased blood supply to growing bones

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27
Q

where is lesion of potts usually located

A

area of endarteritis in the metaphyisis of long bone

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28
Q

most common skeletal site affected by tb

A

spine

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29
Q

most frequent symptom in potts

A

back pain

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30
Q

abdominal lymph node most involved

A

ileocecal

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31
Q

most common form of cutaneous tb

A

scrofuloderma

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32
Q

most common ocular manifestation

A

choroiditis

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33
Q

most frequent GU location in women

A

fallopian tubes

followed by endometrium, ovaries, cervix

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34
Q

definition of congenital TB

A

infant with TB lesion plus ONE or MORE:

  1. present w/in 1st week of life
  2. primary hepatic complex
  3. tb infection of placenta or endometrial tb
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35
Q

how is tb classified

A 
bacteriological status
anatomical site
history of treatment
hiv status
drug susceptability
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36
Q

laryngeal tb with smear positive but no infiltrates on xray

A

extrapulmonary tb

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37
Q

both pulmonary tb plus extrapulmonary component

A

still considered pulmonary tb

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38
Q

definition of new case

A

no tb treatment or has taken it <1 month

isoniazid prophylaxis not counted

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39
Q

definition retreatment case

A

previously treated or started at least 1 month

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40
Q

definition mdr tb

A

resistance to at least both isoniazid and rifampicin

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41
Q

definition xdr tb

A

resistance to any fluoroquinolone and to at least one of three second line drugs

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42
Q

gold standard for diagnosis of tb

A

culture

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43
Q

if absent bacteriologic evidence, may classify as tb if

A

THREE or MORE of ff:

  1. exposure to adult/adol with active tb disease (epidemiologic)
  2. signs and symptoms (clinical)
  3. postivite TST (immunologic)
  4. abnormal CXR (radiologic)
  5. lab findings suggestive of TB (histological, cytological, biochemical, immunological, molecular
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44
Q

definition presumptive TB

A

signs and symptoms of tb or those with cxr suggesting tb

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45
Q

in child below 15 years old, presumptive TB has

A

THREE or more of ff:

  1. cough for 2 weeks
  2. fever for 2 weeks (malaria/pneumonia ruled out)
  3. weight loss
  4. failure to respond to 2 weeks of appropriate antibiotic therapy
  5. failure to regain to previous state of health 2 weeks after viral infection/exanthema
  6. fatigue/lethargy
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46
Q

most important diagnostic in tb

A

tst

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47
Q

most widely used TST

A

Purified protein derivative

PPD RT 23

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48
Q

where to administer TST

A

2 inches below elbow joint in volar aspect of forearm

apply wheal 6-10mmin diameter

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49
Q

how to measure TST

A 
measure induration (palpable raised hardened area)
measure perpendicular to the long axis of forearm
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50
Q

causes of false positives

A 
infection with nontuberculous mycobacteria
previous bcg
incorrect method
incorrect measurement
incorrect strength of antigen
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51
Q

dose of PPD

A

0.1ml 2TU of RT23 = 0.1ml 5TU PPD-S

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52
Q

when do expect kids with bcg vaccination to have waning TST

A

after 5 years

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53
Q

causes of false negatives

A 
infection
vaccination (MMR, polio, varicella)
CKD
malnutrition
malignancy
steroids
newborns
elderly
overwhelming TB infection
stress (surgery, burn)
organ transplant
improper use of tuberculin (storage, administration)
improper reading
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54
Q

TST should be postponed __ weeks after live vaccine

A

4-6 weeks

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55
Q

TST should be delayed __ after bout of measles, mumps, varicella, pertussis

A

2 months

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56
Q

TST should be delayed __ in kids with scabies, impetigo

A

after skin lesions healed

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57
Q

positive TST

A 
15mm if no risk factors
10mm in prevalent areas
5mm if: 
1. malnourished
2. immunocompromised
3.  CXR findings
4. organ transplant
5. close contact with TB
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58
Q

advantage of using IGRA (interferon gamma release assays)

A

requires only single visit

result affected by prior BCG

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59
Q

cxr findings in tb

A

parenchymal focus
lymphadenitis
lymphangitis
pleural effusion

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60
Q

most common cxr findings

A

parenchymal focus

lymphadenitis

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61
Q

bronchial obstruction due to tuberculous lymph nodes may present as

A

hyperaeration
segmental atelectasis
collapse consolidation

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62
Q

cxr of chronic ptb

most common

A

apical and posterior segment of upper lobes

right lung > left lung

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63
Q

cxr miliary tb

A

2mm nodules stipple both lungs

they may coalesce (snowstorm effect)

64
Q

modality of choice for potts vertebra

A

ct

65
Q

modality of choice for potts intervertebral space

A

mri

66
Q

four types of tb osteomyelitis

A

cystic
infiltrative
foacl erosions
expansile lesion

67
Q

most common type tb osteomyelitis in kids

A

cystic

68
Q

spina ventosa

A

bone destruction and periosteal thickening and fusiform expansion of bone

69
Q

modality of choice for tb osteolmyelitis

A

mri
t1 marrow changes low signal intensity
t2 high signal

70
Q

triad of radiograph abnormalities

for TB arthritis

A

PHEMISTER TRIAD
juxtaarticular osteoporosis
peripherally located osseous erosions
gradual narrowing of interosseous space

71
Q

modality of choice for TB meningitis

A

mri

72
Q

predilection of TB in brain

A

interpenduncular and suprasellar cisterns

73
Q

most common complication of tb meningitis

A

communicating hydrocephalus

74
Q

majority of infarcts in brain seen

A

basal ganglia and internal capsule

due to occlusion of small vessels

75
Q

mri for brain tuberculoma

A

T1 - hypointense relative to gray matter
T2 - hyperintense
gad - rim enhancement
solid center in caseous - isointense t1/t2
liquid center t1 hypointense, t2 hyperintense

76
Q

complication of spinal tb meningitis

A

syringomyelia

77
Q

most common radiologic manifestation of abdominal TB

A

lymphadenopathy

most commonly involved: mesentric, omental, peripancreatic

78
Q

most common clinical manifestation of abdominal TB

A

peritonitis

79
Q

thickening of the valve lips with narrowing terminal ileum in abdominal TB

A

Fleischner sign

80
Q

earliest radiologic abnormality in GU TB

A

moth eaten calyx due to erosion

81
Q

primary sign of tb pericarditis

A

pericardial thickening 3mm

82
Q

volume gastric aspirate

A

5-10ml

83
Q

volume gastric lavage

A

25 to 50ml

84
Q

transportation of gastric lavage

A

within 1 hour in room temp

may add 100mg sodium bicarbonate

85
Q

volume of sputum

A

3ml

86
Q

how to collect sputum

A
  1. rinse mouth with water
  2. breathe 3x
  3. cough hard
  4. expectorate in steril vial
87
Q

volume respiratory wash

A

3ml with up to 5ml steril saline
room temp 1 hr
may be stored in fridge if >1hr

88
Q

specimen for tissue

A

add up to 3ml sterile saline
room temp 1 hr
may be stored in fridge if >1hr

89
Q

specimen for blood

A

10ml in yellow top sodium polyanetholsulfonate or green top with heparin

90
Q

specimen for body fluids

A

10-15ml
room temp 1 hr
may be stored in fridge if >1hr

91
Q

specimen for bone marrow

A

10ml in yellow top sodium polyanetholsulfonate
room temp
do not put in fridge

92
Q

specimen for urine

A

40ml, minimum 10-15ml
room temp 1 hr
may be stored in fridge if >1hr

93
Q

most effective bactericidal drugs

A

isoniazid and rifampicin

94
Q

pyrazinamide is only active in

A

acidic environment of macrophages

used in acute inflammation

95
Q

ethambutol prevents

A

resistant bacilli

96
Q

older kids and adolescents use adult dosing when

A

> 25kg

97
Q

MOA of isoniazid

A

10mkday (10-15) max 300mg
bactericidal
inhibits mycolic acid synthesis
inhibits catalase peroxidase enzyme

98
Q

side effect isoniazid

A

hepatitis
hemolysis g6pd def
peripheral neuropathy

99
Q

MOA of rifampicin

A

15mkday (10-20) max 600mg

inhibits dna dependent rna polymerase

100
Q

side effect rifampicin

A

hepatitis
red orange urine
hypersensitivity

101
Q

MOA of pyrazinamide

A

30mkday (20-40) max 2g

disruption of membrane energy metabolism

102
Q

side effect of pyrazinamide

A

hepatitis
hypersensitivity
arthralgia

103
Q

MOA of ethambutol

A

20 (15-25) max 1.2g

inhibits transferase in cell wall synthesis

104
Q

side effect ethambutol

A

reversible optic neuritis

105
Q

moa amikacin kanamycin streptomycin

A

inhibit protein synthesis

106
Q

side effect amikacin kanamycin streptomycin

A

nephro and ototoxic

107
Q

moa capreomycin

A

inhibit protein synthesis

108
Q

side effect capreomycin

A

psychosis

seizure

109
Q

moa ofloxacin levofloxacin moxifloxacin

A

inhibit dna gyrase

110
Q

side effect ofloxacin levofloxacin moxifloxacin

A

tendon rupture

prolonged QT

111
Q

moa prothionamide ethionamide

A

block mycolic synthesis

112
Q

side effect prothionamide ethionamide

A

neurotoxic
hepatotoxic
gynecomastia
reversible hypothyroidism

113
Q

category I

A

pulmo or extra pulmo CNS, bones, jointsNEW
2hrze
4hr

114
Q

category Ia

A

extra pulmo NEW CNS, bones, joints
2hrze
10hr

115
Q

category II

A

pulmo or extra pulmo tb (except CNS, bones, joints)

  1. relapse
  2. treatment after failure (5mo still smear+)
  3. treatment after lost to f/u
  4. prev tx unknown

2hrzes
1hrze
5hre

116
Q

category IIa

A

extra pulmo CNS, bones, joints
2hrzes
1hrze
9hre

117
Q

isoniazid preventive therapy IPT

given to

A
  1. hiv
  2. <5yo with household contact smear (+) regardless of kids TST
  3. <5yo with household contact smear (-) but with kids TST (+)
118
Q

for isoniazid preventive therapy IPT

repeat TST done after

A

3 months
if (-) give BCG
if (+) continue INH to complete 6 months

119
Q

corticosteroids most beneficial when given

A
  1. tb menigitis
  2. tb pericarditis
  3. tb pleural effusion
  4. endobronchial tb
  5. miliary tb
120
Q

how to give corticosteroids in tb

A

prednisone 2kday x 4-6weeks
then taper 1-2 weeks then d/c
for seriously ill give 4mkday MAX 60mg/day

121
Q

definition CURED

A

treatment completed with no evidence of failure and three or more consecutive cultures take at least 30 days apart (-)

122
Q

breastfeeding with TB

A

safe
breastfeed first before taking meds
supplement with pyridoxine

123
Q

asymptomatic pregnant woman with positive TST, normal cxr, and contact with TB

A

isoniazid 9 months, begin after first trimester

124
Q

newborn with asymptomatic mother but mom is TST (+) and normal xray

A

don’t separate

give BCG

125
Q

mom has TB but has completed at least 2 weeks at time of delivery

A

DO NOT GIVE BCG
given ISONIAZID first for 3 months then do TST
if (-) STOP ISONIAZID and give BCG
if (+) and baby is well, continue ISONIAZID for another 3 months -> if after 6mo baby is well, give BCG

if no TST available, give ISONIAZID for 6 months then do BCG

126
Q

mother has current tb but no Tx

A

give ISONIAZID
if mom is isoniazid resistant, give RIFAMPICIN
placenta sent for studies, workup baby
TST (-) then repeat after 3 mo
TST (+) but normal cxr, complete ISONIAZID/RIFAMPICIN 6 months
if TST (-) and CXR (-) and mom completed treatment may stop ISONIAZID/RIFAMPICIN and administer BCG

127
Q

kid with liver problem with tb

A

monitor ALT 2x/week first 2 weeks
then WEEKLY until 2nd month
then MONTHLY until end of tx

128
Q

if pyrazinamide cant be given

A

2mo INH, RIF, ETH
7mo INH RIF
or PZA can be substituted with fluoroquinolone

129
Q

if with liver cirrhosis

A

aminoglycoside, fluoroquinolone, cycloserine for 18-24 months

130
Q

should we stop if kid <5yo, with elevated transaminase 5x but asymptomatic

A

no

131
Q

drug induced liver injury

A

AST 3x elevated with symptoms
or 5x elevated w/o symptoms

AST <5x mild
5-10x moderate
>10x sever

132
Q

how to restart meds in drug induced liver injury

A

one at a time after AST returns to <2x

RIF first, then INH, then PZA

133
Q

caution in renal impairment

A

PZA (metabolites accum) and EMB (cleared renally)

longer dosing interval is needed

134
Q

drug efficiently removed by dialysis

A

pyrazinamide

135
Q

when to administer drugs when ongoing dialysis

A

after dialysis

136
Q

drug not removed by dialysis

A

rifampicin

137
Q

primary prophylaxis in HIV kids

A

kids >12mo old
IPT, no known exposure at home but prevalent
6mo INH

138
Q

t or f

all kids with HIV and TB after completing treatment shoudl received additional 6 mo isoniazied

A

true

139
Q

increased risk smear (+) in DM at hba1c of

A

9% and above

140
Q

interaction of DM drugs and anti kochs

A

need to increase hypoglycemic agents because of increased metabolism cyp450 by rifampicin

141
Q

transplant patients

A

TST prior to transplantation

142
Q

indication of IPT in transplant patients

A
  1. > 5mm before transplantation
  2. A. cxr of old tb, B. hx of inadequate tb tx, C. close contact to person w/ tb, D. recipient of donor with hx of inadequate tb tx
  3. newly infected
143
Q

patient for gastrectomy with TST (+)

A

ideally give INH prophylaxis

144
Q

patient for jejunoileal bypass with TST (+) >10mm

A

ideally give INH prophylaxis 6 mo

145
Q

prior to anti TNF treatment

A

TST done first

146
Q

prophylaxis prior to anti TNF tx

A

6mo INH
3mo INH RIf
AST baseline then q3mo

147
Q

minor rash after taking drugs

A

rif and pza

give diphen, loratadine then continue meds

148
Q

petechial rash after taking drugs

A

check cbc if thrombocytopenia

rifampicin stopped

149
Q

generalized rash after taking drugs

A

stop all meds, give alternate drugs
can be restarted one by one interval 2-3 days
start with INH, rifampicin etc

150
Q

vomiting after taking drugs

A

may give with food

check ALT

151
Q

diarrhea while taking anti kochs

A

stop all

restart one at a time q4 days

152
Q

jaundice after taking drugs

A

stop all
may give streptomycin and ethambutol
order of rechallenge: rif, inh, pza q4days

153
Q

drug fever

A

check if no infection
stop meds, may give alternative
should resolve in 24 hours

154
Q

adverse effect joint pain

A

pza

155
Q

adverse effect flu

A

rifampicin

156
Q

adverse effect neurotoxicity (drowsiness, dizziness, seizures)

A

inh

PPS - From Nelson's (24 decks)

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