TB and Lung Abscess

Question 1

Tuberculosis

Answer 1

-Infects 1/4 of world’s population-1.7 bill
-In 2021, 10.1 million people around the world sick with TB disease -> 1.6 million TB-related deaths worldwide.
-TB disease- actually sick -> different than TB infected (not sick)
-US: estimated 13 million people are infected with M tuberculosis
-Disproportionately among malnourished, homeless, and marginally housed

Question 2

latent TB

Answer 2

90% of TB in US is reactivation
-more common reactivation within first 2 years
-reactivation TB tends to be apical (TB disease tends to be bases)
-can lay dormant anywhere in the body -> potts spine

Question 3

TB transmission

Answer 3

-aerosolized
-inhale airborne droplet nuclei containing viable organisms
-smallest may remain suspended in air for hours
-may reach terminal air passages when inhaled
-organisms reach lungs -> host defenses activated
-some organisms survive and are transported to regional lymph nodes -> host cell mediated immunity is further activated to contain infection

Question 4

immunocompromised vs immunocompetent host

Answer 4

-compromised- spread rapidly -> progression of early active disease is more frequent
-competent- organisms do not find suitable area to proliferate
-survival in areas of high oxygen content/blood flow

Question 5

primary pulmonary tuberculosis: AKA Primary TB disease

Answer 5

-10%
-pt is sick
-Clinical illness directly following infection
-Inhalation of airborne droplets containing viable tubercle bacilli
-Subsequent lymphangitic and hematogenous spread before immunity develops
-Middle and lower lung zones most common
-Severe cases (5%) central portion undergoes necrosis & cavitation develops (progressive primary tuberculosis)

Question 6

Primary tuberculosis: AKA TB infection

Answer 6

-90%
-latent
-Tubercle bacilli reaching alveoli are ingested by alveolar macrophages and T cells.
-T cells and macrophages surround the organisms in granulomas*
-Spreads to regional lymph nodes
-Some may spread to organs but are contained
-Within 3-6 weeks host develops immunity to reinfection but you can still get TB (+ppd) but may not be able to eliminate what is in lung.
-Infection contained but not eradicated (latent TB)

Question 7

secondary or reactivation (or postprimary tuberculosis)

Answer 7

-reactivation TB- latent people got sick
-dormant bacilli (latent TB) reactivate
-more infectious than primary disease due to cavitation
-reactivation occurs if hosts immune defenses impaired
-very infectious
-happens when persons immune system goes down

Question 8

postprimary disease/reactivation

Answer 8

-Usually apical and posterior segments of upper lobes
-Extent of lung involvement varies -> Small infiltrates to extensive cavitary disease
-Up to 1/3 of untreated pts die within few weeks- mos ->Miliary TB- its everywhere
-Others have spontaneous remission or chronic progressively debilitating course (usually)

Question 9

why do we do ppds

Answer 9

-10% with latent infection develop active TB
-50% of these cases occur in the 2 years following primary infection.
-90% of tuberculosis in adults is reactivation

-Immunosuppressed: increased risk
-Up to 50% of HIV-infected patients will develop active tuberculosis

Question 10

clinical feature of active TB

Answer 10

-Slowly progressive: malaise, anorexia, weight loss, fever, and night sweats
-Chronic cough is MC:
-Dry then productive
-Blood-streaked sputum common

-Chest exam:
-No physical findings specific for tuberculosis
-May reveal posttussive apical rales

Question 11

TB diff dx

Answer 11

-Tuberculosis is a great mimic-strongly consider
-Pneumonia
-Malignancy
-Non-tuberculous mycobacterium
-Fungal infection
-Histoplasmosis
-Sarcoidosis- also causes granulomas

Question 12

approach to TB diagnosis

Answer 12

-clinical suspicion for disease -> risk factors, compatible H and P
-meeting clinical criteria:
-order chest radiograph -> if imaging suggest TB…
-order 3 sputum specimens (8 hrs apart) for acid fast baciili AFB smear, mycobacterial culture, and NAA testing (PCR)-> differentiates TB from mycobacterium
-send for culture- will take a long time
-TB skin test or interferon-gamma release assay (IGRA)

Question 13

TB: labs

Answer 13

-Definitive diagnosis:
-M tuberculosis from cultures or by DNA or RNA amplification techniques (PCR)
-Acid-fast bacilli on sputum smear does not confirm a diagnosis -> can also be mycobacterium
-Bronchoscopy
-Routine blood work and testing for HIV, hepatitis-> tx for tb can affect liver

Question 14

drug susceptibility testing of culture isolates is routine

Answer 14

-First isolate of M tuberculosis- neg pressure room until AFB sputum smear is neg
-Treatment regimen is failing
-Sputum cultures that remain positive after 2 months of therapy

Question 15

TB: imaging-CXR

Answer 15

-Primary Pulmonary Tuberculosis (active disease):
-Small homogeneous infiltrates
-Hilar and paratracheal lymph node enlargement
-Segmental atelectasis
-+/- pleural effusion
-Cavitation with progressive primary tuberculosis
-necrotizing granuloma
-active disease- + CXR, latent -
-looks like a pneumonia

Question 16

resolution of active TB CXR

Answer 16

-Resolution of active TB:
-Dense nodules in the pulmonary hila
-Upper lobe fibronodular scarring
-Bronchiectasis with volume loss
-Ghon (calcified primary focus)- calcified granulomas ***
-Ranke (calcified primary focus + calcified hilar lymph node)

Question 17

reactivation tuberculosis: radiographic manifestations

Answer 17

-Reactivation tuberculosis is associated with various radiographic manifestations:
-Fibrocavitary apical disease
-Nodules, and pneumonic infiltrates
-Apical or posterior segments of the upper lobes or in the superior segments of the lower lobe

-“Miliary” pattern:
-Diffuse small nodular densities
-Can be seen with hematologic or lymphatic dissemination of the organism

Question 18

tuberculin skin test

Answer 18

-Identifies individuals who have been infected with M tuberculosis
-Does not distinguish between active and latent infection*
-Diameter of induration not erythema
-look for induration NOT redness

-+ test and when to treat:
->=5mm- pt with…HIV, close contact with exposure, abnormal chest x-ray, immunosuppressed (disease or meds)
->=10mm- pt with…less than 4 years, foreign born country with high incidence, high risk settings, comorbidity
->=15mm- patient with…healthy person with low likelihood of tube TB

Question 19

QuantiFERON-TB hold in-tube (QFT-GIT) assay

Answer 19

-ELISA-based, whole-blood test that uses peptides from 3 TB antigens (ESAT-6, CFP-10, and TB7.7)
-Positive for M. tuberculosis infection if the IFN-gamma response to TB antigens > test cut-off
-Specificity >95%, 80% sensitivity for latent TB
-tell you if your exposed not sick- doesn’t differentiate

-Preferred over TST:
-Received BCG
-Individuals from groups that historically have poor rates of return for TST reading

Question 20

TB treatment

Answer 20

-Nonadherence:
-Causes of treatment failure
-Continued transmission of tuberculosis
-The development of drug resistance

-Directly observed therapy (DOT):
-Preferred for all patients
-when you have active disease you are isolated until sputum is neg and then you still do DOT
-Especially:
-Drug-resistant tuberculosis - very bad
-On antiretrovirals or methadone

Question 21

treatment of tuberculosis in HIV neg person: for primary or reactivation

Answer 21

-Tx is approx 6 mos
-Initial phase: 2-months
-Daily isoniazid, rifampin, pyrazinamide, ethambutol
-If the M tuberculosis is susceptible to isoniazid and rifampin (as shown by culture) ->
-Second phase of therapy:
-Isoniazid and rifampin for a minimum of 4 additional months, with treatment to extend at least 3 months beyond documentation of neg sputum

-Pyridoxine (vitamin B6)- 25-50 mg orally each day -> all pts being treated with isoniazid

Question 22

pyridoxine (vitamin B6)

Answer 22

-25–50 mg orally each day
-All patients being treated with isoniazid
-Reduce central and peripheral nervous system side effects
-Monitor for hepatoxicity
-peripheral neuropathy if not
-isoniazid causes depletion

Question 23

treatment of tuberculosis in HIV + pts

Answer 23

-The CDC has published detailed recommendations for the treatment of tuberculosis in HIV-positive pts
-done by infectious disease doctor
-(1) longer duration of therapy
-(2) drug interactions between rifamycin derivatives
-DOT should be used for all HIV-positive tuberculosis patients

Question 24

tx of drug resistant tuberculosis

Answer 24

-Multidrug-resistant tuberculosis (MDRTB):
-Need expert
-Some experts recommend at least 18– 24 months of a three-drug regimen

Question 25

tx of extrapulmonary tuberculosis

Answer 25

-Same regimens as for pulmonary TB
-Many experts recommend 9 months
-Miliary, meningeal, or bone and joint disease -> Skeletal tuberculosis tx is enhanced by early surgical drainage and debridement of necrotic bone

-Corticosteroid therapy:
-Prevent cardiac constriction from TB pericarditis
-Reduce neurologic complications from TB meningitis

Question 26

before and during tx of TB

Answer 26

-Bilirubin, hepatic enzymes, BUN, creatinine, CBC
-Consider Hep B, C, and HIV

-During treatment:
-Monthly questioning for symptoms of drug toxicity (hepatotoxicity)
-Rash, numbness in hands or feet, jaundice, abdominal pain, nausea, vomiting, or anorexia
-MDRTB should have sputum cultures monthly during the entire course of treatment -> resistance, see if its working

Question 27

tx of latent tuberculosis

Answer 27

-Essential to controlling and eliminating TB
-Reduces risk it will progress to active disease
-Testing targets high risk groups who stand to benefit from tx of latent infection
-Undergo a careful assessment to exclude active disease

-Rifampin (RIF) daily for 4 months*** (just know this)
-Isoniazid (INH) and RIF daily for 3 months
-INH and rifapentine (RPT) weekly for 3 months
-INH daily for 9 months

Question 28

TB prognosis

Answer 28

-Almost all properly treated patients with tuberculosis can be cured.
-Relapse rates are less than 5% with current regimens.
-The main cause of treatment failure is nonadherence to therapy

Question 29

lung abscess

Answer 29

-Pulmonary parenchymal necrosis and cavitation resulting from infection
-Development:
-High microorganism burden
-Inadequate microbial clearance from the airways
-anaerobic bacteria MC- immune response sends fluids and immune cells to flood the alveoli -> aerobic bacteria die but anaerobic can survive
-aerobic bacteria and opportunistic pathogens MC if immunocompromised

Question 30

lung abscess risk factors

Answer 30

-Aspiration MC**
-Periodontal disease
-Alcoholism- no gag reflex when passed out

Question 31

lung abscess presentation + symptoms

Answer 31

-Anaerobic infection: insidious
-Aerobic bacteria: acute and abrupt
-Cough, purulent sputum, pleuritic chest pain, fever, and hemoptysis
-+/- rales or crackles where the abscess is
-Fetid breath, poor dentition
-bad breath

Question 32

lung abscess imaging

Answer 32

-Chest radiograph:
-1-2 thick-walled cavities in dependent areas of the lung
-MC: posterior segment of upper lobes and superior segments of lower lobes
-Air-fluid level common
-laying down aspiration- upper lobe
-standing aspiration- lower lobe
-right lung MC- anatomy

-CT of chest:
-Size and location of the abscess
-Evaluate for additional cavities, empyema, infarction pleural disease
-Blood, sputum cultures, +/- pleural fluid cultures

Question 33

lung abscess dx

Answer 33

-clinical symptoms
-identification of predisposing condition
-chest radiograph/CT findings

Question 34

lung abscess tx

Answer 34

-Start with IV therapy and switch to oral
-oral - Augmentin or Clindamycin up to several months
-Surgery indications:
-Refractory hemoptysis
-Inadequate response to medical therapy

Question 35

lung abscess prognosis

Answer 35

-Pts with typical primary lung abscess (including alcoholics and IVDU) cure rates 90–95%

-Higher mortality rates (up to 75% mortality rate):
-Immunocompromised patients
-Significant comorbidities
-Infection with P. aeruginosa, S. aureus, and K. pneumoniae