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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > TB / Atypical Mycobacteria > Flashcards

TB / Atypical Mycobacteria Flashcards

1
Q

How many people with latent TB go on to have active disease

A

5-10%

In HIV its 10% per year

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2
Q

When is a 5mm on PPD mantoux test positive? Who is 10mm? 15mm?

A

-HIV-positive or immunosuppressed patients
-Recent contacts of TB case
-fibrotic changes on chest radiograph consistent with old healed TB

10mm - pepeople with some risk factor eg immigrants
- work in healthcare

15mm - no risk factors and healthy

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3
Q

Why use Quantiferon-TB to test for latent infection

A

Zero cross-reactivity with BCG

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4
Q

latent TB rx? in HIV? Alternative?

A

6 months isoniazid daily (WHO)
9 months in HIV

Rifampicin for 4 months alternative

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5
Q

What % Tb is pulmonary? What if HIV positive ?

A

85%

In HIV
- PULMONARY– 40%
- EXTRAPULMONARY AND SYSTEMIC 30-40%
- PULMONARY PLUS EXTRAPULMONARY– 20-30%

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6
Q

Which TB usually causes GI TB infection? from?

A

Bovine TB
Consumption of milk

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7
Q

How much TB do you need for a positive AFB in sputum

A

Requires 10,000 organisms/ml
-Often takes 5 months of infection

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8
Q

Best quick way to test for TB

A

Molecular (Xpert MTB/RIF assay) - most specific and tells if rifampicin resistant

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9
Q

Pleural TB best dx if no Xpert MTB/RIF assay

A

Biopsy more sensitive than effusion

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10
Q

Pleural TB best dx if no Xpert MTB/RIF assay

A

Culture effusion - much more sensitive than biosy

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11
Q

Where 90% of TB lymphadenitis? Key Sx

A

Neck and head
Often Systemicall well - With NO fever

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12
Q

3 types of cutaneous TB

A
  1. Primary cutaneous (exogenous source)
    -More like an ulcer
  2. Secondary Acute hematogenous papules and pustules
    * Lupus vulgaris: Multiple nodules and plaques
    on face and neck
  3. Tuberculids
    -Allergic reaction without AFB in the skin
    -Commonly with erythema nodosum
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13
Q

Most common presentation of GU TB

A

“Aseptic” pyuria (50-80%) i

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14
Q

Who has very high rates of developing tb meningitis as their presenting feature in 10%

A

children <1

Pulmonary disease 30-40%
TB meningitis or miliary disease 10%

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15
Q

Prevention of tb in children

A

BCG at birth

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16
Q

Logistic reasons sputum samples are poor for TB diagnosis

A

Smear only analyses 0.1ml
Requires cold chain transportation
Lack of well trained lab technicians

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17
Q

How to improve sensitivity of sputum collection for TB

A

Early morning
Centrifuge
Well trained staff
Fluorescence (auramine) microscopy

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18
Q

Why is fluorescence (auramine) microscpy better than ZN

A

Cheaper
Takes less time
More sensitive

[BUT microscope is much more expensive]

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19
Q

Culture for TB done on?

A

Lowenstein-jensen medium

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19
Q

Culture for TB done on?

A

Lowenstein-jensen medium

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20
Q

ZHeill-neilson stain what do cultured TB look like

A

Cording (like a purple star)

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21
Q

TB Drug sennsitiviy testing is usually using a …. medium? Eg?

A

Liquid - MGIT (Mycobacteria Growth Indicator Tube)

Solid - Eg Lowenstein-Jensen medium
-Add different abx to various tubes

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22
Q

Which is fastest diagnosis of TB

A

Xpert MTB/Rif - also works for csf

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23
Q

Which TB molecular test is read with a naked eye key issue?

A

LAMP - Can do multiple samples at once
Does NOT give any drug resistance

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24
Q

Who could you use a TB urine test for

A

LF-LAM test - Only patients with active disease
HIV positive with CD4 <100
Results in <30mins

Low sensitivities 50% if not above population

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25
Q

Which population is the XpertMTB ultra especially better in? Issue with all xpertmtb vs LAMP or PCR?

A

Hiv positive
If power goes out loose sample unlike pcr - also a bit less robust eg to dust / temperature

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26
Q

Which tb test for rapid screening of big populations eg prison

A

LAMP - Does16 tests at once

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27
Q

TB rx

A

RIPE

RI 6m
PE 2m only

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28
Q

Mono-resistance:
* Poly-resistance:
* Multidrug-Resistant ( MDR-TB): r
* Pre-XDR :
* Extensively Drug Resistant (XDR-TB):

A

Mono-resistance: One single drug

  • Poly-resistance: Multiple drugs but not MDR/RR-TB
  • Multidrug-Resistant ( MDR-TB): At least resistant to INH and Rif
  • Rifampin resistant (RR-TB): Rifampin resistant tuberculosis. Consider equivalent as MDR ~90%.
  • Pre-XDR : MDR/RR-TB + resistant to any fluoroquinolone
  • Extensively Drug Resistant (XDR-TB): MDR/RR-TB + resistant to any fluoroquinolone + one additional Group A drug
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29
Q

which of the 1st line TB drugs is has the highest bacteriocidal activity

A

Isoniazid

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30
Q

Which RIPE TB drug has the best sterilising activity

A

Pyrazinamide
- Kills inactive bacteria in macrophages - > prevents relapse

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31
Q

TB where means you need to extend therapy to 12 months

A

CNS
Bone and joints

To 12 months

[Disseminated only 6months]

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32
Q

In TB meningitis and new diagnosis HIV when start ARV?

A

Not until end of the intensive phase (within 4-8weeks)

Start ARV within 2 weeks if CD4 <50 and prophylactic abx in resource rich setting

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33
Q

Most common acute complications TB meningitis

A

SIADH / cerebral salt wasting - HypoNa in 50%

Vasculitis/stroke ~60% Eg Hemiparesis

Tuburculomas

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34
Q

TB meningitis how to prevent vasculitis

A

Aspirin

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35
Q

Which TB course can be 4 months

A

Rifapentine / INH /PZA / Moxifloxacin

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36
Q

Protrusion of back with bruising clinical name [in Potts]

A

Gibus

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37
Q

What part of vertebrae does pots start on?

A

Lytic destruction of anterior portion of the vertebral body

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38
Q

50% of MDRTB from

A

India
Russia
China

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39
Q

rifampicin-susceptible and isoniazid-resistant
tuberculosis rx? Exemptions?

A

rifampicin, ethambutol, pyrazinamide
and levofloxacin for 6 (or 9) months§

in cases where resistance to rifampicin cannot be
excluded (i.e. unknown susceptibility to rifampicin;
indeterminate/error results on Xpert MTB/RIF);
* known or suspected resistance to levofloxacin;
* known intolerance to fluoroquinolones;
* known or suspected risk for prolonged QT-interval;

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40
Q

MDR TB short course rx

A

BPaLM is 6 months
bedaquiline, pretomanid, linezolid, moxifloxacin

BPaL is 9 months (I’ll B your PaL for longer)

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41
Q

How to make long regime for xdr TB

A

Group A Pick 3
Levofloxacin/Moxifloxacin
Bedaquiline
Linezolid

Add 2 of: Group B
Clofazimine
Cycloserine or
Terizidone

If still don’t have 4 drugs…Add from Group C
Ethambutol
Delamanid
Pyrazinamide
Amikacin
Ethionamide/Prothionamide
Imipenem-cilastatin
Meropenem
PAS

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42
Q

Key side effects linezolid

A

Myelosuppression, peripheral and optic neuropathy

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43
Q

TB resistant to Rif/Isoniazid, fluoro/aminoglycoside =? rx?

A

XDR TB

Individualised long regime
-At least 4 drugs in the intensive phase
-At least 3 drugs when bedaquiline stopped (as max 6m)
-Treat for 15m following culture conversion

Surgery if localised disease
Treatment in hospital

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44
Q

When must you treat TB in a hospital?

A

XDR TB

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45
Q

Household contact rx of MDR TB

A

Moxifloxacin 6 months

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46
Q

Who should get screened for TB in HIV

A

Any 1 of 4 symptoms

current cough, fever, weight loss or night sweats

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46
Q

Who should get screened for TB in HIV

A

Any of 4 symptoms
-current cough, fever, weight loss or night sweats

Crp>5

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47
Q

Benefits of LAM urine POC testing in HIV

A

Picks up most cases of those who would die soon
Cheap test

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48
Q

Rx of TB in HIV? When start ARV?

A

Same as normal RIPE

Start early ARV during TB rx
ALWAYS within 2 weeks if CD4 <50
Or within 8 weeks otherwise

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49
Q

Only side effect of starting ART within 2 weeks of TB therapy

A

Immune reconstruction syndrome (no increase in mortality)

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50
Q

When might you delay ARV slightly in TB-HIV coinfection

A

TB meningitis - wait 4-8 weeks

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51
Q

Best ARV combo for HIV TB? What extra consideration?

A

2 NRTIs
-Tenofovir (TDF)
-Emtricitabine (FTC)

Intergrase inhibitor
-Dolutegravir (DTG)
Double dose as interaction with rifampicin
[Double D]

52
Q

How do kids present differently with TB

A

More variable - Still mostly pulmonary
Lymphadenitis in 40%
Failure to thrive
[Also higher proportion of disseminated/extrapulmonary]

53
Q

Rx TB in kids who are a contact of positive case

A

6 months isoniazid (other options to….)

54
Q

Key indicator a kid has TB

A

Failure to thrive
Especially static weight /weight loss

55
Q

Joint disease in paediatric TB is usually

A

1 joint - usually large Eg Hip/knee

56
Q

What sample can you use in Xpert for kids TB

A

Sputum, gastric aspirate, stool

57
Q

Tb Rx kids? Dosing? When adult doses?

A

Same as adulits
Dosing based on weight - often needs re dosed monthly

Adult dosing when >25kg

58
Q

Key indicator of improvement in kids on TB rx

A

Weight gain

59
Q

When start ART in kids with TB? Other key considerations?

A

ART within 2-8 weeks of starting TB Rx

Cotrimoxazole preventive therapy
Pyridoxine supplement
Nutritional support - eg continue breast feeding until 2yrs (with solid food introduction at 6m)

60
Q

TB drug side effects in kids

A

Rare
[Be aware of hepatotoxicity]

61
Q

When can congenital TB be diagnosed

A

Proven TB in the infant + one of the following:

Lesions in 1st week of life
primary hepatic complex
maternal genital tract or placental tuberculosis
exclusion of postnatal transmission by thorough investigation of contacts

62
Q

Neonatal TB / congenital TB Rx?

A

RIPE for 6 months and for mother

63
Q

When BCG contraindicated in babies

A

preterm <34weeks
weight <2kg

64
Q

Which tb drug may cause thrombocytopenia

A

Rifampicin

65
Q

Which tb drug may cause CN VIII damage and ototoxicitiy

A

Streptomycin

66
Q

Unilateral chain of matted lymph nodes with occasionaly ulcerate =?

A

Tb lymphadenitis

67
Q

Who needs latent TB testing if ASx

A

Household contacts, HIV

68
Q

2 options for screening test for LTBI? if positive?

A

TST / IFGRA

CXR
If neg - treat for latent TB
If positive - screen for active TB

69
Q

If prev BCG + positive PPD …?

A

Treat as positive result

70
Q

Key thing to do with follow up of TB rx

A

Smear test +/- XR after 2 months
[Ideally fluroscopy]

71
Q

Fully suseptible RIPE TB. Positive smear after 2 months plan?

A

Suspicion of Drug resistant - switch to second line regime

Not suspicious [eg pt cliically improved]- c§arry on and switch to continuation phase

72
Q

Pregnant women with TB rx? Which commonly used drug (not in RIPE) is contraindicated? Management of baby?

A

RIPE as normal
with pyridoxine supplement

Sreptomycin is contraindicated - congenital deafness in 17%

Rule out TB (gastric aspirate) in baby then 6 months Isoniazid

73
Q

Differentials of Potts’

A

Brucella
Staph aureus
Salmonella

74
Q

Bar TB meningitis what other TB infection should you use steroids

A

Pericarditis

75
Q

Key thing to exclude in new maculopapular rash starting drug therapy Eg RIPE? When would you re challenge pt

A

Oral / mucosal lesions - SJS

Re challenge if only maculopapular rash
DO NOT re challenge if blisters/bullae/urticaria

76
Q

LFTS to stop TB strugs and re challnge

A

AST/ALT >3x upper limit with Sx
or 5x Upper limit

77
Q

Which TB drug is most common for hepatitis if if <2weeks? >1m of therapy

A

Rifampicin
Pyrazinamide

78
Q

What is the rpoB gene

A

RNA polymerase B sub unit

Mutations = rifampicin resistance

79
Q

What is GenoTypeMTBDR plus ? Benefit over geneXpert ? Issue?

A

Manual PCR test for TB

Gives Rifampicin and Isoniazid resistance

Needs to be sent to regional centre - Biosecuirty level 3

80
Q

Which gene Xpert gives more than rifampicin resistance testing

A

Xpert MTB/XDR
Isoniazid, fluoroquinolones, streptomycin, amikacin, ethambutol..

81
Q

katG and inhA are?

A

Genes that confer isoniazid resistance
[inhA - less resistance but still some]

82
Q

rpoB and katG gene mutations in TB means? Rx?

A

Rifampicin and isoniazid resistance
=MDR TB rx

BPaLM - bedaquiline, pretomanid, linezolid, moxifloxacin
for 6 months

83
Q

2 main risk factors of having MDR TB

A

Previous Rx
Household contact of MDR-TB

84
Q

Bedaquiline and pretomanid class?

A

Bedaquiline - ATP synthase inhibitor
-Bactericidal and sterilising activity

Pretomanid - Nitroimidazole
- Prevents bedaquiline resistance
-Bacteriocidal and sterilising activity

85
Q

What type of TB - Isoniazid, Rifapmpicin and a fluoroquinolone resistance is? rx?

A

Pre-XDR TB

BPaL

86
Q

Who is BPaL not recommended for in MDR TB

A

CNS / Bone/joint / milliary disease as poor penetration

CD4<50

87
Q

“Swimming pool” or “fish tank granuloma”

A

M. marinum
– Optimal growth temp. 30 C

88
Q

Middle age male smokers, often heavy alcohol users. Upper lobe cavitary disease; resembles M. tuberculosis disease

A

MAI, M. kansasii

89
Q

Older nonsmoking females, no apparent underlying disease
RML, lingular bronchiectasis (Lady Windermere Syndrome).
Which non TB mycobacteria?

A

MAI, M. abscessus

90
Q

what am I

A

Rice bodies
Due to granuloma formation in tendon sheaths
-Often mycobacteria (eg MAC) or fungal (eg sporotrichosis)

91
Q

HIV uncontrolled with anaemia neutropenia diarrhoea weight loss
BM biopsy -

A

Globi associated with disseminated MAC (BM biopsy
-All the red is MAC

92
Q

Mycobacterium kansasii rx

A

RIPE

93
Q

What am I if not TB? rx?

A

Scrofula: M scrofulaceum

Rifampin + clary + ethambutol

94
Q

immunocompromised. What do you Suspect in situation of recurrent positive AFB smear and negative routine AFB culture?

A

Mycobacterium hemophilum

[Cipro+ rifabutin+ clarithromycin]

95
Q

Contact with fish tanks at home or work prior to infection.
papulonodular lesion on finger or hand remained confined to the skin and lymphatics resembling sporotrichosis =? rx?

A

Mycobacterium marinum

Clary(or rifampin) + Ethambutol
+ debridement if possible

[Marinum = sea = CE]

96
Q

MAC rx

A

Azithromycin
Ethambutol
Rifampin

[Minimum 12 months]

97
Q

Rx M abscessus/chelonae

A

clarithromycin (l00%)
+linezolid (90%)

[tobramycin (l00%) only IV]

98
Q

Most common finding CT TB meningitis?

A

Normal

Most common abnormal - hydrocephalus

99
Q

How many ml of csf for tb gene expert?

A

Need 6ml =120 drops for good sensitivity

100
Q

Define congenital TB

A

hematogenous spread - umbilical cord or aspiration/ingestion AF at birth

101
Q

Define neonatal TB

A

TB acquired from infectious contact after birth

102
Q

How specific is TB LAM

A

100%
Ie if its positive, you’ve got TB

103
Q

MDR TB CNS rx?

A

CNS penetrating group A
Levo/moxi, linezolid

B - None penetrate

C - meropenem + co-amox
Amikacin

104
Q

Requirements for an anti-TB drug

A

Ability to prevent emergence of resistance in the companion drug, early bactericidal activity, and sterilizing activity

105
Q

Define early bactericidal activity

A

The fall in log (10) colony forming units of mycobacterium tuberculosis per ml sputum per day during the first 2 days of treatment

106
Q

Define sterilizing activity

A

The ability to kill either these non-replicating bacteria or dormant bacteria under hypoxic conditions

107
Q

When do you use corticosteroids in TB

A

As an adjunct when treating TB meningitis and DR TB has been ruled out

108
Q

Who is the 4-month TB rx regimen recommended for?

A

People who are 12 yrs and older
Weight > 40 kg
HIV, CD4 > 100 who are on or planning to be on efavirenz
No contraindications to this regiment
People who have a negative sputum culture, considered to have paucibacillary disease

109
Q

XDR TB additional non-medication treatment

A

Surgery if localized dz
Treat in hospital
Treat HIV
Comprehensive monitoring with full social support to enable adherence

110
Q

Who should receive LTBI treatment for 36 months

A

Adults and adolescents living with HIV, in settings with high TB incidence and transmission who are unknown or have a positive TST

111
Q

How long should pregnant women (at high risk) and children receive treatment for LTBI

A

9 months, daily or twice weekly

112
Q

What are the alternative treatments for LTBI

A

*Just learn isoniazid 6 months

Rifampicin + INH x3 months
Rifapentine + INH weekly x3 months
Rifampicin x3-4 months

113
Q

What are the adverse effects of INH

A

Hepatitis, neuropathy, hypersensitivity, and lupus like syndrome

114
Q

What are the adverse effects of rifampin

A

maculopapular rash, flushing, hepatitis, GI upset, thrombocytopenia, drug interactions (p450 cytochrome interaction)

115
Q

What are the adverse effects of pyrazinamide

A

athralgia, hyperuricemia, GI upset, (late) hepatitits

116
Q

what are the adverse effects of ethambutol

A

retro-bulbar neuritis, rash (rare)

117
Q

what are the adverse effects of streptomycin

A

ototoxicity, dermatological reactions (DRESS, SJS, mouth ulcers)

118
Q

Linezolid adverse effects

A

Myelosuppression, peripheral and optic neuropathy

119
Q

BPaL/BPaLM adverse effects

A

Myelosuppression, peripheral and optic neuropathy (LNZ)
Hepatotoxicity, lactic acidosis, QT prolongation (>500), and pancreatitis

120
Q

Which mycobacteria is wound, skin and soft tissue infections, disseminated and pulmonary infections, particularly in immunocomprosed hosts and a rapid grower?
Rx?

A

M chelonae
Clarithromycin + linezolid

121
Q

Why is sputum in miliary TB often negative

A

It’s interstitial rather than intraalveolar

122
Q

Multi bacillary cutaneous TB - name 3

A

-primary-inoculation TB or tuberculous chancre (by direct inoculation)
-(scrofula) by extension from underlying tissue
-TB periorificialis (by extension)
-acute military TB
-gumma (by hematogenous dissemination).

123
Q

What are the molecular tests for TB

A

Gen Xpert (high sensitivity/Specificity)

TrueNAT (high sensitivity/Specificity)

LAMP (not ideal for high HIV prevalence settings, due to poor sensitivity in smear negative patients, but ideal for mass screenings in low HIV settings)

Line probe Assay ( Hain TEST MTBDR _ resistance to Rif and INH)

124
Q

TB treatment length is extended when?

Drug combo for a 4 month course in pulm tb?

A

Bone / joint / CNS - 9-12 months

Rifapentin / INH / Pyrazidamide / Moxifloxacin

125
Q

Who can get a 4-month regime for TB

A

[Rifapentin / ING / Pyrazidamide / Moxifloxacin]

People who are 12 years and older / Weight > 40 Kg /

People with HIV with CD4 >100 cells, on/planning efavirenz

No interactions between antituberculosis and antiretroviral medications

People who have no contraindications to this regimen

People with a negative sp§utum culture who are considered to have a paucibacillary disease

126
Q

Which of the molecular tests do not cover INH resistance? What does this mean?

A

Gene Xpert or TruNAT alone will miss INH-resistant mycobacteria.

So ideally a Hain test (line probe assay combine for early detection)

127
Q

What is the LAM urine test looking for?

A

lipoarabinomanam

128
Q

Name the group B drugs for TB

A

Clofazimine

Cycloserine OR terizodone

129
Q

INHA confers resistance to?

A

INH and ethionamide

130
Q

Which molecular TB test not favourited in HIV positive

A

LAMP not favorable due to poor sensitivity in smear neg

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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