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Clin Med II- Exam 2 > TB/Histo/Cocci > Flashcards

TB/Histo/Cocci Flashcards

1
Q

Where else besides the lungs can TB spread?

A

lymph nodes
kidneys
spine
brain

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2
Q

Etiology of TB

A

droplet nuclei inhaled and reach alveoli; exposure usually requires PROLONGED exposure

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3
Q

Progression of TB

A

transmission –> skin test conversion in 6-8 weeks –> primary TB –> spontaneous healing in 6 mo (latent)–> progression w/i 2 yrs, progression after 2 yrs, progression w/ concurrent HIV infection (reactivation )

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4
Q

Latent TB

A

bacteria in body w/o Sx
macrophages ingest TB bacilli creating a barrier (GRANULOMA)
unable to transmit
LTBI may activate if pt becomes immunocompromised and granulomas break down

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5
Q

TB disease

A

Sx w/i weeks or years later when immune system compromised (HIV @ high risk)
Pt CONTAGIOUS!

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6
Q

Risk in normal human w/ no risk factors

A

10% in a lifetime

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7
Q

Risk for TB in DM

A

30% in a lifetime

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8
Q

Risk for TB in HIV individuals

A

7-10% PER YEAR

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9
Q

Testing in TB

A
  1. TST or IGRA
  2. CXR: done if + for skint est; r/o other things
  3. Bacteriological examination: dx microbiology needed with + infection testing
  4. Drug Susceptibility Testing (DST)
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10
Q

Risk factors for RB

A 
HIV
<5 YO
DM
Silicosis
Malnutrition
Substance abuse
immunosuppressive therapy
Immigrant
Injection drug users
close living quarters
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11
Q

Sx of TB

A
  1. Fever
  2. Cough (+/- productive or hemoptysis)
  3. CP (pleuritic or retrosternal)
  • others: weakness, weight loss, anorexia, chills, night sweats, dyspnea
  • extrapulmonary TB depends on location
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12
Q

PE for TB

A

POSTTUSSIVE CRACKLES
dullness/dec fremitus
LAD
Clubbing

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13
Q

Dx for TB

A

Mantoux tuberculin skin test (TST): intradermal in forecarm - create wheal w/ 0.1 ml Purified protein derivative (PPD)

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14
Q

How soon do you read TST?

A

48-72 hours; induration measured

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15
Q

When will TST be positive after exposure?

A

2-8 weeks following exposure

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16
Q

Reading TST

A

> 5 mm: high risk group: HIV, contact w/ TB active indiv, evidence of TB on CXR, immunosuppressed, organ transplant

> 10 mm: immigrant from country w/ high rates, HIV neg injection drug users, mycobacteria lab personnel, high congregate setting, med conditions, children <4, children and adol exposed to high risk adult

> 15mm: + in anyone w/o risk factors

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17
Q

2 Step TB test

A

1st negative, repeat in 1-3 weeks

2nd postive, TB present

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18
Q

How does 2 step work

A

creates boosted response and is likely due to past exposure

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19
Q

What creates false + in 2 step test?

A

BCG (bacillus Calmette-Guerin) vaccine

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20
Q

IGRA

A

quintiferon-TB GOld & T-spot TB

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21
Q

What is IGRA

A

measures immune response in blood to TB; blood incubated w/ TB antigen and response measured (IFN-g concentration)

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22
Q

Limitation of IGRA

A

can’t distinguish between active and latent TB infection;

more expensive than TST

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23
Q

Benefit of IGRA

A

pt. does not have to return for reading

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24
Q

TB CXR primary active

A

Hilar lymphadenopathy*
may progress w/ effusions or infiltrates
cavities seen w/ progressive pulm. TV
miliary pattern!

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25
Q

Latent TB CXR

A

dense nodules or lesions w/ possible calcification

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26
Q

Reactivation of latent TB

A

cavities, infiltrates, and possible adenopathy

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27
Q

Where are TB abnormalities normally found

A

apical/posterior upper lobes*** or superior areas of lower lobes

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28
Q

HIV CXR

A

may have atypical presentation

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29
Q

2nd line imaging

A

CT- more sensitive

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30
Q

Ranke Complex (healed primary pulm TB)

A
  1. Ghon Lesion: calcified parenchymal granuloma (tuberuloma)

2. Ipsilateral calcified hilar lymph node

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31
Q

Ghon lesion

A

calcified parenchymal granuloma

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32
Q

Bacteriological exam (Sputum)

A

3 specimens (8-24 h apart) - @ least 1 in the morning

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33
Q

What do you do once you have sputum samples?

A
  1. Smear: AFB - supports dx
  2. Cytology: nucleic acid ampfliciation test (NAA) - supports dx
  3. Culture *: gold standar - confirms dx but takes 2- 6wks
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34
Q

Final dx of TB based on bacteriological exam

A

+ AFB and NAA: TB presumed, start tx immediately

culture +: TB present, do DST

Culture - and TB still suspected: treat and monitor response to tx

Bx if needed

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35
Q

Bx of TB

A

Necrotizing (caseating) granuloma***

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36
Q

What has necrotizing granulomas?

A

Bx of TB

GPA (granulomatosis w/ polyangiitis)

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37
Q

Xpert MTB/RIF assay

A

automated NAA test using disposable cartridges

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38
Q

What does Xpert MTB/RIB detect?

A

M. tuberculosis DNA and rifampin resistance

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39
Q

Benefits of Xpert MTB

A

Takes only 2 hours

minimal training needed

40
Q

disadvantages for Xpert MTB

A

cost

does not replace AFB smear or culture

41
Q

Tx for active TB

A
  1. isolation, negative pressure
  2. Rifampin, INH, Pyrazinamide, Ethambutol
  3. DOT - direct observed tx
42
Q

SE of rifampin

A

orange secretions

skin sensitivity

43
Q

SE of INH

A

hepatotoxicity (monitor LFT)
peripheral neuropathy
Fatal hepatitis (prego women)

44
Q

How to help peripheral neuropathy associated w/ INH

A

give Vit B6

45
Q

PZA SE

A

hepatotoxicity

Hyperuricemia

46
Q

EMB SE

A

optic neuritis: test visual acuity and color vision

47
Q

Criteria to not be considered infectious

A
  1. 2 weeks of tx
  2. 3 negative sputum smears
  3. sx improve
48
Q

Going home while infectious

A
  • strict follow up
  • no children <5 or immunocompromised living in home
  • unable to travel except to health care visits
49
Q

Active TB doses

A

initial phase for 8 weeks: 56 doses

continuation phase for 18 weeks: 126 doses (daily) or 36 doses (2x weekly)

50
Q

Latent TB tx

A
  1. ) INH: 9 mo (6 mo minimum): 300 mg daily or 900 mg 2x/week; preferred in pregnant and children 2-11
  2. ) INH + Rifapentine (RPT): 12 weekly doses; unable to use in pregnancy; recommended for otherwise healthy patients w/ HIV; preferred adults and children >12 YO
  3. ) Rifampin: 4 mo: 120 doses; given if can’t tolerate INH
51
Q

Preferred Latent TB tx for pregnant women and kids 2-11

52
Q

Preferred Tx for adults and children >12

53
Q

Given to those that can’t tolerate INH

54
Q

MDR TB does not respond to

A

at least INH and Rif

55
Q

Causes of MDR-TB

A

inadequate med or dosing
premature tx interruption
spontaneous mutation

56
Q

XDR-TB

A

responds to even less drugs, including fluoroquinolones

surgery to remove necrotic tissue important but not always available

57
Q

Bacillus Calmette-Guerin (BCG) Vaccine

A

intradermal live vaccine

decrease risk of severe consequences due to TB disease; does not prevent primary infection of activation of LTBI; protects against meningitis and disseminated RB in children

58
Q

Recommendation of BCG vaccine

A

single dose at birth in developing countries (WHO)

children w/ negative TST and continual exposure (CDC) - not recommend giving to HIV positive childre;

health care workers if high risk of MDR-TB

59
Q

Contraindications of BCG Vaccine

A

immunosuppressed

pregnancy

60
Q

Testing w/ BCG vaccine

A

blood test less likely to produce false-positive

TST not contraindicated (may have false +)

61
Q

Fungal Pneumonias

A

Histoplasmosis
Coccidiomycosis

Others: Aspergillus, candida, cryptococcus, blastomycosis, pneumocystis jiroveci

62
Q

Etiology of histoplasmosis

A

soil contaminated w/ bird or bat droppings (inhalation of fungal spores, body temp converts spores to yeast, proliferates in lungs and spreads to lymph or other organs)

Highest rates: midwest: OH and Mississippi River Valleys ***

HIV/AIDS or other immunocompromised indiv.

63
Q

Activity associated w/ histoplasmosis

A 
SPELUNKING
construction
demolition
mining
roofing
farming
gardening
AC unit installation
64
Q

Sx of Histoplasmosis

A

90% asymptomatic
mild flu-like sx
most sx resolve in weeks-a month unless severe

65
Q

Asymptomatic histoplasmosis

A

most common in healthy

CXR: may show residual granuloma

66
Q

Acute symptomatic pulmonary histoplasmosis

A

fever, marked fatigue, few resp. sx
sx: 1 week - 6 mo
Mild sx usually self-limited

67
Q

Progressive disseminated histo

A

pt immunocompromised
fever, fatigue, cough, dyspnea, weigh loss
multiple organ involvement
fatal w/i 6 weeks!

68
Q

Chronic pulmonary histoplasmosis

A

older COPD pts

progressive lung changes: apical cavities

69
Q

Dx for Histo

A

Antibody tests: Immunodiffusion (ID) and complement fixation (CF)

Antigen detection: enzyme immunoassay (EIA)

Bx

Culture: chronic or severe disease; 6 weeks to become +

CXR

70
Q

Immunodiffusion (ID) test

A

tests for acute and chronic infection

71
Q

Complement fixation (CF)

A

may take up to 6 weeks

more sensitive, less specific than ID

72
Q

Enzyme immunoassay (EIA)

A

urine** or serum testing

73
Q

When to do culture for histo

A

chronic or severe disease

74
Q

CXR in histo

A

hilar adenopathy

patchy or nodular infiltrates in lower lobes

75
Q

Cause hilar adenopathy

A

Sarcoidosis
TB
Histo
Cocci

76
Q

Tx for histo

A 
acute mild-mod: no tx
mod-severe: ampho or azole
progressive: ampho or azole
chronic: azole
HIV/AIDS: ampho + azole
77
Q

When to suspect histo

A 
pneumo w/ mediastinal or hilar LAD
mediastinal or hilar mass
pulm nodule
cavitary lung disease
pulm sx w/ arthritis/arthralgia + erythema nodosum
dysphagia w/ esophageal narrowing
78
Q

Valley fever

A

coccidiomycosis

79
Q

Etiology of cocci

A

contaminated soil;

lower deserts of wester hemisphere

outbreaks after dust storm and earthquakes

80
Q

Presentation of cocci

A

lives/recently traveled to endemic area
excavation, construction, gardening, digging
60% asymptomatic
severe in immunocomp, prego, DM, African and filipino

81
Q

Sx of cocci

A

asymptomatic: residual granuloma on CXR

symptomatic: mild resp sx, self-limited, weeks to months
may progress w/ chronic pulm disease or disseminated disease (high risk pts)

82
Q

Primary cocci infection sx

A

CAP 7-21 days after exposure: fever cough, pleuritic CP, fatigue, HA, athralgia (desert rheumaticism)

rash: erythema multiform, erythema nodosum***

83
Q

Disseminated cocci disease

A

immunocompromised

lung findings: abscess
bone lesions
lymphadenitis, meningitis

84
Q

Dx of cocci

A

EIA
ID (more specific: used after EIA; detects IgM antibodies)
CF (detects IgG; assess disease severity)
Labs
Sputum culture
Skin test
CXR

85
Q

detects disease severity

86
Q

detects IgM

87
Q

Labs for cocci

A

Eosinophilia w/ slight leukocytosis

88
Q

Sputum culture for cocci

A

hard to obtain w/ dry cough

89
Q

Skin test for cocci

A

coccidiodin or spherulin - reactivity is life not; not diagnostic

90
Q

CXR for cocci

A

hilar adenopathy
patchy, nodular pulm infiltrates
miliary infiltrates
thin wall cavities

91
Q

Chronic pulmonary disease w/ cocci CXR

A

residual lung nodules w/ thin walled cavities (disappear w/i 2 years)
chronic cavitary lesions w/ infiltrates (may mimic TB)

92
Q

Tx for cocci

A

not typically required; only required in high risk/severe

sx therapy: -azole; ampho if severe or pregnant

93
Q

teratogenic

94
Q

f/u for cocci

A

every 2-4 weeks (regardless of tx provided)
sx resolve in weeks to months: continue to follow every 3-6 mo

no med: f/u for 1 year
meds: f/u annually for 2+ years for potential recurrence

95
Q

think cocci

A

pulm complaints AND:

  • erythema nodosum
  • erythema multiforme
  • eosinophilia

Clin Med II- Exam 2 (7 decks)

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