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X Clin Med II Exam 2 > TB, Histoplasmosis and Cocci > Flashcards

TB, Histoplasmosis and Cocci Flashcards

1
Q

What is the number 1 killer of the HIV pt?

A

TB

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2
Q

Where does mycobacterium affect?

A

Mostly the lungs (can be lymph nodes, kidneys, spine or brain)

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3
Q

How is TB transmitted?

A

Through airborne droplet nuclei
Occurs when inhaled nuclei reach the alveoli
Usually requires prolonged exposure from active TB

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4
Q

What is active TB classified as?

A

Disease sxs that occur within 2 yrs of transmission

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5
Q

What is a latent TB infection?

A

Macrophages ingested tubercle bacilli and created barrier shell called a granuloma so that pt is unable to transmit infection to others

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6
Q

When does LTBI become a disease state?

A

If pt becomes immunocompromised and granulomas break down because immune system is unable to fight the infection

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7
Q

What percent of TB cases are active?

A

10% (5 initially and 5 develop from latent)

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8
Q

Who else is at higher risk of developing active TB?

A

Pts with diabetes

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9
Q

When is CXR recommended?

A

With positive infection testing or sxs present

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10
Q

Who is at greater risk for TB?

A

Immunocompromised (HIV, <5, DM, silicosis, malnutrition, substance abuse, immunosuppressive therapy)
Immigrants from areas with high TB prevalence
Injection drug users
Close living quarters (nursing homes, institutions etc)

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11
Q

Sxs of TB

A

Fever
Cough (3+ weeks, maybe productive or hemopytis)
Pleuritic or retrosternal CP
May have weakness, weight loss, anorexia, chills, night sweats, dyspnea or extrapulm manifestations

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12
Q

What is seen on the physical exam with TB?

A 
*might be normal
Classic is posttussive crackles
Dullness or decreased fremitus if pleural thickening
LAD
Clubbing if severe
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13
Q

What is the Mantoux tuberculin skin test?

A

Create wheal with .1 ml purified protein derivative in forearm intradermally
Rd 48-72 hrs later and measured mm
(may not be present for 2-8 wks after exposure)

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14
Q

What is measured on the TB skin test?

A

Induration not erythema

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15
Q

Who is positive based on TB skin test rxn > 5mm?

A 
HIV positive pts
Recent contacts of those with active TB
Persons with evidence of TB on CXR
Immunosuppressed pts (chronic steroids)
Organ transplant pts
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16
Q

Who is positive based on TB skin test rxn > 10mm?

A

Recent immigrants from countries with high rate of TB infection
HIV negative injection drug users
Mycobacteriology lab personnel
Residents/employees of high risk congregate settings
Persons with certain high risk medical conditions
Kids <4
Kids and adolescents exposed to adults at high risk

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17
Q

Who is positive based on TB skin test rxn >15mm?

A

Everyone!!!

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18
Q

What is the 2 step TB test?

A

Recommended as initial test for health care workers and individuals that need periodic retesting
1st neg: repeat in 1-2 wks
2nd pos: TB infection is present and this creates a boosted response likely due to past exposure so don’t see a false positive

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19
Q

What might create a false positive on TB skin test?

A

Bacillus Calmette-Guerin vaccine

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20
Q

What is the IGRA:Quantiferon gold test?

A

Measures immune response in blood to TB because blood is incubated with TB antigen
Used when pt won’t follow up or if they have BCG vaccine
Neither can differentiate active and latent disease
More expensive

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21
Q

What is seen on a CXR in TB?

A

Hilar LAD or normal
May progress to pleural effusions or infiltrates
Cavities seen in progressive pulm TB
Miliary pattern
Cannot determine between active and latent

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22
Q

What is normal for latent TB on CXR?

A

Dense nodules or lesions with possible calcifications

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23
Q

What is seen for reactivation of latent TB on CXR?

A

Cavities, infiltrates and possible adenopathy

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24
Q

Where is the most common place to see abnormalities on CXR?

A

Apical/posterior upper lobes mostly (or superior areas of lower lobe)

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25
Q

What is Ranke complex?

A

Healed primary pulmonary TB with Ghon lesion (calcified parenchymal granuloma) and ipsilateral calcified hilar lymph node

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26
Q

How do you collect sputum?

A 
3 specimens (8-24 hrs apart)
At least one in the morning because that is the best specimen
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27
Q

3 ways to test sputum

A

Smear (acid-fast bacilli, easy and quick, supportive)
Cytology (nucleic acid amplification test, supportive)
Culture (gold standard to confirm dx but takes a long time)

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28
Q

What does it mean if AFB and NAA are both positive?

A

TB disease is presumed and tx begins (do not delay while waiting for culture)

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29
Q

What does it mean if the culture is positive?

A

TB disease is present (use drug susceptibility testing)

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30
Q

What does it mean if culture is negative and TB disease still suspected?

A

Treat and monitor response to tx

31
Q

What is the hallmark of TB on biopsy?

A

Necrotizing (caseating) granulomas

only if needed

32
Q

What is the Xpert MTB/RIF assay used for?

A

IDs M tuberculosis DNA and rifampin resistance (NAA test with cartridges)
Quick but costly
Approved for dx in pts with < 3 days of therapy

33
Q

Where are active TB pts treated?

A

Isolated, negative pressure inpatient hospital room

34
Q

First line drugs for active TB

A 
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
All with direct observed treatment
35
Q

Side effects of rifampin

A

Orange secretions

Skin sensitivity

36
Q

Side effects of isoniazid

A 
Hepatotoxic
Peripheral neuropathy (give vit B6)
Fatal hepatitis (pregnant women at increased risk)
37
Q

Side effects of pyrazidamide

A

Hepatotoxic
Hyperuricemia
Not in pregnancy!!

38
Q

Side effects of ethambutol

A

Optic neuritis (test visual acuity and color vision)

39
Q

Initial and continuation phase of TB tx

A

Initial: 4 meds daily X 2 mos
Continuation: RIF and INH daily or twice weekly x 4 mos

40
Q

Modifications to tx

A

HIV: extends tx 9-12+ mos (intermittent dosing)
Pregnant women: no pyrazinamide
Infants/kids: ethambutol not given and may extend tx

41
Q

What are the criteria to not be considered infectious?

A

2 wks of tx regimen
3 negative sputum smears
Sxs improve

42
Q

When can someone go home while still infectious?

A

If they have strict f/u
DOT is arranged
No kids <5 or immunocompromised ppl in the home
Unable to travel except for healthcare visits

43
Q

When is tx completion for TB?

A

Based on doses not duration
Initial for 8 wks: 56 doses
Continuation for 18 wks: 126 doses daily or 36 doses twice weekly
*for active

44
Q

Options for tx of latent TB

A

Isoniazid for 9 mos (300 mg daily for 900 mg twice weekly with DOT)- preferred in pregnancy and kids 2-11
INH and rifapentine is newly preferred for adults (not pregnant) and kids >12- 12 weekly doses
Rifampin at 4 mos regiment with 120 doses

45
Q

What drugs classify MDR TB?

A

INH and RIF (because of inadequate medication, premature tx interruption or spontaneous mutation)

46
Q

XDR-TB

A

Responds to less drugs including fluoroquinolones

Surgery to remove necrotic tissue is important

47
Q

Bacille Calmette-Guerin vaccine

A

Intradermal live strain vaccine
Decreases risk of severe consequences due to TB (does not prevent primary infection or activation)- proven to protect against meningitis and disseminated TB in kids

48
Q

Recommendations for BCG vaccine

A

Kids with negative TST and have continual exposure (not HIV+ tho)
Healthcare workers if high risk for MDR

49
Q

Contraindications for BCG vaccine

A

Immunosuppressed

Pregnancy

50
Q

Where do you contract histoplasmosis?

A

From soil contaminated with bird or bat droppings (inhale fungal spores)
Mostly in OH and mississippi river valleys

51
Q

History associated with histoplasmossis

A 
Recent exposure (spelunking, construction etc)
90% asymptomatic or mild-flu like sxs that resolve in a few wks
52
Q

Asymptomatic primary histoplasmosis

A

Most common in healthy people

CXR may show residual granuloma

53
Q

Acute symptomatic pulmonary histoplasmosis

A

Fever, marked fatigue, few respiratory sxs
Sxs 1 wk-6 mos
Mild sxs usually self-limited

54
Q

Progressive disseminated histoplasmosis

A

Pt typically immunocompromised
Fever, fatigue, cough, dyspnea, weight loss
Multiple organ involvement
Fatal within 6 wks

55
Q

Chronic pulmonary histoplasmosis

A

Older COPD pts

Progressive lung changes like apical cavities

56
Q

Serology for histoplasmosis

A

Antibody tests like immunodiffusion test (acute and chronic) or complement fixation (more sensitive but takes longer)
Antigen detections with enzyme immunoassay (urine or serum testing)

57
Q

What can be seen on the CXR in histoplasmosis?

A

Hilar adenopathy

Patchy or nodular infiltrates in lower lobes

58
Q

Tx for asymptomatic histoplasmosis

A

None (<4 wks)

59
Q

What kinds of drugs might be used for histoplasmosis?

A

Amphotericin or azoles

60
Q

When to suspect histoplasmosis?

A 
Pneumonia with mediastinal or hilar LAD
Mediastinal or hilar mass
Pulm nodule
Cavitary lung disease
Pulmonary sx with rheumatologic arthritis/arthralgia +erythema nodosum
Dysphagia with esophageal narrowing
61
Q

How do you get coccidiomycosis?

A

Contaminated soil (lower deserts of western hemisphere)–AZ, San Joaquin Valley CA, new mexco etc

62
Q

Who has a more severe presentation of cocci?

A

Immunocompromised, pregnant, diabetics and in African or Filipino descent

63
Q

Sxs of cocci

A

Most are asymptomatic (residual granuloma on CXR)
Mild respiratory sxs that are self-limited about wks to mos- may progress with chronic pulm disease or disseminated disease

64
Q

Primary infection of cocci

A

Usually present with CAP (7-21 days after exposed)
Fever, cough, pleuritic CP (may also have fatigue, HA or arthralgia-desert rheumatism)
Rash: erythema multiform or erythema nodosum

65
Q

Disseminated disease of cocci

A

Seen in those higher risk groups
More pronounced lung findings
Bone lesions
Lymphadenitis, meningitis

66
Q

Serology for cocci

A 
Enzyme immunoassay
Immunodiffusion test (IgM antibodies)
Complement fixation (IgG antibodies- detect severity)
67
Q

Other diagnostics for cocci

A

Labs (eosinophilia with slight leukocytosis)
SPutum culture
Skin test (not diagnostic)

68
Q

What might be seen on a CXR with cocci?

A

Hilar adenopathy
Patchy nodular, pulmonary infiltrates
Miliary infiltrates
Thin wall cavities

69
Q

CXR of chronic pulmonary disease of cocci

A

Residual lung nodules with thin walled cavities (disappear within 2 yrs)
Chronic cavitary lesions with infiltrates (may mimic TB)

70
Q

Tx for cocci

A

Tx typically not required (only for high risk group or have severe illness)-use azoles but not ketoconazole (increased side effects)

71
Q

Tx in pregnancy for cocci

A

Amphotericin b (because azoles are teratogenic)

72
Q

F/u for cocci

A

Every 2-4 wks regardless of tx (goes for 1 yr if no meds, if tx then for 2 years for recurrence)

73
Q

When do you think cocci??

A 
Pulmonary complaints
AND
One or more of the 3 Es:
Erythema nodosum
Erythema multiforme
Eosinophilia

X Clin Med II Exam 2 (6 decks)

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