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Clinical 2.0 > Tuberculosis > Flashcards

Tuberculosis Flashcards

1
Q

describe mycobacterium tuberculosis

A

aerobic and anaerobic
extra and intracellular
multidrug resistance
slow growing, latent

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2
Q

describe the pathophysiology of Tb

A

very communicable spreads easily
aerosolized droplets
enter the bronchials then alveoli and settle in lower lobe
first line macrophage immunity followed by t cell over 2-8wks

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3
Q

risk factors for exposure

A 
close contacts 
endemic areas - northern ca 
poor living conditions, crowded, correctional facilities 
health care workers 
homelessness
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4
Q

results of tests in latent TB

A

negative xray, sputum stain and culture

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5
Q

symptoms of latent TB

A

asymptomatic
spreads to regional lymph nodes
latent or dormant in seeded foci (ghon node) for months - years
NOT CONTAGIOUS

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6
Q

how does tst test work

A

heat sterilized protein derivative

delayed hypersensitivty response delayed 48-72hrs

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7
Q

what can cause false negatives

A 
cutaneous anergy (absence of an IR to an antigen) 
preconversion 
neonate
elderly 
HIV
chemo 
lymphoma 
corticosteroids 
** use positive control mumps or candida
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8
Q

tst does not distinguish latent from what

A

active TB
BCG vaccination
other mycobacterial infection

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9
Q

interferon gamma assay

A

blood test measures t cell release of interferon gamma

does not distinguish from active disease but most specific with patients vaccinated with BCG

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10
Q

TST result <4mm indicates

A

negtive result

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11
Q

TST result >/=5

A 
positive in certain people 
HIV 
exposure in past 2 years 
fibronodular disease on chest xray 
ESRD 
therapy with immunosuppressants
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12
Q

TST result >10

A

TST conversion within 2 years

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13
Q

when should you treat latent TB how effective is it

A

90% effective
only if exposure to infectious TB wihtin the previous 2 years
assess risk vs benefit

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14
Q

standard latent TB therapy

A

isonazid daily for 9 months

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15
Q

alternative latent tb therapy

A

isonazid 6 months
isonazide/rifampin 3mon
rifampin 4 months

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16
Q

when does primary tb occur

A

early within 4-12 months

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17
Q

risk factors for primary tb

A

age

immune function

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18
Q

disseminated primary including cns tb most common in who

A

young and immunocompromised

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19
Q

most common place for primary tb

A

lymph node or pleural disease

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20
Q

when does reactivation tb occur

A

18-24 months after infections

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21
Q

what is most common for reactivation tb

A

pneumonia - upper lobe pulmonary

extra pulmonary in immunocompromised

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22
Q

high risk factors for active tb

A 
silicosis 
HIV AIDS 
chronic renal disease 
head and neck carcinoma 
recent TB infection 
abnormal chest xray-fibronodular disease 
immunosuppresive therapy
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23
Q

moderate risk factors for active tb

A

diabetes
glucocorticoids
TNFalpha
0-4 years old when infected

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24
Q

diagnosis for active pulmonary tb

A

signs and symptoms
radiograph
microbiology testing

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25
Q

clinical signs and symptoms

A

dry then productive cough >2weeks
fever, night sweats
anorexia, weight loss
hemoptysis, chest pain

26
Q

microbial testing for active disease

A

acid fast bacilli smear stain - rapid inexpensive
mycobaterial culture/susceptibility - gold standard, 2-8wks
molecular diagnositics - pcr and susceptibility

27
Q

radiograph for active disease

A

apical and upper lobe patchy infiltrates

volume loss and cavitation

28
Q

goals of treatment for active tb

A

eradicate the bug to cure the disease, prevent complications, and reduce mortality
prevent AM resistance
prevent transmission

29
Q

how often do you follow up sputum samples

A

monthly until to consecutive negatives

30
Q

how long is someone with active tb in isolation

A

initial 2 weeks and until 3 consecutive negative results

31
Q

principles of active tb AM

A

combo therapy
adherance important
both to optimize killing and decrease resistance

32
Q

standard regimen 1 for active tb

A

isonazid, rif, ethambutol, pyranzinimide for 2 months

then inh and rif for 4 months

33
Q

regimen 2 for active tb

A

inh, rif, emb for 2 months

then inh and rif for 7 months

34
Q

what regimen should elderly use for active tb

A

regimen 2, higher hepatooxicity in the older people

35
Q

what regimen should pregnant women use for active tb

A

either one

36
Q

what is direct observed therapy

A

initial 2 months instead of daily 5x a week and then for the continuation 3x a week at higher doses

37
Q

why is ethambutol added

A

in case there is resistance to the other agents can discontinue once results come back that its senstive to the others

38
Q

risk factors for ressitance

A

high local resistance rates
previous tb infection
exposure to resistant tb

39
Q

isonazid dose

A

5mg/kg max 300

40
Q

rifampin dose

A

10mg/kg max 600

41
Q

pyranzinamide dosing

A

20-25mg/kg

42
Q

ethambutol dosing

A

15-20mg/kg

43
Q

second line drugs for active tb

A

levofloxicin, moxi

ampikacin

44
Q

ampikacin dosing

A

15mg/kg injection

45
Q

which drugs have to be changed in hemodialysis

A

pyranzinimide 25- 35 3x a week

ethambutol 15-25 3x a week

46
Q

which are cidal

A

rif, inh, pyr

47
Q

which are static

A

emb

48
Q

which are extracellular

A

inh, rif

49
Q

which are intracellular

A

pyr, emb, rif

50
Q

inh adverse effects

A

hypersensitivity
hepatotoxicity
NV
peripheral neuropathy

51
Q

what can you do to prevent peripheral neuropathy

A

give vit B6

52
Q

what drug should be avoided when on therapy

A

tylenol - affects liver

53
Q

what increases the incidence of hepatotoxicity

A 
age >35 
female
pre existing liver disease 
other hepatotoxic drugs 
alcohol use
54
Q

when should you monitor for hepatotoxicity

A

baseline then in 2 weeks then monthly

55
Q

inh drug interactions

A

inhibits cyp 2C9 and 3A4

antacids reduce absorption

56
Q

rifampin adverse effects

A

hypersensitivity
hepatotoxicity
orange discoloration of saliva urine and tears

57
Q

rifampin drug interactions

A

inducer of 3A4 and pgp

max in 7 days and returns to baseline in 14

58
Q

pyranzinamide adverse effects

A

hepatotoxicity
hypersensitivity
hyperuricemia - gout if preexisting, arthralgias

59
Q

ethambutol adverse effects

A

ocular neritis - eye exams indicated, dose dependent (high dose long time)
CNS, peripheral neuritis
hypersensitivity - rash, fever, dermatitis

60
Q

what to do if the patient gets a drug induced rash

A

stop all drugs and start second line agent
review other potential causes
once rash resolves start inh
in 3 days start rif (can take off second line here)
in 3 days start emb
if no rash assume it was pyr
if rash occurs with any step then discontinue and restart all the others, adjust regimen based on those continues

61
Q

what to do if patient experiences drug induced hepatotoxicity AST or ALT >5x ULN or clinical jaundice

A

discontiue all meds and start second line agent
check for other causes , cehck viral hep serologies
when levels normal start rif
after 2 weeks start inh
if normal transaminases after 2 weeks assume pyr and do not rechallenge
if hepatitis occurs with any then discontinue and restart the others
adjust treatment based on remaining

Clinical 2.0 (24 decks)

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