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Respiratory: Patient History, etc > Tuberculosis and Pleural Infection > Flashcards

Tuberculosis and Pleural Infection Flashcards

1
Q

Where is tuberculosis most commonly found on a CXR?

A

Upper lobes

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2
Q

What is a tubercle?

A

A swelling (in TB, found in the bronchial tube)

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3
Q

What is pus in the bronchi/bronchioles indicative of?

A

Infection e.g. TB

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4
Q

What is tuberculosis?

A

Infectious disease of respiratory tract

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5
Q

Why is TB prominent in the upper lobes?

A

It is airborne - inhaled pathogens tend to infect upper lobes

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6
Q

What pathogen causes TB?

A

mycobacterium tuberculosis

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7
Q

How does TB spread to other organs?

A

Infects upper lobes, travels distally into alveoli, macrophages encapsulate mycobacterium to prevent spread forming granulomas. Granulomas can rupture and contents can enter the bloodstream

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8
Q

What is the purpose of granuloma formation in tuberculosis?

A

To ‘wall off’ infection and prevent spread

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9
Q

Why is granuloma formation somewhat beneficial to mycobacterium tuberculosis?

A

From bacterial perspective, granuloma is a growing collection of phagocytic cells to infect and replicate within

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10
Q

What happens after exposure to TB?

A

Infection or disease

  • Infection - 90% remain well (up to 50% clear TB spontaneously)
  • 10% become infected with disease
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11
Q

Of the 10% that suffer from the disease after being exposed to TB, what percentage suffer from primary tuberculosis?

A
  • 5% primary tuberculosis

* 5% reactivation of latent disease

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12
Q

Is TB picked up from the environment?

A

M.tuberculosis has no known environmental reservoir; humans are its only known reservoir

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13
Q

What are the general clinical features of tuberculosis?

A
  • Weight loss
  • malaise
  • night sweats
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14
Q

What are the respiratory clinical features of tuberculosis?

A
  • Cough
  • haemoptysis
  • breathlessness
  • Upper zone crackles
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15
Q

What are clinical features of meningeal tuberculosis?

A
  • Headache
  • Drowsy
  • Fits
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16
Q

What are clinical features of gastrointestinal tuberculosis?

A
  • Pain
  • bowel obstruction
  • perforation
  • peritonitis
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17
Q

What are clinical features of spinal tuberculosis?

A
  • Pain
  • Deformity
  • Parapleigia
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18
Q

What other systemic clinical features are caused by TB?

A
  • Lymphadenopathy

* Cold abscess

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19
Q

What is a cold abscess?

A

collections of pus without the pain and acute inflammation seen in a conventional abscess

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20
Q

What are clinical features of pericardial, renal, septic arthritis, and adrenal tuberculosis?

A
  • Pericardial - tamponade
  • Renal - renal failure
  • Septic arthritis - cold monoarthritis of large joints
  • Adrenal - hypoadrenalism
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21
Q

Why should you never inject steroids into a solitary arthritic joint?

A

Might be tuberculosis

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22
Q

What are modern day diagnostic tests for TB?

A
  • ZN stain, acid fast bacilli
  • Auramine stain
  • PCR
  • Culture
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23
Q

What is the process of a ZN stain?

A
  • stain the whole slide with a vivid pink stain
  • wash the slide with acid and alcohol, this removes the stain from everything except mycobacteria
  • the mycobacteria hang on to the stain due to the high wax content of their cell wall
  • add a blue counter stain which helps to visualise the pink mycobacteria
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24
Q

What are positive slides called and wha do they indicate?

A

Smear positive - indicate that patient is infectious to other people

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25
How long are sputum samples cultured for tuberculosis?
12 weeks
26
What does a smear negative, culture positive result indicate?
these patients are not usually regarded as being infectious to other people because the number of mycobacteria in their sputum is tiny
27
What are the advantages of PCR?
* Only takes 2 hours * Picks up all of the smear positive cases and most culture positive cases * Tells us if organism is resistant to rifampicin
28
How can histology be used to diagnose tuberculosis?
* Multinucleate giant cell granulomas * Caseating necrosis * Sometimes visible mycobacteria
29
How can you differentiate between TB and sarcoidosis via histology?
Sarcoidosis has similar features but lacks the caseating necrosis and has no mycobacteria
30
What are key characteristics of TB on a CXR?
* Upper lobe predominance * Cavity formation * Tissue destruction * Scarring and shrinkage * Heals with calcification
31
Are pneumonia and TB found in the same areas of the lung?
No * Tuberculosis has upper lobe predominance * Pneumonia has lower lobe predominance
32
Explain why the following CXR is unlikely to be lung cancer (pic)
The film shows bilateral upper zone disease with cavities. It would be most unusual for lung cancer to look like this
33
What is miliary tuberculosis?
Massive seeding of mycobacteria through the bloodstream, seen to affect entire lung on CXR
34
What is the combination therapy of tuberculosis?
6 months total * Two months of - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol * Then four months of - Rifampicin - Isoniazid
35
What is the problem with the large set of tablets prescribed for TB treatment? How can this problem be overcome?
* Compliance is poor | * Problem can be overcome via combination pills
36
What are the side effects of rifampicin?
* Colours urine and all bodily fluids orange | * Is a potent inducer of cytochrome (liver) enzymes
37
What does inducement of cytochome enzymes by rifampicin result in?
* Rapid breakdown of all steroid molecules including hormonal contraception * Similar breakdown of opiate analgesics and many other drugs
38
What are the side effects of ethambutol?
Can cause optic neuritis
39
What are the side effects of isoniazid?
* Hepatitis * Renal failure * Neuropathy
40
What result should sputum show before decreasing the number of antibiotics?
Sputum should be acid fast negative before you decide to decrease number of antibiotics
41
What are types of drug resistance in tuberculosis?
* Single agent - commonly isoniazid * Multi-drug resistance (MDR) - rifampicin and isoniazid * Extensive drug resistance (XDR) - MDR and quinolone and injectable
42
What is latent TB?
* Symptom free * Culture negative * A balance between the organism and your immune system
43
What is the criteria for latent TB?
* No evidence of active TB - Symptoms - X-ray - Culture * Evidence of previous TB infection - History of TB prior to 1960 - Calcification on x-ray - Exposure to high prevalence area
44
What are tests for previous exposure to TB?
* Interferon Gamma Release Assay (Blood test) - Detects previous exposure to TB * Mantoux (tuberculin) test (Skin test) - Detects previous exposure to TB and BCG
45
What is a tuberculin (Mantoux) skin test (TST)?
* Tuberculin is a protein derived from the culture of mycobacteria * 0.1ml of the solution is injected intradermally * The patient has to return at least 48 hours later to see if there has been a delayed hypersensitivity reaction at the site of injection
46
What are the drawbacks of a TST?
* False positive BCG | * Cannot distinguish between: latent TB, cured TB, active TB, BCG
47
What is interferon gamma release assay (IGRA)?
* IGRA tests are performed on blood samples * The assay looks for interferon gamma specific to antigens found only in m.tuberculosis * It does not react with BCG which is an attenuated strain of m.bovis
48
What are the differences between TST and IGRA?
* TST requires 2 visits, IGRA is 1 * TST has a risk of false positives/negatives, IGRA is high sensitivity * IGRA ignored BCG, TST doesn't
49
Why does TST have a risk of false negatives?
* The TST relies on the patient’s immune system in a type 4 hypersensitivity reaction * If the patient is immunocompromised from drug treatment or disease then the reaction may be diminished * This explains some of the false negative TSTs
50
How is latent TB managed?
Through treating it or leaving it alone
51
What are the treatment options for latent TB?
Anti-TNF therapy * 6 months of isoniazid (less side effects) * 3 months of rifampicin + isoniazid (more side effects but quicker)
52
Why is anti-TNF therapy given to individuals with rheumatoid, crohn's, psoriasis, or ankylosing spondylitis?
* Tuberculosis can cause serious complications in these individuals
53
What is a characteristic of latent TB on a CXR?
Calcified lymph nodes
54
How is tuberculosis prevented?
* Contact tracing to identify further cases * Screening of high risk subgroups (esp migrants and prior to immunosuppressive agents) * Isolation of infectious cases * BCG immunisation * Social measures (housing, nutrition)
55
What is the BCG immunisation?
Attenuated strain of mycobacterium bovis - given by intradermal injection
56
What infection does TB go hand in hand with?
HIV
57
What relationships are there between TB and HIV infection?
* 12% of all new active TB disease cases occur in HIV positive individuals * 25% of all TB-related deaths occur in HIV-positive individuals
58
What should all TB cases and HIV cases be offered?
* All TB cases should be offered an HIV test | * All HIV cases should be offered a chest X-ray
59
What is a risk of using HIV treatments on an individual who also suffers from TB?
Steroids and other immunosuppressant drugs can reactivate latent tuberculosis
60
Why is pleural infection (empyema, etc) important?
* Increasing incidence esp extremes of age | * Significant mortality (up to 20%)
61
Why is treatment of pleural infection with antibiotics not always 100% effective?
Can rapidly coagulate and organize to form fibrous peels even with antibiotics
62
What are risk factors for pleural infection?
* diabetes mellitus * immunosuppression including corticosteroids * gastro-oesophageal reflux * alcohol misuse * intravenous drug abuse
63
What are types of pleural infection?
* Simple parapneumonic effusion * Complicated parapneumonic effusion * Empyema
64
How are parapneumonic effusions that require urgent drainage identified?
Sampling pleural fluid
65
Why is it difficult to resolve empyema with antibiotics?
Have septations of fibrin that are very thick and difficult for antibiotics to penetrate
66
What is a characteristic of empyema?
Pus
67
What are characteristics of complicated effusions?
* +ve Gram stain * pH <7.2 * Low glucose * Septations * Loculation (mass) of fluid
68
What treatment does a large effusion require?
Chest drainage and antibiotics
69
What treatment do very small effusions (<1cm require)?
Left untapped (no pleural aspiration)
70
What is the management for pleural effusions?
* Antibiotics (often for several weeks) * Drain effusion as needed * Early discussion with surgeons if persistent sepsis * Nutrition – sufficient albumin levels required to fight infection * Venous thromboembolism prophylaxis * Fibrinolytics/DNAase - break down clots * Reassess patients who do not improve

Respiratory: Patient History, etc (10 decks)

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