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

Tuberculosis and Pleural Infection Flashcards

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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
Q

How long are sputum samples cultured for tuberculosis?

A

12 weeks

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26
Q

What does a smear negative, culture positive result indicate?

A

these patients are not usually regarded as being infectious to other people because the number of mycobacteria in their sputum is tiny

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27
Q

What are the advantages of PCR?

A
  • 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
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28
Q

How can histology be used to diagnose tuberculosis?

A
  • Multinucleate giant cell granulomas
  • Caseating necrosis
  • Sometimes visible mycobacteria
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29
Q

How can you differentiate between TB and sarcoidosis via histology?

A

Sarcoidosis has similar features but lacks the caseating necrosis and has no mycobacteria

30
Q

What are key characteristics of TB on a CXR?

A
  • Upper lobe predominance
  • Cavity formation
  • Tissue destruction
  • Scarring and shrinkage
  • Heals with calcification
31
Q

Are pneumonia and TB found in the same areas of the lung?

A

No

  • Tuberculosis has upper lobe predominance
  • Pneumonia has lower lobe predominance
32
Q

Explain why the following CXR is unlikely to be lung cancer (pic)

A

The film shows bilateral upper zone disease with cavities. It would be most unusual for lung cancer to look like this

33
Q

What is miliary tuberculosis?

A

Massive seeding of mycobacteria through the bloodstream, seen to affect entire lung on CXR

34
Q

What is the combination therapy of tuberculosis?

A

6 months total

  • Two months of
  • Rifampicin
  • Isoniazid
  • Pyrazinamide
  • Ethambutol
  • Then four months of
  • Rifampicin
  • Isoniazid
35
Q

What is the problem with the large set of tablets prescribed for TB treatment? How can this problem be overcome?

A
  • Compliance is poor

* Problem can be overcome via combination pills

36
Q

What are the side effects of rifampicin?

A
  • Colours urine and all bodily fluids orange

* Is a potent inducer of cytochrome (liver) enzymes

37
Q

What does inducement of cytochome enzymes by rifampicin result in?

A
  • Rapid breakdown of all steroid molecules including hormonal contraception
  • Similar breakdown of opiate analgesics and many other drugs
38
Q

What are the side effects of ethambutol?

A

Can cause optic neuritis

39
Q

What are the side effects of isoniazid?

A
  • Hepatitis
  • Renal failure
  • Neuropathy
40
Q

What result should sputum show before decreasing the number of antibiotics?

A

Sputum should be acid fast negative before you decide to decrease number of antibiotics

41
Q

What are types of drug resistance in tuberculosis?

A
  • Single agent - commonly isoniazid
  • Multi-drug resistance (MDR) - rifampicin and isoniazid
  • Extensive drug resistance (XDR) - MDR and quinolone and injectable
42
Q

What is latent TB?

A
  • Symptom free
  • Culture negative
  • A balance between the organism and your immune system
43
Q

What is the criteria for latent TB?

A
  • 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
Q

What are tests for previous exposure to TB?

A
  • Interferon Gamma Release Assay
    (Blood test)
  • Detects previous exposure to TB
  • Mantoux (tuberculin) test
    (Skin test)
  • Detects previous exposure to TB and BCG
45
Q

What is a tuberculin (Mantoux) skin test (TST)?

A
  • 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
Q

What are the drawbacks of a TST?

A
  • False positive BCG

* Cannot distinguish between: latent TB, cured TB, active TB, BCG

47
Q

What is interferon gamma release assay (IGRA)?

A
  • 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
Q

What are the differences between TST and IGRA?

A
  • 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
Q

Why does TST have a risk of false negatives?

A
  • 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
Q

How is latent TB managed?

A

Through treating it or leaving it alone

51
Q

What are the treatment options for latent TB?

A

Anti-TNF therapy

  • 6 months of isoniazid (less side effects)
  • 3 months of rifampicin + isoniazid (more side effects but quicker)
52
Q

Why is anti-TNF therapy given to individuals with rheumatoid, crohn’s, psoriasis, or ankylosing spondylitis?

A
  • Tuberculosis can cause serious complications in these individuals
53
Q

What is a characteristic of latent TB on a CXR?

A

Calcified lymph nodes

54
Q

How is tuberculosis prevented?

A
  • 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
Q

What is the BCG immunisation?

A

Attenuated strain of mycobacterium bovis - given by intradermal injection

56
Q

What infection does TB go hand in hand with?

A

HIV

57
Q

What relationships are there between TB and HIV infection?

A
  • 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
Q

What should all TB cases and HIV cases be offered?

A
  • All TB cases should be offered an HIV test

* All HIV cases should be offered a chest X-ray

59
Q

What is a risk of using HIV treatments on an individual who also suffers from TB?

A

Steroids and other immunosuppressant drugs can reactivate latent tuberculosis

60
Q

Why is pleural infection (empyema, etc) important?

A
  • Increasing incidence esp extremes of age

* Significant mortality (up to 20%)

61
Q

Why is treatment of pleural infection with antibiotics not always 100% effective?

A

Can rapidly coagulate and organize to form fibrous peels even with antibiotics

62
Q

What are risk factors for pleural infection?

A
  • diabetes mellitus
  • immunosuppression including corticosteroids
  • gastro-oesophageal reflux
  • alcohol misuse
  • intravenous drug abuse
63
Q

What are types of pleural infection?

A
  • Simple parapneumonic effusion
  • Complicated parapneumonic effusion
  • Empyema
64
Q

How are parapneumonic effusions that require urgent drainage identified?

A

Sampling pleural fluid

65
Q

Why is it difficult to resolve empyema with antibiotics?

A

Have septations of fibrin that are very thick and difficult for antibiotics to penetrate

66
Q

What is a characteristic of empyema?

A

Pus

67
Q

What are characteristics of complicated effusions?

A
  • +ve Gram stain
  • pH <7.2
  • Low glucose
  • Septations
  • Loculation (mass) of fluid
68
Q

What treatment does a large effusion require?

A

Chest drainage and antibiotics

69
Q

What treatment do very small effusions (<1cm require)?

A

Left untapped (no pleural aspiration)

70
Q

What is the management for pleural effusions?

A
  • 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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