Tuberculosis & Other Mycobacteria

Question 1

In which individuals would you consider a TST result of > or = 5 mm diagnostic for latent tuberculosis (5)?

Answer 1

(1) HIV
(2) Contact with infectious TB case in the past 2 years
(3) Immunosuppressed : Organ transplant, TNF-alpha inhibitor use, other immunosuppression meds.
(4) ESRD
(5) Presence of fibronodular disease on CXR

Question 2

What are the treatment regimen options for latent tuberculosis?

Answer 2

Preferred:
Isoniazid + vitamin B6 daily x 9 mon

Alternative:
(A)Isoniazid + vitamin B6 daily x 9 mon
(B) Isoniazid + B6 + rifampin x 3 mon

Question 3

Why do we supplement isoniazid with vitamin B6 (pyridoxine) in TB treatment?

Answer 3

Prevention of peripheral neuropathy

Question 4

When are steroids indicated in the treatment of TB?

Answer 4

If meningitis or pericardial disease (but not in patients with HIV unless high risk of IRIS)

Question 5

What is the standard treatment regimen for tuberculosis?

Answer 5

RIPE therapy!

Isoniazid + vitamin B6 x 6 months
Rifampin x 6 months
Pyrazinamide x 2 months
Ethambutol x 2 months

Question 6

If an untreated HIV patient is diagnosed with latent or active tuberculosis, when would you initiate anti-retro viral therapy?

Answer 6

Caution due to risk of IRIS. After initiation of TB therapy:

If CD4 < 50: Start ART within 2 weeks
If CD4 > 50: Start ART within 8 weeks
IF TB meningitis: Defer to ~ 8 weeks given high risk of IRIS

Question 7

What is the general treatment for non-TB mycobacterial infection?

Answer 7

Minimum 3 drug regimen:

Macrolide + ethambutol +/- rifampin +/- aminoglycoside