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Clin Med II Unit II > 7 TB Histo Cocci > Flashcards

7 TB Histo Cocci Flashcards

(61 cards)

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1
Q

Number one killer of HIV+ patients

A

TB

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2
Q

TB is transmitted through …

A

Airborne droplet nuclei

Expelled with coughing, sneezing, shouting, singing

Transmission occurs when inhaled nuclei reach alveoli

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3
Q

Can a drunk hobo give you TB by coughing on you as you walk past?

A

No - usually requires prolonged exposure - someone you live with or residents of prisons, nursing homes, etc

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4
Q

95% of TB infections are…

A

Latent

TB bacteria present in the body without symptoms

Macrophages ingest tubercle bacilli creating barrier shell called a granulomatous - can see on CXR

Unable to transmit infection to others

Latent TB may activate to disease state if pt becomes immunocompromised and granulomas break open

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5
Q

____% initially develop TB disease within 2 years after infection and another ____% develop from latency later (reactivation TB)

A

5% and 5% - for a total of 10% exposed healthy individuals have lifetime risk of getting active TB

TB only becomes active if immune system unable to fight infection

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6
Q

Without treatment, the risk of developing TB disease once infected is ________ for people with HIV

A

100x higher

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7
Q

Without treatment, the risk of developing TB disease once infected is ______ for diabetics

A

3X higher

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8
Q

Main TB risk factors

A

Immunocompromised (HIV, kids<5, DM, Silicosis, malnutrition, substance abuse, immunosuppressive therapy)

Immigrants from areas with high TB prevalence

Injection Drug Users

Close living quarters (nursing homes, institutions, correctional facilities, hospitals)

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9
Q

Main Sx of TB

A

Fever
Cough (3+ weeks, +/- productive, +/- hemoptysis)
CP (pleuritic or retrosternal)

Other Sx: weakness, weight loss, anorexia, chills, night sweats, dyspnea

Extrapulmonary TB disease Sx depends on location

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10
Q

Classic physical exam finding for TB

A

POSTTUSSIVE CRACKLES

PE may be normal

May also have dullness or decreased fremitius if pleural thickening

LAD

Clubbing if more severe

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11
Q

How is the Mantoux TST given?

A

Intradermal injection, create wheal with 0.1 ml Purified Protein Derivative

Read in 48-72 hours and measure INDURATION, not redness

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12
Q

5 mm is a positive TST response in ..

A 
HIV+ persons
Recent contacts of those with active TB
Persons with evidence of TB on CXR
Immunosuppressed patients (ie chronic steroids)
Organ transplant patients
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13
Q

10 mm is a positive TST in …

A

Recent immigrants from countries with high rates of TB infection
HIV negative IVDUs
Mycobacteriology lab personnel
Residents/employees of high risk congregate settings
Persons with certain high risk medical conditions
Children <4
Children and adolescents exposed to high risk adults

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14
Q

Positive TST result in anyone without risk factors for TB

A

15 mm

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15
Q

2 step TST is recommended as initial test for …

A

Health care workers and individuals requiring periodic testing

1st negative, repeat in 1-3 weeks

2nd positive, TB infection present (creates boosted response and is likely due to past exposure)

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16
Q

What might cause a false positive on TST?

A

BCG (bacillus Calmette-Guerin) vaccine

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17
Q

Test that measures immune response in blood to TB

A

IGRA: Quantiferon-TB Gold and T-SPOT TB

Blood incubated with TB antigen and response measured

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18
Q

When might you use QuantiFeron-TB Gold instead of TST?

A

Concerns of patient not returning for reading

Patients who received BCG vaccination

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19
Q

Why don’t we just use the Quantiferon-TB gold test for everyone?

A

Expensive

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20
Q

CXR findings in Primary active TB

A

Initial: Hilar LAD or normal

May progress with pleural effusions and/or infiltrates

Cavities seen with progressive pulmonary TB

May also see miliary pattern

CXR helpful but cannot determine active vs inactive disease

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21
Q

Why is calcification a good thing when reviewing CXR of suspected TB patient?

A

Dense nodules or lesions indicate latent disease, less likely to reactivate

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22
Q

Signs of reactivation of TB on CXR

A

Cavities, infiltrates, and possible LAD

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23
Q

CXR abnormalities usually appear in ….

A

Apical/posterior upper lobes (80-90%) or superior areas of lower lobe

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24
Q

What is the Ranke Complex?

A

Indicates healed primary pulmonary TB

Ghon lesion (Focus): calcified parenchymal granulomatous (tuberculoma)

Ipsilateral calcified hilar lymph nodes

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25
How do you do sputum collection for TB Dx?
3 specimens, at least 8-24 hours apart At least one first thing in the morning
26
What are the three methods for analyzing sputum in possible TB cases?
1. Smear (acid fast bacilli - AFB) - quick and easy, supports Dx but not confirmatory 2. Cytology (nuclei acid amplification - NAA) takes 48 hours, supports Dx but does not confirm 3. Culture - GOLD STANDARD; confirms Dx but takes weeks If Smear and Cytology positive, begin Tx while waiting for Culture
27
Once TB culture is positive, what do you do?
Drug susceptibility testing
28
If culture is negative and TB disease still suspected, what do you do?
Treat anyway and monitor response to treatment
29
If you do a biopsy for TB, what will you see?
Necrotizing (caseating) granulomas
30
What are these new fangled Xpert MTB/RIF Assays?
Automated NAA test using disposable cartridges - can ID M tuberculosis DNA and rifampin resistance Takes only 2 hours and requires minimal training but its expensive and doesn’t replace AFB smear or culture
31
Treatment of Active TB
Isolated, negative pressure inpatient hospital room Direct Observed Therapy (DOT) ``` “RIPE” drugs Rifampin Isoniazid Pyrazinamide Ethambutol ```
32
Rifampin side effects
Excreted as red-orange compound in tears, sweat, urine | Skin sensitivity
33
Isoniazid side effects
Hepatotoxicity (monitor LFTs) Peripheral Neuropathy: Vitamin B6 may be given Fatal hepatitis (pregnant women at increased risk)
34
Pyrazinamide side effects
Hepatotoxicity | Hyperuricemia
35
Ethambutol side effects
Optic neuritis: test visual acuity and color vision
36
How are the RIPE drugs administered?
Initial (intensive) phase: 4 meds daily x 2 months (DOT) Repeat CXR, AFB smear, and culture Continuation phase: RIF and INH daily or twice weekly x 4 months (may be extended based on sputum culture and med tolerance
37
Treatment considerations for special cases
HIV: extends treatment 9-12 months (intermittent dosing) Pregnant women: No PZA given Infants/children: EMB not given and may extend treatment
38
Criteria to not be considered infectious for TB
2 weeks of treatment 3 negative sputum smears Symptoms improve
39
Who can go home while still infectious?
Those who can strictly follow up and have DOT arranged No children < 5 or immunocompromised individuals in home Unable to travel except to healthcare visits
40
How is latent TB treated?
9 month regiment of Isoniazid 300mg daily or 900mg twice weekly using DOT (this is preferred therapy for pregnant women and children 2-11 - but monitor LFTs) New preferred regime for adults and children ≥ 12: Combined INH and Rifapentine for 12 weekly doses (NOT used in pregnancy)
41
How is MDR-TB defined?
Does not respond to at least INH and RIF Causes: inadequate meds or dosing, premature treatment interruption, spontaneous genetic mutation
42
How is XDR-TB defined
Extensively drug resistant TB, responds to even fewer drugs including fluoroquinolone Surgery to remove necrotic tissue important but often not available
43
What is the purpose of the BCG vaccine
To decrease risk of severe consequences due to TB Does not prevent primary infection or activation of latent TB Proven to protect against meningitis and disseminated TB in kids though Given as single dose at birth in developing countries
44
Fungal infection associated with soil contaminated with bird or bat droppings
Histoplasmosis Occurs most frequently in OH and Mississippi River valleys (midwestern states) Most common among individuals with HIV/AIDs or other weakened immune systems
45
Clinical presentation of histoplasmosis
Hx of SPELUNKING, construction, demolition, mining, roofing, farming, gardening, installing AC units Incubation period is 3-17 days after exposure 90% asymptomatic or mild flu-like symptoms Most symptoms resolve in few weeks to a month unless infection becomes more severe
46
50-90% of pt with histoplasmosis are ...
Asymptomatic CXR may show residual granuloma
47
What is acute symptomatic pulmonary histoplasmosis?
Fever and marked fatigue, few respiratory symptoms Symptoms extend from 1 week to 6 months Mild Sx are typically self-limited
48
Progressive disseminated histoplasmosis occurs in ...
Immunocompromised patients Fever, marked fatigue, cough, dyspnea, weight loss Multiple organ involvement Fatal within 6 weeks
49
Chronic pulmonary histoplasmosis occurs in...
Older COPD patients and those with progressive lung changes (apical cavities)
50
Dx of histoplasmosis is usually via...
Serology Antibody tests (Immunodiffusion (ID) and Complete Fixation (CF) tests Antigen detection via enzyme immunoassay (EIA test) - can be either urine or serum testing
51
CXR findings for histoplasmosis
Hilar adenopathy Patchy or nodular infiltrates in lower lobes
52
Treatment for histoplasmosis
Acute mild to moderate - no treatment Others - either an azole or Ampho B if pregnant
53
Fungal infection endemic to lower deserts of Western Hemisphere
Coccidioidomycosis (Valley Fever) Inhalation of spores from contaminated soil - outbreaks occur following dust storms and earthquakes
54
Clinical presentation of Cocci
Lives or recently traveled to SW Activities increasing exposure: excavation, construction, playing in the dirt (dogs can get it too) Incubation 1-3 weeks 60% asymptomatic More severe presentation in immunocompromised, pregnant women, DM, African and Filipinos
55
Sub-acute valley fever
Mild respiratory Sx that are self-limited and last weeks to months - may be considered protective from future disease
56
Symptoms of primary Cocci infection
Typically present with community acquired pneumonia 7-21 days following exposure Primary Sx: Fever, cough, pleuritic CP Others: Marked fatigue, HA, arthralgia, erythema multiform, erythema nodosum
57
Sx of disseminated disease in Cocci patients
Has spread to Lungs Bones or Brain Higher Risk: HIV, African or Filipino descent, 3rd trimester of pregnancy More pronounced lung findings (ie abscess) Bone lesions Lymphadenitis, meningitis
58
Lab findings in Cocci
Eosinophils with slight leukocytosis
59
CXR findings vary in cocci but include...
Hilar LAD Patchy, nodular pulmonary infiltrates Miliary infiltrates Thin wall cavities
60
Treatment of cocci not generally required but for patients who are high risk or have severe illness...
Symptomatic therapy = -azole Ampho B if severe or pregnant Prognosis = good with limited disease, but 50% mortality if disseminated
61
Think cocci when ...
Pulmonary complaints and one or more of the 3 Es: Erythema nodosum Erythema multiforme Eosinophilia

Clin Med II Unit II (7 decks)

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