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Unit 2 Clin Med II > L15: TB+cocci > Flashcards

L15: TB+cocci Flashcards

1
Q

how is TB spread?

A

must have active TB to spread infection

Transmission by prolonged exposure to airborne droplet nuclei→ inhaled nuclei reach alveoli

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2
Q

primary TB

A

skin test conversion in 6-8 weeks→ spontaneous healing in 6 months→ latent TB

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3
Q

latent TB risk of progressing to reactivated TB

A

5% progress by 2 years
5% progress after 2 years
90% don’t progress
But HIV patients have a 10% risk/year of progression

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4
Q

latent TB

A

No symptoms, not contagious
Macrophages ingest tubercle bacilli→ barrier shell: granuloma
Can activate to disease state if immunocompromised→ granuloma breakdown

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5
Q

MDR-TB

A

does not respond to INH or RIF

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6
Q

XDR-TB

A

does not respond to INH, RIF, fluoroquinolones

→ surgery to remove necrotic tissue

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7
Q

Treatment for active TB

A

Isolated, negative pressure inpatient hospital room

RIPE: rifampin (RIF) + isoniazid (INH) + pyrazinamide (PZA) + ethambutol (EMB)

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8
Q

Treatment for active TB lengths

A

Initially 4 meds daily x 2 months→ 56 doses→ repeat CXR, AFB smear, culture
Continuation: RIF + INH for 4 months daily or twice weekly→126/36 doses sputum culture→ +/- phase extended

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9
Q

completion of TB treatment is based on

A

total doses, not duration of treatment

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10
Q

Treatment of TB in HIV+

A

9-12 months with intermittent dosing

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11
Q

Treatment of TB in children

A

no ethambutol, extend tx

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12
Q

Treatment of TB if pregnant

A

no pyrazinamide
INH+RPT contraindicated
INH: risk of fatal hepatitis

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13
Q

Side effects of rifampin

A

orange tears, sweat, urine

skin sensitivity

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14
Q

Side effects of isoniazid

A

hepatotoxicity→ monitor LFTs

peripheral neuropathy→ give vitamin B6

→fatal hepatitis: esp in pregnant women

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15
Q

Side effects of pyrazinamide

A

Hepatotoxicity, hyperuricemia

→ contraindicated in pregnancy

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16
Q

Side effects of ethambutol

A

Optic neuritis→ test visual acuity/color vision

→ contraindicated in children

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17
Q

when is TB in treatment considered noninfectious

A

after 2 weeks+3 (-) sputum smears symptoms improve

:

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18
Q

Going home while still infectious

A

no travel, DOT, no children <5 or immunocompromised in home

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19
Q

Latent TB treatment options

A
  1. INH 9 months 300 mg daily or 900 mg twice weekly
    Preferred therapy for pregnant women and children 2-11 years old
  2. INH+Rifapentine (RPT)
    12 weekly doses DOT
    Newly preferred in 2018 for adults and children >12 years, otherwise healthy patients with HIV
    Contraindicated in pregnancy
  3. Rifampin
    4 months daily→ 120 daily
    If cannot tolerate INH
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20
Q

INH + RPT contraindication

A

less than 12 years old

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21
Q

high risk for TB

A

Immunocompromised: HIV, <5 years, DM, silicosis, malnutrition, substance abuse, immunosuppressants
Immigrants
IVDU
Close living quarters

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22
Q

TB symptoms

A

Fever, cough (3+ weeks), pleuritic/retrosternal chest pain

+/- weakness, weight loss, anorexia, chills, night sweats, dyspnea

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23
Q

TB physical exam

A

+/- normal

+/- posttussive crackles (classic), LAD, pleural thickening→ dullness/decreased fremitus, clubbing (severe)

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24
Q

TB buzzwords:

A

Exam:
Fever, cough
posttussive crackles
dullness/decreased fremitus

CXR:
apical/posterior upper lobes
miliary pattern
hilar LAD

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25
preferred monotherapy for latent TB
INH Rifampin if can't tolerate new guidelines: INH + RPT: no longer monotherapy but suggested bc only 12 doses
26
Bacille Calmette-Guerin (BCG) Vaccine
Intradermal live strain vaccine→ single dose at birth→ protects against severe consequences: meningitis, disseminated TB
27
Bacille Calmette-Guerin (BCG) Vaccine is recommended for
(-) TST and continual exposure | high risk MDR-TB healthcare workers
28
Bacille Calmette-Guerin (BCG) Vaccine is contraindicated in
immunosuppressed, children, HIV+ children
29
Mantoux tuberculin skin test
Forearm intradermal wheel with .1 ml purified protein derivative (PPD) Read for induration in mm at 48-72 hours False negatives: 2-8 weeks following exposure
30
>15 mm: positive if:
Positive for everyone
31
>10 mm: positive if:
Intermediate risk: recent immigrants, HIV(-) IVDU, mycobacteriology lab personnel, health care providers, high risk medical conditions, <4 years old, children and adolescents exposed to adults at high risk
32
>5 mm: positive if:
High risk: HIV, recent contact, +CXR, immunosuppressed (steroids), organ transplant
33
2 step TB skin test (PPD)
recommended as initial test for health care workers and individuals requiring periodic retesting. Repeat test in 1-3 weeks, if (+) on 2nd test→ boosted response due to past exposure: TB infection False positives: Bacillus Calmette-Guerin vaccine→ test with IGRA
34
Interferon Gamma Release Assays (IGRA): Quantiferon TB Gold and T-Spot TB:
measures immune response in blood to TB antigen: IFN-g concentration Cannot distinguish disease from latent infection
35
how to collect sputum for TB testing
3 specimens 8-24 hours apart with at least 1 in the morning
36
acid fast smear is
supportive but nonspecific
37
nucleic acid amplification test is
supportive, can't confirm TB
38
presumed TB, empirically treat while waiting for results of culture
both AFB and NAA positive
39
gold standard for TB diagnosis
``` culture If (+), do drug susceptibility testing ```
40
if your patient has a negative TB culture but you remain suspicious
treat and monitor response to treatment
41
Confirmed and suspected cases:
Report within 24 hours | identify contacts
42
Hallmark of TB on biopsy
necrotizing/caseating granulomas
43
Xpert MTB/RIF assay:
Automated NAA testing using disposable cartridges, takes 2 hours → identifies M tuberculosis DNA and rifampin resistance Does not replace AFB smear or culture
44
CXR for TB in general
Can rule out TB, but cannot determine active vs. latent or rule out other causes Abnormalities usually seen in *apical/posterior upper lobes* or superior areas of lower lobe HIV→ atypical presentation CT more sensitive (2nd line)
45
abnormalities on CXR of TB are seen in
*****apical/posterior upper lobes*****
46
CXR of Primary active TB:
+/ hilar LAD→ pleural effusions/infiltrates→ cavities | Miliary pattern
47
CXR of Latent TB:
Dense nodules/lesions +/-calcification
48
CXR of Reactivation of latent TB:
Cavities, infiltrates, possible adenopathy
49
Ranke complex
Healed primary pulmonary TB: 1. Ghon lesion/Focus: calcified parenchymal granuloma (tuberculoma) 2. Ipsilateral calcified hilar lymph node
50
Histoplasma Capsulatum
soil contaminated with bird/bat droppings→ inhalation of fungal spores→ convert to yeast at body temp Midwestern states, Ohio and mississippi river valleys, Central and South America
51
Histoplasma Capsulatum incubation
Incubation: 3-17 days
52
Asymptomatic primary histoplasmosis
90% | asymptomatic/mild flu like→ resolve in few weeks/month
53
symptomatic pulmonary histoplasmosis
Fever, marked fatigue, few respiratory sx for 6 months | Mild symptoms typically self limited
54
Progressive disseminatedhistoplasmosis
Immunocompromised→ fever, marked fatigue, cough, dyspnea, weight loss, multi-organ involvement, fatal within 6 weeks
55
Chronic pulmonary histoplasmosis
Older COPD pts→ progressive lung changes→ apical cavities
56
Who to suspect histoplasmosis in
pneumonia with mediastinal/hilar LAD, mediastinal/hilar mass, pulmonary nodule, cavitary lung disease, pulmonary symptoms with rheumatologic arthritis/arthralgia and erythema nodosum, dysphagia with esophageal swallowing
57
CXR of histoplasmosis
Hilar adenopathy, patchy or nodular infiltrates in lower lobes Asymptomatic: residual granuloma Chronic pulmonary: apical cavities
58
Immunodiffusion of histoplasmosis
detects acute and chronic
59
complement fixation of histoplasmosis
more sensitive, less specific that ID, takes 6 weeks
60
antibody detection of histoplasmosis
Enzyme immunoassay (EIA) of urine/serum
61
culture of histoplasmosis
severe or chronic disease, takes 6 weeks
62
coccidioidomycosis aka
valley fever
63
valley fever causes
Coccidioides immitis, coccidioides posadasii Contaminated soil→ inhalation of spores Outbreaks: dust storms, earthquakes Lower deserts of western hemisphere: Southwest US, Mexico, Central and South America
64
histoplasmosis treatment
Amphotericin B | Methylprednisolone (respiratory complications)
65
valley fever treatment
Typically not required High risk/serious illness→ azoles → no ketoconazole due to side effects → teratogenic Pregnant or severe→ amphotericin B
66
your otherwise healthy patient has valley fever, what's the treatment of choice
nothing, will resolve on its own
67
the only azole you shouldn't use bc of side effects
ketoconazole
68
pregnant+valley fever
ampho B
69
pregnant+histoplasmosis
gonna guess ampho B is fine since it's okay for valley fever
70
valley fever follow up
every 2-4 weeks for 1 year w/o therapy, 2 years if therapy needed
71
valley fever incubation
1-3 weeks
72
% of valley fever which is asymptomatic
60%
73
high risk of valley fever, more likely to have disease progress
More severe presentation: immunocompromised, DM, pregnant, african, filipino
74
Subacute valley fever
mild respiratory symptoms, self limited, weeks to months Protective from future disease → +/- progression
75
Primary infection valley fever presentation
CAP 7-21 days after exposure Fever, cough, pleuritic chest pain, marked fatigue, HA, arthralgia (desert rheumatism), rash: erythema multiforme, erythema nodosum
76
Disseminated disease valley fever
Lungs (more pronounced lesions), bone lesions, brain LAD, meningitis More likely in high risk group
77
CXR of valley fever
+/- hilar adenopathy, patchy nodular pulmonary infiltrates, miliary infiltrates, thin wall cavities Asymptomatic: residual granuloma Chronic pulmonary disease: Residual lung nodules with thin walled cavities→ disappear within 2 years Chronic cavitary lesions with infiltrates
78
finding of valley fever that can mimic TB on CXR
Chronic cavitary lesions with infiltrates | ***if you see this buzzword look closely at the history***
79
Enzyme immunoassay (EIA) for valley fever
more sensitive that ID
80
Immunodiffusion (ID) for valley fever
more specific, used following a positive EIA | Detects IgM antibodies: recent/active infection
81
Complement fixation (CF) for valley fever
Detects IgG antibodies→ assess disease severity
82
Immunodiffusion vs Complement fixation: antibodies, assesses
Immunodiffusion: IgM antibodies, recent/active infection | Complement fixation: IgG antibodies, disease severity
83
labs of valley fever
***eosinophilia with slight leukocytosis***
84
Valley fever skin testing
Coccidioidin or spherulin | lifelong reactivity, can’t indicate when exposed, not diagnostic
85
sputum culture for valley fever
difficult to obtain due to dry cough

Unit 2 Clin Med II (7 decks)

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