TB Flashcards
1
Q
Sixth leading cause of mortality in Philippines
A
TB
2
Q
T or f
Most of mdr tb cases are new cases
A
False
Most are retreatment
3
Q
indicated by negative skin test
caused by malnutrition, hiv, steroid, severe TB
A
anergy
4
Q
TB gene xpert used for what tissues
A
sputum, gastric lavage, csf, lymph node
5
Q
TB gene xpert not applicable for
A
stool, blood, urine
6
Q
difference between th1 and th2 response
A
th1 protective role
th2 produce cytokines (humoral immunity)
7
Q
factors that promote latency TB
A
low oxygen and nutrients
local production of TNF alpha and nitric oxide
8
Q
key factors for getting TB
A
household contact with newly diagnosed smear +
age <5
immunocompromised state
9
Q
age with lowest risk of TB
A
5-10 years
10
Q
transmission of tb
A
droplet
11
Q
how many bacilli necessary for successful infection
A
5 to 200
12
Q
lung lesion primary tb
A
ghon focus
13
Q
time period after primary tb infectioon is highest risk for disseminated tb
A
1 to 3 months
14
Q
mortality rate of TST (+) versus (-)
A
3 times
15
Q
classification according to bacteriological status
A
bacteriologically confirmed
clinically diagnosed
16
Q
most common extrapulmonary sites
A
lymph nodes, bones, joints, liver
17
Q
which lobe prone to obstruction and atelectasis/hyperaration
A
right middle lobe
18
Q
most common extrapulmonary tb and most common cause of chronic lymphadenitis in kids
A
tuberculous lymphadenitis
19
Q
most common location in CLAD
A
anteriro cervical
followed by axillary and supraclavicular
20
Q
fistula in CLAD seen in
A
10%
21
Q
most severe form of extrapulmonary tb
A
tuberculous meningitis
22
Q
CSF in TB meningitis
A
clear, opalescent
5-500 WBC with PMNs first then lymphocytes later
glucose may be low normal in 2nd stage then very low on 3rd stage
protein may be normal initially but becomes high
23
Q
what do you see if high protein in csf
A
pellicle forms
24
Q
common findings on CT/MRI
A
hydrocephalus meningeal enhancement hypodensities due too cerbral infarcts cerebral edema nodular enhancing lesion
25
most common location brain tuberculoma
infratentorial or at the base of the brain
26
why are children more prone to pott's
have increased blood supply to growing bones
27
where is lesion of potts usually located
area of endarteritis in the metaphyisis of long bone
28
most common skeletal site affected by tb
spine
29
most frequent symptom in potts
back pain
30
abdominal lymph node most involved
ileocecal
31
most common form of cutaneous tb
scrofuloderma
32
most common ocular manifestation
choroiditis
33
most frequent GU location in women
fallopian tubes
| followed by endometrium, ovaries, cervix
34
definition of congenital TB
infant with TB lesion plus ONE or MORE:
1. present w/in 1st week of life
2. primary hepatic complex
3. tb infection of placenta or endometrial tb
35
how is tb classified
```
bacteriological status
anatomical site
history of treatment
hiv status
drug susceptability
```
36
laryngeal tb with smear positive but no infiltrates on xray
extrapulmonary tb
37
both pulmonary tb plus extrapulmonary component
still considered pulmonary tb
38
definition of new case
no tb treatment or has taken it <1 month
| isoniazid prophylaxis not counted
39
definition retreatment case
previously treated or started at least 1 month
40
definition mdr tb
resistance to at least both isoniazid and rifampicin
41
definition xdr tb
resistance to any fluoroquinolone and to at least one of three second line drugs
42
gold standard for diagnosis of tb
culture
43
if absent bacteriologic evidence, may classify as tb if
THREE or MORE of ff:
1. exposure to adult/adol with active tb disease (epidemiologic)
2. signs and symptoms (clinical)
3. postivite TST (immunologic)
4. abnormal CXR (radiologic)
5. lab findings suggestive of TB (histological, cytological, biochemical, immunological, molecular
44
definition presumptive TB
signs and symptoms of tb or those with cxr suggesting tb
45
in child below 15 years old, presumptive TB has
THREE or more of ff:
1. cough for 2 weeks
2. fever for 2 weeks (malaria/pneumonia ruled out)
3. weight loss
4. failure to respond to 2 weeks of appropriate antibiotic therapy
5. failure to regain to previous state of health 2 weeks after viral infection/exanthema
6. fatigue/lethargy
46
most important diagnostic in tb
tst
47
most widely used TST
Purified protein derivative
| PPD RT 23
48
where to administer TST
2 inches below elbow joint in volar aspect of forearm
| apply wheal 6-10mmin diameter
49
how to measure TST
```
measure induration (palpable raised hardened area)
measure perpendicular to the long axis of forearm
```
50
causes of false positives
```
infection with nontuberculous mycobacteria
previous bcg
incorrect method
incorrect measurement
incorrect strength of antigen
```
51
dose of PPD
0.1ml 2TU of RT23 = 0.1ml 5TU PPD-S
52
when do expect kids with bcg vaccination to have waning TST
after 5 years
53
causes of false negatives
```
infection
vaccination (MMR, polio, varicella)
CKD
malnutrition
malignancy
steroids
newborns
elderly
overwhelming TB infection
stress (surgery, burn)
organ transplant
improper use of tuberculin (storage, administration)
improper reading
```
54
TST should be postponed __ weeks after live vaccine
4-6 weeks
55
TST should be delayed __ after bout of measles, mumps, varicella, pertussis
2 months
56
TST should be delayed __ in kids with scabies, impetigo
after skin lesions healed
57
positive TST
```
15mm if no risk factors
10mm in prevalent areas
5mm if:
1. malnourished
2. immunocompromised
3. CXR findings
4. organ transplant
5. close contact with TB
```
58
advantage of using IGRA (interferon gamma release assays)
requires only single visit
| result affected by prior BCG
59
cxr findings in tb
parenchymal focus
lymphadenitis
lymphangitis
pleural effusion
60
most common cxr findings
parenchymal focus
| lymphadenitis
61
bronchial obstruction due to tuberculous lymph nodes may present as
hyperaeration
segmental atelectasis
collapse consolidation
62
cxr of chronic ptb
| most common
apical and posterior segment of upper lobes
| right lung > left lung
63
cxr miliary tb
2mm nodules stipple both lungs
| they may coalesce (snowstorm effect)
64
modality of choice for potts vertebra
ct
65
modality of choice for potts intervertebral space
mri
66
four types of tb osteomyelitis
cystic
infiltrative
foacl erosions
expansile lesion
67
most common type tb osteomyelitis in kids
cystic
68
spina ventosa
bone destruction and periosteal thickening and fusiform expansion of bone
69
modality of choice for tb osteolmyelitis
mri
t1 marrow changes low signal intensity
t2 high signal
70
triad of radiograph abnormalities
| for TB arthritis
PHEMISTER TRIAD
juxtaarticular osteoporosis
peripherally located osseous erosions
gradual narrowing of interosseous space
71
modality of choice for TB meningitis
mri
72
predilection of TB in brain
interpenduncular and suprasellar cisterns
73
most common complication of tb meningitis
communicating hydrocephalus
74
majority of infarcts in brain seen
basal ganglia and internal capsule
| due to occlusion of small vessels
75
mri for brain tuberculoma
T1 - hypointense relative to gray matter
T2 - hyperintense
gad - rim enhancement
solid center in caseous - isointense t1/t2
liquid center t1 hypointense, t2 hyperintense
76
complication of spinal tb meningitis
syringomyelia
77
most common radiologic manifestation of abdominal TB
lymphadenopathy
| most commonly involved: mesentric, omental, peripancreatic
78
most common clinical manifestation of abdominal TB
peritonitis
79
thickening of the valve lips with narrowing terminal ileum in abdominal TB
Fleischner sign
80
earliest radiologic abnormality in GU TB
moth eaten calyx due to erosion
81
primary sign of tb pericarditis
pericardial thickening 3mm
82
volume gastric aspirate
5-10ml
83
volume gastric lavage
25 to 50ml
84
transportation of gastric lavage
within 1 hour in room temp
| may add 100mg sodium bicarbonate
85
volume of sputum
3ml
86
how to collect sputum
1. rinse mouth with water
2. breathe 3x
3. cough hard
4. expectorate in steril vial
87
volume respiratory wash
3ml with up to 5ml steril saline
room temp 1 hr
may be stored in fridge if >1hr
88
specimen for tissue
add up to 3ml sterile saline
room temp 1 hr
may be stored in fridge if >1hr
89
specimen for blood
10ml in yellow top sodium polyanetholsulfonate or green top with heparin
90
specimen for body fluids
10-15ml
room temp 1 hr
may be stored in fridge if >1hr
91
specimen for bone marrow
10ml in yellow top sodium polyanetholsulfonate
room temp
do not put in fridge
92
specimen for urine
40ml, minimum 10-15ml
room temp 1 hr
may be stored in fridge if >1hr
93
most effective bactericidal drugs
isoniazid and rifampicin
94
pyrazinamide is only active in
acidic environment of macrophages
| used in acute inflammation
95
ethambutol prevents
resistant bacilli
96
older kids and adolescents use adult dosing when
>25kg
97
MOA of isoniazid
10mkday (10-15) max 300mg
bactericidal
inhibits mycolic acid synthesis
inhibits catalase peroxidase enzyme
98
side effect isoniazid
hepatitis
hemolysis g6pd def
peripheral neuropathy
99
MOA of rifampicin
15mkday (10-20) max 600mg
| inhibits dna dependent rna polymerase
100
side effect rifampicin
hepatitis
red orange urine
hypersensitivity
101
MOA of pyrazinamide
30mkday (20-40) max 2g
| disruption of membrane energy metabolism
102
side effect of pyrazinamide
hepatitis
hypersensitivity
arthralgia
103
MOA of ethambutol
20 (15-25) max 1.2g
| inhibits transferase in cell wall synthesis
104
side effect ethambutol
reversible optic neuritis
105
moa amikacin kanamycin streptomycin
inhibit protein synthesis
106
side effect amikacin kanamycin streptomycin
nephro and ototoxic
107
moa capreomycin
inhibit protein synthesis
108
side effect capreomycin
psychosis
| seizure
109
moa ofloxacin levofloxacin moxifloxacin
inhibit dna gyrase
110
side effect ofloxacin levofloxacin moxifloxacin
tendon rupture
| prolonged QT
111
moa prothionamide ethionamide
block mycolic synthesis
112
side effect prothionamide ethionamide
neurotoxic
hepatotoxic
gynecomastia
reversible hypothyroidism
113
category I
pulmo or extra pulmo CNS, bones, jointsNEW
2hrze
4hr
114
category Ia
extra pulmo NEW CNS, bones, joints
2hrze
10hr
115
category II
pulmo or extra pulmo tb (except CNS, bones, joints)
1. relapse
2. treatment after failure (5mo still smear+)
3. treatment after lost to f/u
4. prev tx unknown
2hrzes
1hrze
5hre
116
category IIa
extra pulmo CNS, bones, joints
2hrzes
1hrze
9hre
117
isoniazid preventive therapy IPT
| given to
1. hiv
2. <5yo with household contact smear (+) regardless of kids TST
3. <5yo with household contact smear (-) but with kids TST (+)
118
for isoniazid preventive therapy IPT
| repeat TST done after
3 months
if (-) give BCG
if (+) continue INH to complete 6 months
119
corticosteroids most beneficial when given
1. tb menigitis
2. tb pericarditis
3. tb pleural effusion
4. endobronchial tb
5. miliary tb
120
how to give corticosteroids in tb
prednisone 2kday x 4-6weeks
then taper 1-2 weeks then d/c
for seriously ill give 4mkday MAX 60mg/day
121
definition CURED
treatment completed with no evidence of failure and three or more consecutive cultures take at least 30 days apart (-)
122
breastfeeding with TB
safe
breastfeed first before taking meds
supplement with pyridoxine
123
asymptomatic pregnant woman with positive TST, normal cxr, and contact with TB
isoniazid 9 months, begin after first trimester
124
newborn with asymptomatic mother but mom is TST (+) and normal xray
don't separate
| give BCG
125
mom has TB but has completed at least 2 weeks at time of delivery
DO NOT GIVE BCG
given ISONIAZID first for 3 months then do TST
if (-) STOP ISONIAZID and give BCG
if (+) and baby is well, continue ISONIAZID for another 3 months -> if after 6mo baby is well, give BCG
if no TST available, give ISONIAZID for 6 months then do BCG
126
mother has current tb but no Tx
give ISONIAZID
if mom is isoniazid resistant, give RIFAMPICIN
placenta sent for studies, workup baby
TST (-) then repeat after 3 mo
TST (+) but normal cxr, complete ISONIAZID/RIFAMPICIN 6 months
if TST (-) and CXR (-) and mom completed treatment may stop ISONIAZID/RIFAMPICIN and administer BCG
127
kid with liver problem with tb
monitor ALT 2x/week first 2 weeks
then WEEKLY until 2nd month
then MONTHLY until end of tx
128
if pyrazinamide cant be given
2mo INH, RIF, ETH
7mo INH RIF
or PZA can be substituted with fluoroquinolone
129
if with liver cirrhosis
aminoglycoside, fluoroquinolone, cycloserine for 18-24 months
130
should we stop if kid <5yo, with elevated transaminase 5x but asymptomatic
no
131
drug induced liver injury
AST 3x elevated with symptoms
or 5x elevated w/o symptoms
AST <5x mild
5-10x moderate
>10x sever
132
how to restart meds in drug induced liver injury
one at a time after AST returns to <2x
| RIF first, then INH, then PZA
133
caution in renal impairment
PZA (metabolites accum) and EMB (cleared renally)
| longer dosing interval is needed
134
drug efficiently removed by dialysis
pyrazinamide
135
when to administer drugs when ongoing dialysis
after dialysis
136
drug not removed by dialysis
rifampicin
137
primary prophylaxis in HIV kids
kids >12mo old
IPT, no known exposure at home but prevalent
6mo INH
138
t or f
| all kids with HIV and TB after completing treatment shoudl received additional 6 mo isoniazied
true
139
increased risk smear (+) in DM at hba1c of
9% and above
140
interaction of DM drugs and anti kochs
need to increase hypoglycemic agents because of increased metabolism cyp450 by rifampicin
141
transplant patients
TST prior to transplantation
142
indication of IPT in transplant patients
1. >5mm before transplantation
2. A. cxr of old tb, B. hx of inadequate tb tx, C. close contact to person w/ tb, D. recipient of donor with hx of inadequate tb tx
3. newly infected
143
patient for gastrectomy with TST (+)
ideally give INH prophylaxis
144
patient for jejunoileal bypass with TST (+) >10mm
ideally give INH prophylaxis 6 mo
145
prior to anti TNF treatment
TST done first
146
prophylaxis prior to anti TNF tx
6mo INH
3mo INH RIf
AST baseline then q3mo
147
minor rash after taking drugs
rif and pza
| give diphen, loratadine then continue meds
148
petechial rash after taking drugs
check cbc if thrombocytopenia
| rifampicin stopped
149
generalized rash after taking drugs
stop all meds, give alternate drugs
can be restarted one by one interval 2-3 days
start with INH, rifampicin etc
150
vomiting after taking drugs
may give with food
| check ALT
151
diarrhea while taking anti kochs
stop all
| restart one at a time q4 days
152
jaundice after taking drugs
stop all
may give streptomycin and ethambutol
order of rechallenge: rif, inh, pza q4days
153
drug fever
check if no infection
stop meds, may give alternative
should resolve in 24 hours
154
adverse effect joint pain
pza
155
adverse effect flu
rifampicin
156
adverse effect neurotoxicity (drowsiness, dizziness, seizures)
inh
