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X Clin Med II Exam 2 > TB, Histoplasmosis and Cocci > Flashcards

TB, Histoplasmosis and Cocci Flashcards

(73 cards)

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1
Q

What is the number 1 killer of the HIV pt?

A

TB

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2
Q

Where does mycobacterium affect?

A

Mostly the lungs (can be lymph nodes, kidneys, spine or brain)

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3
Q

How is TB transmitted?

A

Through airborne droplet nuclei
Occurs when inhaled nuclei reach the alveoli
Usually requires prolonged exposure from active TB

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4
Q

What is active TB classified as?

A

Disease sxs that occur within 2 yrs of transmission

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5
Q

What is a latent TB infection?

A

Macrophages ingested tubercle bacilli and created barrier shell called a granuloma so that pt is unable to transmit infection to others

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6
Q

When does LTBI become a disease state?

A

If pt becomes immunocompromised and granulomas break down because immune system is unable to fight the infection

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7
Q

What percent of TB cases are active?

A

10% (5 initially and 5 develop from latent)

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8
Q

Who else is at higher risk of developing active TB?

A

Pts with diabetes

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9
Q

When is CXR recommended?

A

With positive infection testing or sxs present

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10
Q

Who is at greater risk for TB?

A

Immunocompromised (HIV, <5, DM, silicosis, malnutrition, substance abuse, immunosuppressive therapy)
Immigrants from areas with high TB prevalence
Injection drug users
Close living quarters (nursing homes, institutions etc)

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11
Q

Sxs of TB

A

Fever
Cough (3+ weeks, maybe productive or hemopytis)
Pleuritic or retrosternal CP
May have weakness, weight loss, anorexia, chills, night sweats, dyspnea or extrapulm manifestations

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12
Q

What is seen on the physical exam with TB?

A 
*might be normal
Classic is posttussive crackles
Dullness or decreased fremitus if pleural thickening
LAD
Clubbing if severe
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13
Q

What is the Mantoux tuberculin skin test?

A

Create wheal with .1 ml purified protein derivative in forearm intradermally
Rd 48-72 hrs later and measured mm
(may not be present for 2-8 wks after exposure)

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14
Q

What is measured on the TB skin test?

A

Induration not erythema

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15
Q

Who is positive based on TB skin test rxn > 5mm?

A 
HIV positive pts
Recent contacts of those with active TB
Persons with evidence of TB on CXR
Immunosuppressed pts (chronic steroids)
Organ transplant pts
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16
Q

Who is positive based on TB skin test rxn > 10mm?

A

Recent immigrants from countries with high rate of TB infection
HIV negative injection drug users
Mycobacteriology lab personnel
Residents/employees of high risk congregate settings
Persons with certain high risk medical conditions
Kids <4
Kids and adolescents exposed to adults at high risk

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17
Q

Who is positive based on TB skin test rxn >15mm?

A

Everyone!!!

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18
Q

What is the 2 step TB test?

A

Recommended as initial test for health care workers and individuals that need periodic retesting
1st neg: repeat in 1-2 wks
2nd pos: TB infection is present and this creates a boosted response likely due to past exposure so don’t see a false positive

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19
Q

What might create a false positive on TB skin test?

A

Bacillus Calmette-Guerin vaccine

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20
Q

What is the IGRA:Quantiferon gold test?

A

Measures immune response in blood to TB because blood is incubated with TB antigen
Used when pt won’t follow up or if they have BCG vaccine
Neither can differentiate active and latent disease
More expensive

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21
Q

What is seen on a CXR in TB?

A

Hilar LAD or normal
May progress to pleural effusions or infiltrates
Cavities seen in progressive pulm TB
Miliary pattern
Cannot determine between active and latent

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22
Q

What is normal for latent TB on CXR?

A

Dense nodules or lesions with possible calcifications

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23
Q

What is seen for reactivation of latent TB on CXR?

A

Cavities, infiltrates and possible adenopathy

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24
Q

Where is the most common place to see abnormalities on CXR?

A

Apical/posterior upper lobes mostly (or superior areas of lower lobe)

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25
What is Ranke complex?
Healed primary pulmonary TB with Ghon lesion (calcified parenchymal granuloma) and ipsilateral calcified hilar lymph node
26
How do you collect sputum?
``` 3 specimens (8-24 hrs apart) At least one in the morning because that is the best specimen ```
27
3 ways to test sputum
Smear (acid-fast bacilli, easy and quick, supportive) Cytology (nucleic acid amplification test, supportive) Culture (gold standard to confirm dx but takes a long time)
28
What does it mean if AFB and NAA are both positive?
TB disease is presumed and tx begins (do not delay while waiting for culture)
29
What does it mean if the culture is positive?
TB disease is present (use drug susceptibility testing)
30
What does it mean if culture is negative and TB disease still suspected?
Treat and monitor response to tx
31
What is the hallmark of TB on biopsy?
Necrotizing (caseating) granulomas | only if needed
32
What is the Xpert MTB/RIF assay used for?
IDs M tuberculosis DNA and rifampin resistance (NAA test with cartridges) Quick but costly Approved for dx in pts with < 3 days of therapy
33
Where are active TB pts treated?
Isolated, negative pressure inpatient hospital room
34
First line drugs for active TB
``` Rifampin Isoniazid Pyrazinamide Ethambutol All with direct observed treatment ```
35
Side effects of rifampin
Orange secretions | Skin sensitivity
36
Side effects of isoniazid
``` Hepatotoxic Peripheral neuropathy (give vit B6) Fatal hepatitis (pregnant women at increased risk) ```
37
Side effects of pyrazidamide
Hepatotoxic Hyperuricemia Not in pregnancy!!
38
Side effects of ethambutol
Optic neuritis (test visual acuity and color vision)
39
Initial and continuation phase of TB tx
Initial: 4 meds daily X 2 mos Continuation: RIF and INH daily or twice weekly x 4 mos
40
Modifications to tx
HIV: extends tx 9-12+ mos (intermittent dosing) Pregnant women: no pyrazinamide Infants/kids: ethambutol not given and may extend tx
41
What are the criteria to not be considered infectious?
2 wks of tx regimen 3 negative sputum smears Sxs improve
42
When can someone go home while still infectious?
If they have strict f/u DOT is arranged No kids <5 or immunocompromised ppl in the home Unable to travel except for healthcare visits
43
When is tx completion for TB?
Based on doses not duration Initial for 8 wks: 56 doses Continuation for 18 wks: 126 doses daily or 36 doses twice weekly *for active
44
Options for tx of latent TB
Isoniazid for 9 mos (300 mg daily for 900 mg twice weekly with DOT)- preferred in pregnancy and kids 2-11 INH and rifapentine is newly preferred for adults (not pregnant) and kids >12- 12 weekly doses Rifampin at 4 mos regiment with 120 doses
45
What drugs classify MDR TB?
INH and RIF (because of inadequate medication, premature tx interruption or spontaneous mutation)
46
XDR-TB
Responds to less drugs including fluoroquinolones | Surgery to remove necrotic tissue is important
47
Bacille Calmette-Guerin vaccine
Intradermal live strain vaccine Decreases risk of severe consequences due to TB (does not prevent primary infection or activation)- proven to protect against meningitis and disseminated TB in kids
48
Recommendations for BCG vaccine
Kids with negative TST and have continual exposure (not HIV+ tho) Healthcare workers if high risk for MDR
49
Contraindications for BCG vaccine
Immunosuppressed | Pregnancy
50
Where do you contract histoplasmosis?
From soil contaminated with bird or bat droppings (inhale fungal spores) Mostly in OH and mississippi river valleys
51
History associated with histoplasmossis
``` Recent exposure (spelunking, construction etc) 90% asymptomatic or mild-flu like sxs that resolve in a few wks ```
52
Asymptomatic primary histoplasmosis
Most common in healthy people | CXR may show residual granuloma
53
Acute symptomatic pulmonary histoplasmosis
Fever, marked fatigue, few respiratory sxs Sxs 1 wk-6 mos Mild sxs usually self-limited
54
Progressive disseminated histoplasmosis
Pt typically immunocompromised Fever, fatigue, cough, dyspnea, weight loss Multiple organ involvement Fatal within 6 wks
55
Chronic pulmonary histoplasmosis
Older COPD pts | Progressive lung changes like apical cavities
56
Serology for histoplasmosis
Antibody tests like immunodiffusion test (acute and chronic) or complement fixation (more sensitive but takes longer) Antigen detections with enzyme immunoassay (urine or serum testing)
57
What can be seen on the CXR in histoplasmosis?
Hilar adenopathy | Patchy or nodular infiltrates in lower lobes
58
Tx for asymptomatic histoplasmosis
None (<4 wks)
59
What kinds of drugs might be used for histoplasmosis?
Amphotericin or azoles
60
When to suspect histoplasmosis?
``` Pneumonia with mediastinal or hilar LAD Mediastinal or hilar mass Pulm nodule Cavitary lung disease Pulmonary sx with rheumatologic arthritis/arthralgia +erythema nodosum Dysphagia with esophageal narrowing ```
61
How do you get coccidiomycosis?
Contaminated soil (lower deserts of western hemisphere)--AZ, San Joaquin Valley CA, new mexco etc
62
Who has a more severe presentation of cocci?
Immunocompromised, pregnant, diabetics and in African or Filipino descent
63
Sxs of cocci
Most are asymptomatic (residual granuloma on CXR) Mild respiratory sxs that are self-limited about wks to mos- may progress with chronic pulm disease or disseminated disease
64
Primary infection of cocci
Usually present with CAP (7-21 days after exposed) Fever, cough, pleuritic CP (may also have fatigue, HA or arthralgia-desert rheumatism) Rash: erythema multiform or erythema nodosum
65
Disseminated disease of cocci
Seen in those higher risk groups More pronounced lung findings Bone lesions Lymphadenitis, meningitis
66
Serology for cocci
``` Enzyme immunoassay Immunodiffusion test (IgM antibodies) Complement fixation (IgG antibodies- detect severity) ```
67
Other diagnostics for cocci
Labs (eosinophilia with slight leukocytosis) SPutum culture Skin test (not diagnostic)
68
What might be seen on a CXR with cocci?
Hilar adenopathy Patchy nodular, pulmonary infiltrates Miliary infiltrates Thin wall cavities
69
CXR of chronic pulmonary disease of cocci
Residual lung nodules with thin walled cavities (disappear within 2 yrs) Chronic cavitary lesions with infiltrates (may mimic TB)
70
Tx for cocci
Tx typically not required (only for high risk group or have severe illness)-use azoles but not ketoconazole (increased side effects)
71
Tx in pregnancy for cocci
Amphotericin b (because azoles are teratogenic)
72
F/u for cocci
Every 2-4 wks regardless of tx (goes for 1 yr if no meds, if tx then for 2 years for recurrence)
73
When do you think cocci??
``` Pulmonary complaints AND One or more of the 3 Es: Erythema nodosum Erythema multiforme Eosinophilia ```

X Clin Med II Exam 2 (6 decks)

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