Tuberculosis

Question 1

List 5 commonest symptoms of TB disease

Answer 1

1. Cough
2. Drenching night sweats
3. Fever
4. Weight loss
5. Hemoptysis

Question 2

Who should be checked for TB routinely even when there are no symptoms and when?

Answer 2

1. The client had TB in the last 2 years: yearly and for 2 years after completing TB treatment
2. The client is HIV positive: at diagnosis, yearly and at first antenatal visit if pregnant
3. Excluding TB during TB preventive treatment work up
4. Abnormal TB screening CXR even if no known TB exposure

Question 3

List 6 features of TB you can possibly find on a chest X ray.

Answer 3

1. Hemoptysis of fresh blood>=1 tablespoon
2. Respiratory rate>=30
3. Breathlessness at rest or while talking
4. Accessory muscles usage
5. Neck stiffness
6. Confusion and drowsiness
7. Persistent vomiting
8. New weakness of arm/legs

Question 4

What is the first initial test for diagnosing TB?

Answer 4

Sputum TB nucleic acid amplification test

Question 5

How many sputum samples should be sent for TB work up?

Answer 5

2 taken 1 hour apart

Question 6

Who should get a Urinary LAM done on if TB is being suspected?

Answer 6

HIV positive with CD4 count=<200 or WHO stage 3 or 4 disease

Question 7

List investigations that should be done first in a patient suspected of having TB in order include tests requested in special cases

Answer 7

1. Sputum for TB Nucleic acid amplification test
2. HIV test
3. Chest X ray

Special occasions
4. HIV positive with CD4 count=<200 or WHO stage 3/4: Rapid urinary lam
5. Had TB in last 2 years, Health care workers, prisoner and close contact R-R TB: Smear, TB culture and Line probe assays.

Question 8

When suspecting TB, which group of patients should get a smear, TB culture and line probe assays done for them?[4]

Answer 8

1. Health care workers
2. Prisoners
3. Close R-R TB contact
4. Had TB in the last 2.years

Question 9

Can you diagnose TB with only a urinary LAM?and say what to do if it is negative

Answer 9

Yes if it is positive Tb is diagnosed

But if it is negative it does not rule out TB, you have to use sputum results,. clinical and radiological findings to make a diagnosis

Question 10

What should you do if a patient is unable to produce a sputum for Tb?

Answer 10

Arrange chest X ray.

They should return after 2 days for results

Question 11

How long should a TB patient wait before their results come back?

Answer 11

They should return after 2 days

Question 12

Is chest X ray the initial test for diagnosing TB?

Answer 12

Nope, TB NAAT is number 1 then if it is equivocal and the client has YB symptoms then CXR can be used to diagnose.

Question 13

What should you do if TB NAAT is trace and the patient is asymptomatic?

Answer 13

Depends on whether they had TB in the last two years or not
Yes: Review Line probe assays and culture results and continue assessment for TB preventative therapy and do not start treatment
No: Arrange Chest X ray and doctor review

Question 14

What is the next step if TB NAAT is negative in a patient who had no history of TB in the last 2 years?

Answer 14

1. Check for rifampicin sensitivity:
   If sensitive: Diagnose Drug sensitive TB and start treatment immediately
   If resistant: Diagnose rifampicin resistant TB and start treatment immediately.

Question 15

What should be done after TB NAAT is positive?

Answer 15

Sensitivity for rifampicin

Question 16

What is your next step if a patient who had DS-TB in the last 2 years has TB NAAT that is positive and the smear is negative?

Answer 16

Symptomatic: Arrange CXR
Asymptomatic: Review culture and line probe assays and continue assessment for TPT and avoid treatment

Same thing for PRECIOUS RR-TB

Question 17

If TB NAAT and smear are positive, what should be your next step?

Answer 17

Diagnose DS-TB and Start treatment sme day

Question 18

What is your next step if a patient who had RR-TB in the last 2 years has a positive TB NAAT and smear?

Answer 18

Diagnose RR TB and start treatment

Question 19

What is meant by a TB contact

Answer 19

Any person who shared an enclosed space for >=1 night or frequent/extended daytime periods with an adult/adolescent with pulmonary TB during the 3 months period before the adult/adolescent(index patient) started their treatment

Question 20

What is the best time to obtain a sputum from a patient if they are unable to produce one?

Answer 20

Early morning

If not possible arrange for induced sputum

Question 21

What will the lab people do if the patient who had rifampicin susceptible or unsuccessful Tb is the last 2 years has a TB NAAT that is positive?

Answer 21

Susceptible: Reflex smear on the second sputum
Unsuccessful: Reflex smear,.TB culture and LPA

Question 22

What do the lab people do if the TB NAAT is trace?

Answer 22

Reflex culture and Line probe assays but not culture

Question 23

What is your next step if TB NAAT is negative and the patient is HIV negative?

Answer 23

Symptoms: Arrange CXR
Asymptomatic: Continue assessment for TPT eligibility and advise to retun if TB symptoms develop.

Question 24

What is the next step if TB NAAT is negative and the patient is HIV positive?

Answer 24

Symptomatic: Arrange CXR
Asymptomatic: Continue assessment for TPT, review LPA and culture and avoid starting treatment

Question 25

List 6 features of TB you can possibly finon a chest X ray.

Answer 25

1. Upper lobe cavitations 2. Any opacification can be TB in HIV positive client 3. Pleural effusion(Bilateral=refer) 4. Intrathoracic lymphadenopathy 5. Miliary TB 6. Pericardial effusions (confirm on U/S)

Question 26

In a patient suspected of having TB and pleural effusion on CXR without a positive TB NAAT,what should be done next?

Answer 26

Aspirate the fluid and send 2 samples for Clear: TB culture, LPA, ADA and cell count Pus: TB NAAT, microscopy, TB culture and Drug sensitivity testing(refer same day)

Question 27

List tests that should be done on a clear pleural fluid if TB is suspected

Answer 27

Tb culture, LPA, ADA and cell count

Question 28

Lists 4 tests that should be requested for on a pus containing pleural fluid aspirate in a patient suspected of having TB.

Answer 28

TB NAAT, microscopy, TB culture and drug sensitivity testing

Question 29

Which patients deserve to get DS TB treatment even though the chest X ray findings were not suggestive of TB but they are symptomatic?

Answer 29

1. TB NAAT negative in HIV positive patient 2. TB NAAT trace positive and no TB in last 2 years

Question 30

List 5 commonest symptoms of TB disease

Answer 30

1. Cough 2. Weight loss 3. Drenching night sweats 4. Fever 5. Hemoptysis

Question 31

List 12 tests that should be done at diagnosis of RR TB.

Answer 31

HIV test: If already positive check viral load Pregnancy test FBC and differential count Creatinine and eGFR ALT Urea and electrolytes mainly potassium and magnesium TSH TB microscopy, culture, LPA and drug sensitivity testing from 1 sputum(automatically tested by the lab using the 2nd sputum) EKG and chest X ray Snellen chart for vision Finger prick glucose

Question 32

Name two investigations that should be tested if someone if on linezolid and when it should be done.

Answer 32

FBC and differential count at 2 weeks and monthly Vision with a Snellen chart monthly

Question 33

Why is the EKG done routinely in people with RR TB?

Answer 33

Bedaquiline, clofazimine, moxifloxacin or delamanid are cardiac toxic

Question 34

Name 4 investigations that should be done if someone is on amikacin.

Answer 34

Creatinine Potassium Magnesium Audiometry

Question 35

Name two investigations that

Question 36

Name two drugs that when used for RR TB, TSH should be checked.

Answer 36

Ethionamide Or PAS Checked at 3 months

Question 37

Name two investigations that should be done at 6 months of RR TB.

Answer 37

Chest X-ray If HIV: CD4 AND viral load

Question 38

If a patient with RR TB is unwell which tests should be done?

Answer 38

Chest X-ray, Creatinine, ALT, potassium and magnesium

Question 39

One bedaquiline is stopped, EKG should be done 3 monthly

Question 40

When should TB sputum testing done again after the diagnosis of RR TB?

Answer 40

At 1 months

Question 41

Name 4 RR TB drugs that prolong QT interval.

Answer 41

Bedaquiline Clofazimine Moxifloxacin Delamanid If QTcF>500 STOP THE DRUGS

Question 42

2 Adverse effect of amikacin

Answer 42

Hearing loss Hypokalemia Check with an audiometry

Question 43

When should all TB drugs be stopped based on the liver function test?

Answer 43

ALT>200

Question 44

When should MgCl be given?

Answer 44

Mg<0.6

Question 45

Name 2 combinations of TB and HIV drugs that should never be used together

Answer 45

Zidovudine and linezolid Efavirenz and bedaquiline

Question 46

5 criteria that should be met to confirm that TB is cured.

Answer 46

TB culture converted At least 3 consecutive negative cultures in the continuation phase If on a shorter course: at least 9 months of treatment If on a longer course: at least 12 months of treatment Not clinically worsening

Question 47

5 criteria that should be met to confirm that RR TB treatment is completed.

Answer 47

Tb culture converted If on a shorter course: at least 9 months of treatment If on a longer course: at least 18 months of treatment Not clinically worsening <3 consecutive negative cultures in continuation phase

Question 48

4 criteria that should be met to confirm that RR TB treatment has failed.

Answer 48

Failure of month 4 TB to convert by month 6 At least 2 positive cultures in continuation phase and clinically worsening Treatment stopped on clinical grounds or by instruction from PCAC At least 2 new drugs added to the regimen due to poor clinical response

Question 49

4 clinical features that show slow clinical response to RE TB treatment

Answer 49

Poor weight gain Ongoing TB symptoms Poor improvement on chest X-ray Delayed smear/culture conversion

Question 50

Outline the treatment of RR TB on a shorter course.

Answer 50

Intensive phase: Linezolid 2 months Bedaquiline for at least 6 months Levofloxacin Clofazimine High dose isoniazid Pyrazinamide Ethambutol Continuation phase Bedaquiline Levofloxacin Clofazimine Pyrazinamide Ethambutol

Question 51

When do you typically use delamanid in treatment of tb.

Answer 51

If TB is fluoroquinolone resistant and there is CNS disease

Question 52

Name RR TB drugs that lead to psychosis and seizures

Answer 52

Terizidone Levofloxacin High dose isoniazid

Question 53

Adverse effect of rifabutin

Answer 53

Painful/red eyes with blurry vision and sensitive to light

Question 54

Name a TB durgbathat cause skin darkening and dry skin.

Answer 54

Clofazimine

Question 55

Name three RR TB drugs that lead to peripheral neuropathy

Answer 55

Isoniazid Terizidone Linezolid

Question 56

Name 4 RR TB drugs that lead to joint paint

Answer 56

Pyrazinamide Levofloxacin Delamanid Bedaquiline