Phar 352 - Tuberculosis

Front 1

How has the rate of Tuberculosis changed in the past 30 years?

Back 1

Has decreased in the past 20 years but eventually leveled off due to prevelence of TB in 3rd world countries

Front 2

How many organisms can cause Tuberculosis?

Back 2

There are over 20 species but only 3 are pathogenic to humans

Front 3

Which organism is the most common cause of Tuberculosis?

Back 3

Mycoplasma tuberculosis (M.tuberculosis)

Front 4

What are the physical characteristics of M.tuberculosis? (4)

Back 4

1) Aerobic 2) Rod Shaped (Bacilli) 3) Slow Growing 4) Acid-fast positive

Front 5

What is the description of TB class 0?

Back 5

No TB exposure, not infected.

No history of exposure, negative reaction to tuberculin skin test.

Front 6

What is the description of TB class 1?

Back 6

TB exposure, no evidence of infection.

History of exposure, negative reaction to tuberculin skin test

Front 7

What is the description of TB class 2?

Back 7

TB infection, no disease.

Positive reaction to tuberculin skin test AND negative bacteriologic studies AND no clinical, bacteriological or radiographic evidence of active TB

Front 8

What is the description of TB class 3?

Back 8

TB, clinically active.

M.tuberculosis cultured OR clinical/ CXR evidence of disease AND positive tuberculin test

Front 9

What is the description of TB class 4?

Back 9

TB, not clinically active.

1) History of episodes of TB OR

2) Abnormal but stable radiographic findings +positive reaction to PPD+negative bacteriologic studies AND

3) No clinical radiographic evidence of current disease

Front 10

What is the description of TB class 5?

Back 10

TB suspected.

Diagnosis pending

Front 11

What is the method of transmission of M.tuberculosis?

Back 11

Spread by droplet nuclei.

Expelled when a person with infectious TB coughs, sneezes or speaks in close contacts for extended periods of time

Front 12

Which patients of Tuberculosis are infectious?

Back 12

Persons with positive smears are highly infectious

{latent TB patients are not infectious}

Front 13

What factors increase the probability that TB will be transmitted?

Back 13

1) Infectiousness of person with TB

2) Closeness of individuals

3) Duration of exposure

4) Virulence of the organism

Front 14

What are the common sites of TB disease?

Back 14

1) Apical segment of Lung

2) Pleura of lung

3) Central Nervous System

4) Lymphatic system

5) Genitourinary systems

6) Bones and Joints

7) Disseminated

Front 15

What is the pathogenesis of Latent TB Infection?

Back 15

Macrophages form granulomas to contain the organism, and activated lymphocytes now begin to destroy the TB containing macrophages. Dissemination is halted, and bacteria within granulomas avoid lysis

Front 16

What is the pathogenesis of Active TB Infection?

Back 16

If the immune system cannot keep the bacilli under control, the bacilli begin to multiply rapidly in the lung and may spread via the bloodstream to seed a variety of organisms with high blood flow

Front 17

What are the conditions that increase the risk of progression to TB disease? (9)

Back 17

1) CXR suggestive of previous TB

2) HIV infection

3) Substance abuse

4) Cancer

5) Diabetes mellitus

6) Malnutrition

7) Prolonged Corticosteroid therapy

8) Other immunosupressives

9) Chronic Renal Failure

Front 18

How do you perform the Tuberculin Skin Test?

Back 18

Injected intradermally 0.1ml of 5TU PPD tuberculin.

Read in 48-72hrs, read the induration not the redness

Front 19

What is the positive TST criteria for >5mm reaction?

Back 19

1) CXR suggestive of previous TB

2) HIV (+ve) patients

3) Injecting Drug Users

4) Recent close contacts of people with active TB 5) Organ transplants or immunosupressed patients

Front 20

What is the positive TST criteria for >10mm reaction?

Back 20

1) Recent arrivals from foreign born countries

2) Injecting drug users known to be seronegative for HIV

3) Institutionalized patients (nursing homes, prisons)

4) Mycobacteriology personnel

5) Medical conditions that increase the risk of developing TB disease

6) Children <4 years of age or children and adolescents

Front 21

What is the positive TST criteria for >15mm reaction?

Back 21

No known risk factors

Front 22

What are the factors that affect TB skin test results?

Back 22

1) BCG Vaccine

2) Infection with other mycobacteria

3) Anergy Control

Front 23

What is the role of the Anergy Control in the TB skin test?

Back 23

Used for patients who may have dysfunctional immune system such that they would not react to the skin test.

(E.g. HIV patients, elderly, critically ill, malnourished and patients on chronic immunosuppressives)

Front 24

What does a positive PPD and positive Anergy Control indicate?

Back 24

Infected

Front 25

What does a negative PPD and positive Anergy Control indicate?

Back 25

Not Infected

Front 26

What does a negative PPD and negative Anergy Control indicate?

Back 26

Unknown

Front 27

What is a IGRA and what is its role?

Back 27

Interferon Gamma Release Assay.

Detects patients who have been infected but doesn’t determine if they have active disease.

Front 28

What are examples of IGRAs?

Back 28

Quantiferon Gold or T-SPOT

Front 29

What is the goal of therapy for Latent TB Infection?

Back 29

To prevent patients with TB infection developing disease

Front 30

Which patients are candidates for treatment of Latent TB Infections? (3)

Back 30

1) +ve PPD skin test AND

2) -ve smears and cultures AND

3) No clinical or xray evidence of disease

Front 31

What is the recommended treatment of Latent TB Infection?

Back 31

1st line: Isoniazid 300mg PO daily x 9month

[2nd line: Rifampin 600mg PO daily x 4months]

can be given twice weekly if directly observed

Front 32

What is the goal of therapy for Active TB Infections?

Back 32

To cure patients with TB disease

Front 33

Which patients are candidates for treatment of Active TB Infections?

Back 33

1) +ve smears and cultures OR

2) Clinical or Xray evidence of disease AND +ve PPD skin test

Front 34

What are the symptoms of Active TB Infections? (9)

Back 34

1) Fever

2) Cough

3) Chills

4) Chest Pain

5) Night Sweats

6) Hemoptysis (coughing blood)

7) Appetite loss

8) Weight loss

9) Easy fatigability

Front 35

What are the physical examination signs of Active TB? (4)

Back 35

1) Shortness of Breath

2) Tachypnea

3) Dullness to percussion

4) Crackles or rales

Front 36

What is the typical chest radiograph result of Active TB?

Back 36

Abnormalities often seen in apical segment of upper lobe or superior segments of lower lobe

Front 37

How long does it take Smear Examination of TB to decrease?

Back 37

With treatment, bacteria load decreases within 2 weeks and some patients may take up to 4 months to clear

Front 38

How do you identify that the TB has become latent via Smear Examination?

Back 38

Should get 3 consecutive negative smear results (taken 5-7 days apart)

Front 39

Would you culture a patient if the smear examination was negative?

Back 39

Culture all specimens, even if the smear is negative

Front 40

What is the role of TB Culture?

Back 40

Used to confirm diagnosis of TB

Front 41

What are the first line Anti-tuberculosis drugs? (4)

Back 41

1) Isoniazid

2) Rifampin

3) Pyrazinamide

4) Ethambutol

Front 42

What are the second line Anti-tuberculosis drugs? (7)

Back 42

1) Streptomycin

2) Cycloserine

3) p-Aminosalicylic acid

4) Ethionamide

5) Amikacin/Kanamycin

6) Capreomycin

7) Levofloxacin/Moxifloxacin/Gatifloxacin

Front 43

What is the recommended initial treatment regimen for Active TB?

Back 43

Standard four drug regimen. (Isoniazid, Rifampin, Pyrazinamide, Ethambutol) for 2 months

Front 44

What is the recommended Continuation treatment regimen for Active TB?

Back 44

Additional 4 months (or 7 months if cavitary disease, extra-pulomonary TB, or clinical complications)

Front 45

What is the recommended treatment if cultures come back and ALL 4 drugs are sensitive?

Back 45

drop the Pyrazinamide and Ethambutol. Continue Isoniazid and Rifampin.

Front 46

What is Directly Observed Therapy ?

Back 46

Health care worker watches patient swallow each dose of medication

Front 47

When would you recommend DOT?

Back 47

Consider DOT for all patients, and shoud be used with all intermittent regimens

Front 48

What is the primary reason for failure of TB treatment?

Back 48

Non adherence

Front 49

What are the efficacy monitoring parameters for active TB?

Back 49

Resolution of signs and symptoms, physical exam parameters, diagnostic parameters (AFB and culture, CXR)

Front 50

What are the common ADRs of Ethambutol?

Back 50

Eye Damage: Blurred/Changed vision, Changed color vision

Front 51

What are the common ADRs of Isoniazid?

Back 51

Peripheral Neuropathy: Tingling sensation in hands/feet.

Hepatitis: Abdominal pain, abnormal liver functional tests, fatigue, lack of appetite, nausea, vomitting, yellowish skin or eyes, and dark urine.

Front 52

What are the common ADRs of Pyrazinamide?

Back 52

Gastrointestinal Intolerance: Upset stomach, vomitting, lack of appetite

Arthralgia/Arthritis: Joint aches and Gout (rare)

Hepatitis: Abdominal pain, abnormal liver functional tests, fatigue, lack of appetite, nausea, vomitting, yellowish skin or eyes, and dark urine.

Front 53

What are the common ADRs of Streptomycin?

Back 53

Ear Damage: Balance problems, Hearing loss, ringing in the ears

Kidney Damage: Abnormal Kidney function tests

Front 54

What are the common ADRs of Rifamycins?

Back 54

Thrombocytopenia: Easy bruising, Slow blood clotting

GI Intolerance: Upset Stomach, interferes with birth control and methadone

Hepatitis: Abdominal pain, abnormal liver functional tests, fatigue, lack of appetite, nausea, vomitting, yellowish skin or eyes, and dark urine.

Front 55

What are the common drug interactions of Rifamycins?

Back 55

decrease serum concentrations of many drugs to sub-therapeutic levels (birth control and methadone)

Front 56

What are the common drug interactions of Isoniazid?

Back 56

increase concentrations of some drugs (e.g.phenytoin) to toxic levels