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24 Cards in this Set
- Front
- Back
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Jane is a 68 year old female who is currently being treated for a rheumatoid flare with 20mg of prednisone for the last month. Today her TST (PPD) screening reveals a 6mm induration but she exhibits no signs or symptoms upon physical exam or chest X-ray.
What are your recommendations? a. Her PPD is not positive- no treatment is necessary at this time b. Her PPD is negative-rescreen in 6 months c. Her PPD is positive-treat her for LTBI immediately d. Her PPD is positive- treat her for TB disease immediately |
c. Her PPD is positive-treat her for LTBI immediately
Greater than 15mg prednisone for more than 4 weeks results in extensive immunosuppression and the cut off for treatment is >5mm. Without sign or symptoms this is considered LTBI. |
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You have just returned from spring break in Europe only to learn that the person in the seat in front of you was infected with active TB. What is the lowest recommended TST or PPD cut-off for someone who has been recently exposed?
a. Any sign of induration (you want treatment) b. 5mm c. 10mm d. 15mm |
b. 5mm
5mm with recent exposure is the lowest cut off for treatment. |
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Your PPD turns out to be 20mm (bad luck on seating) and your diagnosis is LTBI.
What is the first line agent along with dose and duration for this diagnosis? a. Isoniazid 300mg daily for 6 months plus pyridoxine 25mg daily b. Isoniazid 900mg weekly for 6 months plus pyridoxine 25mg weekly c. Isoniazid 300mg daily for 9 months plus pyridoxine 25mg daily d. Rifampin 300mg daily for 9 months |
c. Isoniazid 300mg daily for 9 months plus pyridoxine 25mg daily
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Unfortunately the 45 year old lady next to you on the plane was diagnosed with TB disease. What is the daily treatment regimen that you would recommend for her assuming she is of standard weight (70kg) and has no renal or hepatic dysfunction?
a. INH 300mg, RIF 900mg, PZA 2000mg, EMB 1600mg for 6 months b. INH 300mg, RIF 600mg, PZA 2000mg, EMB 1600mg for 6 months c. INH 900mg, RIF 900mg, PZA 2000mg, EMB 1600mg for 2 months and INH 300mg/RIF 900mg for 4 months d. INH 300mg, RIF 600mg, PZA 2000mg, EMB 1600mg for 2 months and INH 300mg/RIF 600mg for 4 months |
d. INH 300mg, RIF 600mg, PZA 2000mg, EMB 1600mg for 2 months and INH 300mg/RIF 600mg for 4 months
A 70kg woman requires the maximum dose per dosing interval. Treatment of active disease requires 4 drug treatment for 2 months followed by at least 4 months of isoniazid and rifampin. |
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Sam is a 45 year-old male construction worker at your clinic for a follow-up
appointment. He was seen five days ago at a local acute care clinic with a chief complaint of coughing for at least two weeks along with occasional night sweats. He was given a 3 day prescription for azithromycin (Zithromax) 500mg daily and a TST (Tuberculosis Skin Test) was placed. His cough has not improved and today’s chest Xray is read as suspicious for TB (tuberculosis). Sam’s acute care clinic reported a TST measurement of 4mm. He admits to a short stay in the local jail about six months ago for check fraud, shamefully revealing that he was using “recreational drugs”. He is currently living with his girlfriend and is “clean” now since his job does unannounced drug screening. Height: 72 inches Weight: 70kg Current Drug therapy: Multivitamin daily HCTZ 25mg daily CBC: Slight elevation in WBCs all other values: WNL. Baseline Labs: Cr:1.0 mg/dl AST:12 IU/L ALT: 10 IU/L Alk Phos: 25 IU/L tbili:0.8 mg/dl What is the most appropriate recommendation for this patient? A. Nothing as the TST was negative B. Wait 4 weeks then retest the TST to determine if TB treatment might be indicated C. Start treatment for LTBI (latent tuberculosis infection) and request an HIV test D. Start treatment for TB disease and request an HIV test |
D. Start treatment for TB disease and request an HIV test
a. Symptoms should be treated regardless of the TST test result. The patient may be in the window stage prior to seroconversion or testing may have not be done correctly etc. b. Increase risk of transmission to others as well during the waiting period. Treatment should be started. c. Patient has symptoms of active disease thus medications should be started. An HIV test is indicated in both LTBI and TB disease treatment. d. Correct answer: Patient has symptoms of active disease waiting on a skin test is not recommended. (An HIV test will allow you to determine whether the alternate to rifampin, Rifabutin should be used in the case where antiretroviral therapy is necessary prior to the completion of TB treatment.) |
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The team would like to know what the best regimen might be for this patient if he
had to be started on treatment at a later date. He is not obese with an ideal body weight of 70kg. What is the most appropriate recommendation? A. INH (isoniazid) 300mg daily for 9 months B. Rifampin 600mg daily for 6 months. C. INH (isoniazid) 300mg, RIF (rifampin) 600mg, PZA (pyrazinamide) 1500mg, EMB (ethambutol) 2000 mg daily 6 months D. INH (isoniazid)300mg, RIF (rifampin) 600mg, PZA (pyrazinamide) 1500mg, EMB (ethambutol) 2000mg daily for 2 months then Rifamate 2 tablets daily for 4 months. |
D. INH (isoniazid)300mg, RIF (rifampin) 600mg, PZA (pyrazinamide) 1500mg,
EMB (ethambutol) 2000mg daily for 2 months then Rifamate 2 tablets daily for 4 months. a. Patient needs treatment for TB disease not infection. This is treatment of choice for LTBI. b. Patient needs treatment of TB disease. This answer has an incorrect duration even for LTBI treatment dose of rifampin 600mg for 4 months. c. While this is the correct regimen the PZA and EMB should discontinued after the initial period of 2 months. d. Correct answer: Treatment dosing correct with initial and continuation phase. |
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Sam was given a two-step TST which resulted in a reading of 17mm and TB disease treatment is started. Two weeks after treatment is started he returns complaining of nausea and occasional vomiting at least 3 days a week during his morning DOT (directly observed therapy). Sam’s AST is now 50 IU/L but a physical exam is unremarkable. How
should Sam’s situation be handled? A. He should be counseled to take his medication with food and given a follow-up appointment. B. He may request to take his medication without DOT at night for a couple of weeks and a platelet count should be ordered. C. AST levels have increased more than three times his baseline and drugs should be stopped. D. Platelet counts are needed prior to making any decisions. |
A. He should be counseled to take his medication with food and given a follow-up
appointment. a. Correct answer: Taking the medication with food (low in glucose) may assist in patient tolerance. In some cases a meal is offered with DOT. b. DOT is not usually offered at night and the platelet counts are recommended for patient’s who develop a rash. The rash may be related to thrombocytopenia of rifampin. c. If AST is three times about the upper limits of normal (30 IU/L) thus 90IU/L the drugs should be stopped. Otherwise drug should be continued with close monitoring is recommended and the addition of food to enhance tolerance. d. Platelet counts are recommended for patient’s who develop a rash. The rash may be related to thrombocytopenia of rifampin. Our patient has no rash. |
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Sam’s girlfriend is now contacted by the public health department. She has no
symptoms at the current time but secretly admits that she is HIV-positive. A placement of a TST yields an induration of 7mm. How should she be treated? A. Counsel her on TB symptoms but do nothing as her TST does not meet criteria for treatment yet B. Wait 4 weeks then retest the TST to determine if TB treatment should be started C. Start treatment with INH (isoniazid) 300mg for 9 months D. Start treatment with Rifampin 600mg for 4 months |
C. Start treatment with INH (isoniazid) 300mg for 9 months
a and b. HIV-positive patients have a treatment cut off point of 5mm as well as those recently exposed. c. Correct answer: This is the preferred regimen. d. Rifampin is neither a preferred regimen or recommended in an HIV-positive patient. |
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JP is a 58 year old male who is on dialysis secondary to renal failure from type 2 diabetes
mellitus. He was recently found to be a contact of an active TB case. His girlfriend who he lives with was diagnosed with active pulmonary TB 2 weeks ago. He returns in 48 hours to have the PPD read. The nurse reads the PPD as 8 mm. What is the most appropriate recommendation? A. Do nothing, PPD only considered positive in patient with diabetes/renal failure if > 10 mm B. Evaluate patient for signs/symptoms of active TB and if ruled out, treat patient for latent TB infection C. Place patient immediately on isoniazid 300 mg qd x 9 months since he is at high risk of developing active TB in the near future D. Place patient on 4 drug regimen for treatment of active TB since he is a close contact of an active TB case |
B. Evaluate patient for signs/symptoms of active TB and if ruled out, treat
patient for latent TB infection Patient with diabetes and end stage renal disease is considered to have a positive PPD unless ≥ 10 mm; however patient is a recent contact of an active TB case so is considered to be positive if ≥ 5mm. All patients with a positive PPD should have active TB ruled out before initiating treatment for LTBI. |
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PM is a 38 year old female with HIV/AIDS who is finishing a 2 month initial phase
treatment for active TB (pan-sensitive) with the preferred combination 4 drug regimen. Her TB was found to be fully susceptible to all drugs tested. She will be starting antiretroviral therapy with a protease inhibitor based regimen [ritonavir-boosted atazanavir (Reyataz®) with emtricitabine/tenofovir (Truvada®]. What changes do you recommend to the patient’s continuation phase of TB treatment? A. Substitute rifapentine (Priftin®) for rifampin (Rifadin®) in the continuation phase of the regimen B. Substitute rifabutin (Mycobutin®) for rifampin (Rifadin®) in the continuation phase of the regimen C. Do not include a rifamycin in the continuation phase of the regimen D. Do not make any changes to the continuation phase of the regimen |
B. Substitute rifabutin (Mycobutin®) for rifampin (Rifadin®) in the
continuation phase of the regimen Patient who are receiving antiretroviral therapy containing a protease inhibitor should have rifabutin substituted for rifampin in the continuation phase of the regimen. Rifapentine should not be used in HIVinfected patients regardless of whether they are receiving ARVs. |
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FJ is a 48 year-old male who is on treatment for active tuberculosis. He reports to
his physician’s office with a complaint of red/orange discoloration of the urine. This is most likely an adverse effect of which of the following agents? A. Rifampin (Rifadin®) B. Ethambutol (Myambutol®) C. Isoniazid (INH) D. Pyrazinamide (PZA) |
A. Rifampin (Rifadin®)
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BJ is a 58 year old male with diabetes and renal insufficiency (CrCL 35 mL/min) He
would require a reduced dose of which of the following antituberculosis agents? A. Isoniazid (INH) B. Ethambutol (Myambutol®) C. Rifampin (Rifadin®) D. Rifabutin (Mycobutin®) |
B. Ethambutol (Myambutol®)
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IM is a 69 year old female who is status-post heart transplant and is on immunosuppressive therapy for prevention of organ transplant rejection. She has undergone yearly testing for tuberculosis infection for the past 2 years. She presents to her physician’s office for a reading of her PPD which was placed 2 days prior. Her PPD is read as having an area of induration of 8 mm. Her prior PPD tests have been negative. She is asymptomatic and her chest x-ray shows no abnormalities. What is the most appropriate recommendation?
A. Do nothing, a PPD is considered positive in this patient if the area of induration is ≥ 10 mm B. Place patient on isoniazid 5 mg/kg po qd + rifampin 10 mg/kg po qd + pyridoxine 25 mg po qd C. Place patient on isoniazid 5 mg/kg po qd + pyridoxine 25 mg po qd D. Place patient on isoniazid 5mg/kg po qd + rifampin 10 mg/kg po qd + ethambutol 20 mg/kg po qd + pyrazinamide 30 mg/kg po qd since patient is at high risk for developing active tuberculosis in the next 2 years. |
C. Place patient on isoniazid 5 mg/kg po qd + pyridoxine 25 mg po qd
Since patient is an organ transplant recipient, PPD > 5mm is considered positive. Recommended regimen is isoniazid (+ pyridoxine) for treatment of latent TB infection. |
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JB is 45 year old male who is placed on a 4 drug regimen consisting of isoniazid, rifampin, pyrazinamide, ethambutol for treatment of active tuberculosis. He returns to the clinic 1 month later for follow up. He is found to have hyperuricemia and reports severe left elbow pain. Which agent would be most likely to cause these adverse effects?
A. Isoniazid B. Ethambutol C. Rifampin D. Pyrazindamide |
D. Pyrazindamide
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Which of the following statements is true regarding the treatment of tuberculosis?
A. HIV-infected patients with CD4 cell counts < 100 cells/mm3 should not receive the twice weekly isoniazid/rifampin continuation phase B. Susceptibility testing should be performed on first-line drugs only if the patient’s sputum culture is still positive despite 2 months of therapy C. Once weekly continuation regimen of isoniazid plus rifapentine should only be considered in HIV-infected patients who have a CD4 cell count > 100 and do not have cavitary lesions seen on chest x-ray D. The continuation phase of the regimen should be extended to 7 months in HIV-infected patients whose sputum cultures remain positive after completion of 1 month of therapy |
A. HIV-infected patients with CD4 cell counts < 100 cells/mm3 should not receive the twice weekly isoniazid/rifampin continuation phase
b. Should be performed initially in all patients. If cultures still positive after 2-3 months of therapy, sensitive repeated and will include second line agents as well. c. Once weekly INH/rifapentine regimen should not be used in any HIV-infected patient. d. Should be extended if sputum culture remains positive after 2 months of therapy. |
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JG is a 43 year old female who immigrated from Haiti 6 months ago. She is being treated for pulmonary tuberculosis with a 4 drug regimen consisting of isoniazid, rifampin, ethambutol, pyrazinamide. She has completed 2 months of this regimen and her presenting symptoms of cough, night sweats, and fatigue have shown signs of improvement. She had 3 consecutive sputum samples done at 2 week intervals that were negative for AFB. Her sputum culture after 1 month of treatment was negative and her sputum is AFB negative at 2 months. She had cavitary lesions on her chest x-ray. Her weight is 75 kg. What is the most appropriate recommendation?
A. Continue 4 drug regimen for the continuation phase since patient is at high risk for development of multi-drug resistant tuberculosis B. Change patient to continuation phase consisting of rifampin 600 mg po qd + pyrazinamide 2000 mg po qd x 2 months C. Change patient to continuation phase consisting of isoniazid 300 mg po qd + rifampin 600 mg po qd +pyridoxine 25 mg po qd x 4 months D. Change patient to continuation phase of isoniazid 300 mg po once weekly + rifapentine 600 mg po once weekly + pyridoxine 25 mg po qd x 7 months |
C. Change patient to continuation phase consisting of isoniazid 300 mg po qd + rifampin 600 mg po qd +pyridoxine 25 mg po qd x 4 months
Recommended regimens for continuation phase are isoniazid + rifampin either once daily (if not given via DOT), twice weekly, or thrice weekly. Since patient had cavitary lesions on chest x-ray, she should not receive isoniazid + rifapentine once weekly regimen. Although being that the patient is from Haiti she is more likely to have ...? |
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HS is a 35 year old nurse who recently had a positive PPD test result (16 mm) following exposure to an active TB case in the hospital. She is prescribed daily isoniazid plus pyridoxine for 9 months. What would be most appropriate for this patient?
A. Clinical monitoring for adverse effects at 2, 4, and 6 weeks B. Clinical monitoring for adverse effects and measure LFTs at 2, 4, and 6 weeks C. Clinical monitoring for adverse effects monthly D. Clinical monitoring for adverse effects and liver function tests monthly |
C. Clinical monitoring for adverse effects monthly
Patient should be monitored monthly for the development of adverse effects. LFTs do not need to be done routinely unless patient has risk factors for Hepatotoxicity or is receiving other hepatotoxic drugs. |
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BJ is a 58 year old male who presents to the Family Medicine with a 1 month history of persistent cough that has become productive over the past 2 weeks. He also complains of malaise, fever, night sweats and a 20 pound weight loss over the past 2 months. He worked as a prison guard for the past 25 years but recently retired. A PPD is placed, sputum is sent to test for acid fast bacilli (AFB), and a chest x-ray is performed. After 48 hours, the PPD is read as 12 mm and the sputum is positive for AFB. Chest x-ray shows a right upper lobe infiltrate with a cavitation. The patient is diagnosed with active tuberculosis. He weighs 85 kg. His past medical history is significant only for hypertension for which he takes an ACE inhibitor.
Which of the following would be most appropriate for this patient at this time? A. Isoniazid 300 mg qd + rifampin 600 mg po qd + pyrazinamide 2000 mg po qd + pyridoxine 25 mg po qd B. Isoniazid 300 mg po qd + rifapentine 600 mg po qd + pyrazinamide 1500 mg po qd + ethambutol 1500 mg po qd + pyridoxine 25 mg po qd C. Isoniazid 300 mg po qd + rifampin 300 mg po qd + pyrazinamide 2000 mg po qd + ethionamide 1600 mg po qd + pyridoxine 25 mg po qd D. Isoniazid 300 mg po qd + rifampin 600 mg po qd + pyrazinamide 2000 mg po qd + ethambutol 1600 mg po qd + pyridoxine 25 mg po qd |
D. Isoniazid 300 mg po qd + rifampin 600 mg po qd + pyrazinamide 2000 mg po qd + ethambutol 1600 mg po qd + pyridoxine 25 mg po qd
Initial therapy should include 4 drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol (as well as pyridoxine). Option D is the only one that contains all of these medications. |
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The patient is placed on the regimen that you recommended and returns to the clinic
1 month later for follow up. He is found to have decreased visual acuity and loss of red/green color perception. The physician is concerned about optic neuritis. Which agent would be most likely to cause this adverse effect? A. Isoniazid B. Ethambutol C. Rifampin D. Pyrazindamide |
B. Ethambutol
Optic neuritis is a dose-related side effect of ethambutol. |
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By month 2, the patient’s sputum is negative for AFB and sputum cultures are negative. Sputum obtained at initial visit had grown Mycobacterium tuberculosis that was sensitive to all agents tested. The physician has heard about a once weekly regimen for the continuation phase of treatment and would like to know more about it and whether it is an option in this patient. Which of the following is most accurate?
A. The once weekly regimen consists of rifabutin and isoniazid and IS NOT an option for this patient since it has only been evaluated in HIV-infected patients. B. The once weekly regimen consists of rifapentine and isoniazid and IS an option for this patient since he is HIV-negative and has a negative sputum smear by month 2. C. The once weekly regimen consists of rifapenitine and isonaizid and IS NOT an option in this patient due to the cavitary lesion on his chest x-ray D. The once weekly option consists of rifampin and isoniazid and IS an option in this patient since his sputum is negative by month 2 and the organism was pan-sensitive. |
C. The once weekly regimen consists of rifapenitine and isonaizid and IS NOT an option in this patient due to the cavitary lesion on his chest x-ray
Once weekly rifapentine regimen should only be considered if patient is HIV-negative, has non-cavitary disease and sputum smear is negative for AFB by month 2. |
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5. Which of the following statements is TRUE regarding the treatment of active tuberculosis?
A. All HIV-infected patients should receive a 4 drug regimen for 2 months followed by a 2 drug regimen for 7 months (prolonged continuation phase) B. Susceptibility testing should be performed on second-line drugs if the patient’s sputum culture is still positive despite 1 month of therapy and the patient will require treatment with a 4 drug regimen for the duration of therapy C. Once weekly continuation regimen of isoniazid (INH) plus rifapentine (RPT) should only be considered in patients who are HIV-negative, have non-cavitary disease, and a negative sputum smear for AFB (acid fast bacilli) at 2 months D. Directly observed therapy (DOT) should only be considered in patient with active drug abuse or another condition which the physician feels places them at risk for being nonadherent to treatment |
C. Once weekly continuation regimen of isoniazid (INH) plus rifapentine (RPT) should only be considered in patients who are HIV-negative, have non-cavitary disease, and a negative sputum smear for AFB (acid fast bacilli) at 2 months
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6. VB is a 52 year old female who works as an admissions clerk at local pediatrics hospital. She reports to Employee Health for reading of a routine PPD that was placed 2 days ago. The PPD (TST, tuberculin skin test) is read as 12 mm. The patient has a past medical history of hypertension and diabetes mellitus. Which of the following would be most appropriate? (Assume that active tuberculosis has been ruled out). She weighs 80 kg.
A. Place patient on isoniazid (INH) 300 mg po qd and pyridoxine 25 mg po qd x 6 months B. Place patient on rifampin (Rifadin) 300 mg po qd x 6 months C. Place patient on isoniazid (INH) 300 mg po 2 x per week and pyridoxine 25 mg po qd x 9 months D. Do nothing, healthcare workers who do not have direct patient care responsibilities are not classified as having a positive PPD unless it is read as >15 mm |
A. Place patient on isoniazid (INH) 300 mg po qd and pyridoxine 25 mg po qd x 6 months
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RW is a 24 year-old HIV-infected patient who presents to his physician’s office with a 4 week history of productive cough x 6 weeks, night sweats, fatigue, and 10 pound weight loss. A PPD is placed is read as 3 mm at 48 hours. Sputums x 3 are sent for AFB (acid fast bacilli) smear and the first one is reported as positive. He is not on antiretroviral therapy at this time. His most recent CD4 cell count was 85 cells/mm3 and viral load was 45,000 copies/mL. Which of the following would be most appropriate for the initial phase of active tuberculosis treatment in this patient?
A. Place patient on rifampin (Rifadin) 600 mg po qd and pyrazinamide (PZA) 2000 mg po qd x 2 months B. Place patient on isoniazid (INH) 300 mg po qd, rifabutin (Mycobutin) 300 mg po qd, ethambutol 20 mg/kg po qd (Myambutol), pyrazinamide (PZA) 20 mg/kg po qd, and pyridoxine 25 mg po qd x 2 months C. Place patient on isoniazid (INH) 300 mg po qd + rifampin (Rifadin) 600 mg po qd + pyridoxine 25 mg po qd x 2 months D. Place patient on isoniazid (INH) 300 mg po qd, rifampin (Rifadin) 600 mg po qd , ethambutol (Myambutol) 20 mg/kg po qd, pyrazinamide 20 mg/kg po qd, and pyridoxine 25 mg po qd x 2 weeks followed by twice weekly therapy x 6 weeks |
B. Place patient on isoniazid (INH) 300 mg po qd, rifabutin (Mycobutin) 300 mg po qd, ethambutol 20 mg/kg po qd (Myambutol), pyrazinamide (PZA) 20 mg/kg po qd, and pyridoxine 25 mg po qd x 2 months
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FJ is a 48 year-old male who is on treatment for active tuberculosis. He reports to his physician’s office with a complaint of blurred vision and states that everything that is red appears orange to him. This is most likely an adverse effect of which of the following agents?
A. Rifampin (Rifadin) B. Ethambutol (Myambutol) C. Isoniazid (INH) D. Pyrazindamide (PZA) |
B. Ethambutol (Myambutol)
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