Evaluation Questions

Evaluation Questions

Clinical Presentation and Diagnosis of TB 1.A 32 year-old man complains of cough and malaise for the past three weeks. His wife is currently being treated for active tuberculosis. Of the following choices, your first step would be: Begin an empiric trial of treatment with a fluoroquinolone antibiotic for a possible community-acquired pneumonia Obtain a chest film to confirm your suspicion for TB which will make sputum testing unnecessary Obtain three sputum specimens for AFB microscopy (including at least one early morning specimen) Both answers A and C

Clinical Presentation and Diagnosis of TB 2.In high prevalence areas, the AFB sputum microscopy smear: Is highly specific for TB Identifies those at greatest risk of dying from TB Identifies those most likely to transmit disease All of the above

Clinical Presentation and Diagnosis of TB 3.A 54 year-old woman complains of cough, fever, and unexpected weight loss over the past month. She admits smoking 10 cigarettes per day for over 20 years. Three sputum smears were negative for AFB. You would consider each of the following except: An empiric trial of antibiotics (non-fluoroquinolone) Obtaining a chest film for further evaluation A trial of bronchodilator medication alone and follow-up in 3 months Sending sputum specimens for AFB culture

Microbiologic Diagnosis of TB 1.All of the following can increase sensitivity of sputum smear microscopy except: • Fluorescence microscopy • Sputum collection after the start of anti-tuberculosis treatment • Concentration by centrifugation and/or sedimentation • Chemical pretreatment

Microbiologic Diagnosis of TB 2.A 37 year-old man with diabetes presents with clinical symptoms highly suspicious for TB. Three sputum smears are negative. The patient collected the specimens ten days before he brought them back and kept them in a cool area of the house (no refrigeration). Which of the following statements is most correct? • Three negative smears predict that a culture would be negative, and therefore a culture offers no further diagnostic advantage and need not be obtained • A lack of response to broad-spectrum antimicrobial agents and a chest film suggestive of TB, would together suggest a diagnosis of smear-negative TB • The delay in transport and lack of refrigeration for the sputum specimens are unlikely to have a negative effect on results • Six sputum specimens for smear microscopy would have doubled the sensitivity for diagnosing TB compared to three specimens

Microbiologic Diagnosis of TB 3.Advantages of culture for TB compared to sputum microscopy alone include all of the following except: • Obtaining a positive culture can allow for drug-susceptibility testing • Culture can allow for identification of non-tuberculous mycobacterium species • Culture has a higher sensitivity than smear microscopy for diagnosing TB. • Culture, particularly by liquid media, can be faster than smear microscopy

Initial Treatment of Tuberculosis 1.A 28 year-old woman taking standard four-drug treatment for TB for five weeks now complains of nausea, vomiting, and right upper-quadrant discomfort. When seen in clinic she is noted to have scleral icterus and right upper-quadrant tenderness. Her urine is dark colored. What is the appropriate action to take at this time? • Stop all drugs • Stop isoniazid • Give pyridoxine (vitamin B6) • Replace pyrazinamide with streptomycin

Initial Treatment of Tuberculosis 2.A 68 year-old woman with smear-positive TB needs to start treatment. She lives too far to be given directly-observed treatment (DOT) by your office. Which treatment regimen is preferred for this patient? • Isoniazid and ethambutol for twelve months • Isoniazid/rifampicin/ethambutol for the first two months, followed by isoniazid/rifampicin for an additional four months • Fixed-dose combination of isoniazid/rifampicin/pyrazinamide for nine months • Fixed-dose combinations of isoniazid/rifampicin/ethambutol/pyrazinamide for the first two months, followed by isoniazid/rifampicin for an additional four months

Initial Treatment of Tuberculosis 3.In considering treatment for extrapulmonary disease, all of the following statements are correct except: • Extrapulmonary disease is a sign of disseminated disease, and therefore always requires a longer duration of treatment • Most presentations of extrapulmonary TB can be treated with the same standard six month regimens used for pulmonary TB • Extending the duration of therapy is recommended by many experts for central nervous system (CNS) and bone/joint extrapulmonary TB • Corticosteroids are sometimes recommended for pericardial and central nervous system (CNS) extrapulmonary TB

Fostering Adherence to Treatment 1.A 62 year-old patient has been taking TB treatment for three months. She has hypertension and has been your patient for ten years. Although she has always been good at listening to all of your advice in the past, she has missed her last two appointments, and her husband now informs you that he is worried because she is not taking her TB medications at home as directed. He states that she rarely goes out of the house now, and she avoids her friends. In addition to asking about possible side effects from the medications, what else would be good to address during her next appointment? • Ask how she is coping with the diagnosis, understanding that emotional factors such as fear, stigma, and depression may play a role in non-adherence • Talk to her about directly-observed therapy as a way to help her succeed with treatment and support her closely • Assess her understanding of TB disease and treatment, and ask her what she thinks might be interfering with her ability to take her medications as directed • All of the above

Fostering Adherence to Treatment 2.As a clinic caregiver and administrator, you note that the clinic has a high rate of TB treatment failure and default. Healthcare team and system interventions that could improve patient adherence and completion rates include all of the following except: • Develop a joint case conference to discuss problem TB cases with doctors, nurses, and other clinic healthcare workers involved with the TB patients, to put together all aspects of patient care and problem-solve jointly • Define a list of strict rules for adherence that patients must follow in order to receive care for tuberculosis at the clinic. Post the rules and enforce. All patients will see the same information, staff will not have to spend time reviewing issues with patients, and the clinic will run more efficiently • Provide written educational material for patients in appropriate languages, and consider a peer-assistance program. • Develop a reminder system to contact defaulters through letters and/or telephone, and consider a system of incentives or enablers that could help improve adherence

Fostering Adherence to Treatment 3.To develop a patient-centered system of care for TB, all of the following would be good to consider except: • The patient may be involved in deciding which TB medications they prefer to take in order to individualize treatment regimens • The patient’s needs and expectations regarding TB care should be explored, looking for ways to improve adherence, and thus, treatment outcomes • Foster relationships between patients and providers that rely on mutual respect and mutual responsibility toward a shared goal, rather than just offering expert advice and assuming passive compliance • Promote patient self-management through appropriate education and support. Support should be gender-sensitive and age-specific, and should be tailored to the cultural context

Tuberculosis and HIV Infection 1.In the evaluation of a patient with a clinical presentation suspicious for both TB and HIV infections, all of the following statements are correct except: In a seriously ill patient, consider initiation of empiric antibiotic treatment early in addition to obtaining sputum for AFB microscopy (and culture if available), chest radiograph and HIV tests. AFB smear-negative cases become more difficult to evaluate due to the need to distinguish TB from other HIV-related pulmonary diseases Infection control issues need to be considered throughout the evaluation process to safeguard other potentially vulnerable patients and healthcare workers. The incidence of smear-negative TB decreases as the CD4 drops (<200).

Tuberculosis and HIV Infection 2.A 25 year-old woman presents with 6 weeks of fever, weight loss, and a large swollen left supraclavicular lymph node. On examination she has patches of white exudate on her oral mucosa. A chest radiograph reveals a left lower lobe infiltrate and left hilar adenopathy. Your evaluation should include all of the following except: A needle aspiration of the lymph node with specimens sent for AFB microscopy (and culture and histopathology if available) Sputum specimens for AFB microscopy An empiric trial of ciprofloxacin HIV testing

Tuberculosis and HIV Infection 3. All of the following statements regarding tuberculosis and HIV co-infection are correct except: The risk of TB is increased only in the later stages of HIV infection (CD4 cell count <100) Advanced HIV disease (lower CD4 cell count) is more often associated with atypical clinical and radiographic presentations of TB The incidence of extrapulmonary TB increases with advanced immunosuppression Isoniazid preventative therapy is effective in HIV-infected individuals

TB/HIV: Treatment A 45 year-old man with AIDS had documented clinical improvement after two months of standard TB treatment and subsequently began ART. After one month of combined TB treatment and ART, symptoms of cough with new infiltrates on chest radiograph are discovered. Which of the following need to be considered in the differential diagnosis at this time: TB treatment failure New opportunistic respiratory infection Immune reconstitution inflammatory syndrome All of the above

TB/HIV: Treatment 2. The antiretroviral therapy regimen of choice for a patient on first-line TB treatment with isoniazid, rifampicin, ethambutol, and pyrazinamide would be: A triple nucleoside (NRTI) regimen Ritonavir “super-boosted” protease inhibitor (PI) regimen A dual protease inhibitor (PI) regimen Efavirenz plus two nucleosides (NRTIs) if not pregnant

TB/HIV: Treatment 3. A 50 year-old woman with sputum smear-positive TB and new HIV infection is started on both a standard four-drug TB regimen and a three-drug ART regimen at the same time. The patient’s adherence is spotty and one week later she complains of severe nausea and vomiting. All of the following statements are correct except: Nausea and vomiting can be side effects seen with either TB or ART drugs The initial high pill burden may be contributing to the patient’s poor adherence Starting both TB and HIV treatments together has made the job of finding the cause of the symptoms more complicated Prioritizing the start of ART first, with a delay in TB treatment would have been the recommended sequence

Drug-resistant Tuberculosis 1.A 68 year-old man presents with cough and weight loss for 2 months. He recalls treatment for TB eight years ago, but believes it only lasted a few months. A chest film reveals a cavitary infiltrate in the right apex of the lung. Factors that predict or are associated with a risk for the development of drug-resistance in this case would include all of the following except: • Poor adherence to prior TB treatment • Development of chronic diarrhea with possible malabsorption of drugs • New diagnosis of diabetes • Persistent cough and weight loss after two months of standard therapy

Drug-resistant Tuberculosis 2.Extensively-drug resistant (XDR) TB is defined as TB that is resistant to: • At least six anti-tuberculosis drugs • At least isoniazid and rifampicin • Isoniazid, rifampicin, ethambutol, pyrazinamide, streptomycin, and a fluoroquinolone • Isoniazid, rifampicin, a fluoroquinolone, and at least one of these three injectable agents (amikacin, kanamycin, capreomycin)

Drug-resistant Tuberculosis 3.Which of the following statements regarding the microbiologic pathogenesis of drug-resistant tuberculosis is most correct? • Patients with cavitary tuberculosis have a low bacillary load and therefore are unlikely to harbor any naturally occurring drug-resistant organisms • Mono-therapy with a single anti-tuberculosis drug can lead to selective proliferation of naturally occurring drug-resistant organisms • Acquired resistance to anti-tuberculosis drugs only occurs for isoniazid and rifampicin • In a patient on a standard initial four-drug treatment regimen with evidence for clinical failure in whom there is a high suspicion for drug resistance, the addition of a fluoroquinolone alone will reduce the risk for further development of drug resistance

Management of Drug-resistant TB 1.The 5 year-old son of a woman you are currently treating for known isoniazid and rifampicin resistant tuberculosis presents with cough and malaise for three weeks and an abnormal chest film. Of the following available regimens, choose the one best option: • Begin empiric treatment with at least four drugs that the mother’s organism is known to be susceptible to • Begin empiric treatment with the standard initial regimen of isoniazid, rifampicin, ethambutol, and pyrazinamide with the addition of a fluoroquinolone • Begin empiric treatment with the standard initial regimen of isoniazid, rifampicin, ethambutol, and pyrazinamide • Treat first for a potential community-acquired pneumonia with a fluoroquinolone

Management of Drug-resistant TB 2.Reasonable steps for building a regimen for multidrug-resistant tuberculosis after drug-sensitivities results are known include all of the following except: • Always start by choosing any available first-line drug that the isolate remains susceptible to • Aim for a total of four to six drugs that the isolate is known to be sensitive to (preferably not drugs used previously by the patient) • Second-line agents (like cycloserine, ethionimide, and PAS) would be preferred over injectable agents to minimize healthcare resources used in association with injections and improve patient comfort • If there are not four to six drugs available among the first- and second-line agents, third-line agents could be considered, preferably in consultation with an expert

Management of Drug-resistant TB 3.Clinical management and monitoring plans for the care of MDR/XDR-TB should include (as resources permit) all of the following except: • Daily patient-centered directly observed treatment (DOT) throughout the entire treatment course • Diligent recording of drugs given, bacteriological results, chest film findings and any occurrence of medication toxicity • Periodic sputum specimens for smear and culture, both to document culture conversion and monitor for signs of treatment failure • Monthly sputum for drug-sensitivity testing throughout the entire course of treatment

Contact Evaluation 1.A 23 year-old school teacher has recently been diagnosed with active pulmonary TB. She is concerned about the risk of transmitting disease to the children she teaches in a small, poorly-ventilated classroom. Aspects of her clinical presentation that would suggest a higher degree of infectious risk include all of the following except: • Sputum smear positive for M. tuberculosis • Significant cough symptoms • Cavitary-disease on chest film • Extrapulmonary cervical lymphadenitis

Contact Evaluation 2.A 42 year-old man has been diagnosed with smear-positive pulmonary TB. He works five days per week as an accountant in a small office with two other co-workers and lives in an apartment building with his wife and son. Other activities include a 2-hour weekly football game with his teammates outdoors. In regards to planning a contact evaluation for this case, all of the following statements are correct except: • It would be important to assess the clinical factors that influence infectious risk in this case, such as the presence and duration of cough symptoms • It would be important to gather information regarding the age, health status (especially if risk for HIV or immunodeficiency), and whether symptoms of TB are present in any of the close contacts • Evaluation of his football teammates as contacts would be a high priority, even if his cough symptoms are minimal • It would be important to consider the size of the office, the level of ventilation, and the amount of contact time between co-workers and the patient when deciding whether further testing and evaluation for the co-workers is needed

Contact Evaluation 3.Contacts to an infectious pulmonary case of TB found to have latent TB infection (LTBI) who have the highest risks for progression to active TB disease once infected include: • Children <5 years of age • Spouses due to the extended duration of exposure • Persons with HIV infection • Both A and C

Evaluation Questions