TB

Question 1

What are the symptoms and signs someone might have TB acute or old?

Answer 1

Cough (++sputum), haemoptyisis, SOB, fever, night sweats, weight loss, recent travel to high risk region

Chest:
- phrenic nerve crush scar
- chest wall deformity with absent ribs
- tracheal deviation towards affected side
- apical fibrosis
- reduced expansion
- dull percussion, normal vocal fremitus
- lobectomy scar

Question 2

What are the TB prevalent areas?

Answer 2

India
Pakistan
Romania
Somalia
Eritrea
Bangladesh
China
Philippines
Indonesia
Sub-Saharan Africa
DoC
Nigeria

Question 3

How is TB diagnosed?

Answer 3

If active TB suspected:
- x3 early AM sputum for AAFB
- myocbacterium culture following but results take a long time

If screening for latent TB:
- Mantoux test (intradermal tuberculin and 5mm or more induration +ve regardless of prior vaccine)
- IGRA (blood test, less likely to be false positive and provides quicker result).

Question 4

Who do we screen for latent TB?

Answer 4

Close contacts of patient diagnosed with active pulmonary or laryngneal TB

Healthcare workers

Pre-biologic work-up

Those who are immunocompromised

New entrants to UK from TB prevalent country ideally should have had pre-entry screening by home office approved clinic BUT high volumes of vulnerable patients i.e. asylum seekers, refugees who do not have this and therefore should be referred to TB MDT for consideration of latent TB testing.

Question 5

Who are classed as ‘close contacts’ of a person with TB?

Answer 5

All household members

Partners

Regular house visitors

Close work colleagues

May be extended to more distant contacts if closer contacts test positive AND/OR if they are immunocompromised

Question 6

What is the difference between sputum smear and culture for TB?

Answer 6

Sputum smear = AAFB microscopy

Sputum culture is the growth of mycobacterium (much slower but gold standard)

Question 7

What are the travel advice for a person with active TB?

Answer 7

Cannot travel until:

Drug susceptible = x2 sputum smear -ve before travel

Drug resistant = x2 sputum culture -ve before travel

Question 8

How is TB managed?

Answer 8

TB MDT, named TB nurse and contact line

Conservative:
- education
- treatment concordance with extra support, supervised drug delivery, assistance with housing if living in high risk environment
- infection control - masks etc

Medical:

Drug susceptible active
6 months treatment
- Isoniazid with pyridoxine
- Rifampicin
First two months with
- ethamabutol
- pyrazinamide

Multi-drug resistant
Prolonged treatment of 18-24 months with at least 6 drugs that are known to treat mycobacterium

Latent
- 3 months isoniazid (with pyridoxine) and rifampicin — typically given to people younger than 35 at low risk of hepatotoxicity.
- 6 months isoniazid (with pyridoxine) — typically given when rifamycin drug interactions may be a concern (e.g. people with HIV or transplant recipients).

Question 9

What are the known serious complications to TB treatment which need to be communicated to patients?

Answer 9

Isoniazid
- peripheral neuropathy (hence why given with pyridoxine)
- hepatitis

Rifampicin
- hepatitis
- enhanced OCP metabolism
- dark orange/red urine

Ethambutol
- hepatitis
- retrobulbar neuritis

Pyrazinamide
- hepatitis

Check whites of eyes every morning, if they turn yellow, stop taking your TB medication and contact your TB nurse straight away.

Notice colours every day, if red becomes less bright than expected, ring your TB nurse that day.

You may develop tingling in your toes, continue your medication but mention it at your next clinic visit.

Contact lenses should be avoided as one of the tablets stains secretions red/orange.

Barrier contraception / copper IUD should be used.