darkhorse
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A 42-year-old man comes to the emergency department with a history of a productive cough and hemoptysis. He is known to be HIV positive and admits to a history of intravenous drug abuse. In the emergency department, his temperature is 38.1 (100.6 F) with stable vital signs. He is admitted to the medical floor for the treatment of pneumonia. A chest x-ray and subsequent CT scan of the chest confirms a cavitary lesion in the right lung. He is started on antibiotics and sputum is sent for a Gram stain, acid-fast bacillus smear, cultures, and sensitivity. The acid-fast bacillus smear comes back positive. He now admits that he was diagnosed with pulmonary tuberculosis 4 years ago and was advised treatment with isoniazid (INH), rifampicin, pyrazinamide, and ethambutol, which he was supposed to take for 6 months. His compliancy in taking these medications is unclear. From the period of his admission to the emergency department and placement on respiratory isolation, several hospital employees were exposed to his respiratory secretions. A PPD test is given to all the exposed employees. Three employees with previously negative PPD test results, now have positive results.The most appropriate post exposure prophylaxis (PEP) plan for these employees is
A. ethambutol and pyrazinamide therapy initially, then the addition of this regimen accordingly to the patient's sensitivity profile
B. to hold postexposure prophylaxis until the patient's sensitivity profile is available and then choose a regimen
C. INH for 6 months,and if PPD is still positive, an extension of the treatment for 12 months
D. INH, rifampicin, pyrazinamide, and ethambutol for 6 months and recheck the PPD
E. no postexposure prophylaxis is necessary
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| dr.wad
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D
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| Kamsi
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C INH for 6 months,and if PPD is still positive, an extension of the treatment for 12 months
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| Doc750
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D
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| darkhorse
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| AAAAA
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C
explanation:
Table 2. Recommended dosing for prophylaxis for TB Drug Adult dosing Pediatric dosing Duration (mo) Toxicities
Isoniazid* (INH) 300 mg/day
or
900 mg biweekly** 10-20 mg/kg/day (maximum, 300 mg) 6-9 Rash, peripheral neuropathy, hepatitis or elevated liver enzyme levels, drug interactions, mild CNS effects or 20-40 mg/kg biweekly (maximum, 900 mg)
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| AAAAA
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The answer should be INH 6-9 months
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| cool doctor
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I agree with you AAAA and a better answer would be CXR and sputum analysis.
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| darkhorse
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The correct answer is B. Tuberculosis exposure is not an emergency and does not require immediate re-initiation of postexposure prophylaxis. Given the potential toxic side effects of antituberculosis medications and the importance of completing a regimen for full efficacy, it is reasonable to withhold initiation of postexposure prophylaxis for tuberculosis until sensitivities are available. Tuberculosis bacilli sensitivities usually take a few weeks to come back. This particular patient is at high risk for multidrug resistant tuberculosis, because he was non-compliant with different medications for tuberculosis in the past. In the case of multidrug resistant tuberculosis, postexposure prophylaxis should consist of 2 drugs to which the index patient's tuberculous strain is susceptible.
Ethambutol and pyrazinamide by themselves may not completely cure tuberculosis, unless the patient's strains are sensitive to this antituberculosis medication (choice A).
INH by itself has shown to be effective in treating tuberculosis. But INH resistant strains are well known, and these patients should be treated with additional rifampicin (choice C).
A combination of 4 different medications (choice D) may be essential depending upon the tuberculosis sensitivity profile, but one should wait before starting this therapy to avoid any side effects and development of drug resistant tuberculosis.
Postexposure prophylaxis is essential after the sensitivity profile is known (choice E).
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| jvo_md
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you already did the CXR and sputum analysis cool doctor ...
I go with INH for 6 months,and if PPD is still positive, an extension of the treatment for 12 months
Answer darkhorse
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| cool doctor
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I think this too much for step 2
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| cool doctor
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not for the employees jvo
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| jvo_md
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oh yes....sorry...but i think there's no time yet to see CXR changes yet and sputum presentation.
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