Justice
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A 34-year-old female health care worker had a tuberculin skin test done as part of her annual physical examination. The result showed a 17-mm induration. Three previous skin tests were negative with no palpable induration. She was advised to take isoniazid prophylaxis. However, after a discussion with her physician, she decided not to take the drug because of concerns about potential hepatotoxicity. The patient was especially concerned about drug side effects because she had recently learned that she has mild multiple sclerosis that does not require treatment.
One month after her annual physical examination, she develops cough and fever. A chest radiograph shows a hazy density in the posterior left upper lobe, and azithromycin is prescribed. When seen 1 week later, she reports only slight improvement. A repeat chest radiograph shows no change, and the density may even have increased.
Which of the following should be done next?
A. Order a swallowing evaluation
B. Change the azithromycin to levofloxacin
C. Order a sputum smear and culture for acid-fast bacilli
D. Repeat the tuberculin skin test
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| dr.wad
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C
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| peter90036
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C
finally, something i can answer
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| ganesha123
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C
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| sandra
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c
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| doc_clotaire
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Agree with C
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| liliaeliz
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C
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| cool doctor
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| milestogo
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agree too...c
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| Markus2009
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Same here C
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| Justice
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The correct answer is C
This patient requires a sputum smear and culture for acid-fast bacilli. The development of reactivation tuberculosis often follows closely after tuberculin skin test conversion. At least 50% of the lifetime risk of tuberculosis occurs within 1 or 2 years of conversion. Chemoprophylaxis is therefore desirable for anyone with known conversion, since the risk of tuberculosis (and possible transmission of tuberculosis to others) exceeds the risk of the medication. This patient had pneumonia that was suggestive of reactivation tuberculosis because of the upper lobe location and the failure to respond to antibiotics. Although aspiration pneumonia could account for the findings in this setting, the upper lobe is an uncommon site, since aspiration pneumonia tends to occur in lung segments favored by the gravitational movement of oral or gastric flora.
Although swallowing disorders do predispose to aspiration, this patient has no clinical manifestations of such disorders and does not require a swallowing function evaluation. Changing antibiotics is sometimes helpful if a resistant organism is a concern. However, levofloxacin is usually preferred to azithromycin for treating resistantStreptococcus pneumoniae, which this patient seems unlikely to have because of the slow progression of her infection. Levofloxacin is not very effective for treating aspiration pneumonia because of its limited activity against oral anaerobes. Repeating a positive tuberculin skin test is not necessary unless this is being done for the evaluation of anergy.
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