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    usmlemate is offline Junior Member
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    Latent Tuberculosis Infection

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    A 40-year-old HIV-infected man with a CD4 count of 337 cells/mm3 and an undetectable HIV RNA level presents for routine follow-up. He is currently asymptomatic and is taking highly active antiretroviral therapy (HAART). He states that his partner whom he is living with was recently diagnosed with active pulmonary tuberculosis (TB) and is currently undergoing treatment.

    Regarding the exposure to his partner, which of the following statements describes appropriate subsequent management of this 40-year-old HIV-infected man?

    A. After excluding active TB with a symptom review and a chest radiograph, you should treat him with 9 months of isoniazid (INH).

    B. You should ask him about current symptoms that would suggest active TB and obtain a chest radiograph. If his chest radiograph is negative, he does not require further treatment.

    C. You should discontinue his HAART and start him on four-drug TB treatment.

    D. You should test for latent TB infection with a tuberculin skin test and for anergy with a mumps control. If, 50 hours later, he has 0 mm of induration for both of the tests, you should inform him he does not require further treatment.

  2. #2
    usmlemate is offline Junior Member
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    Re: Latent Tuberculosis Infection

    Quote Originally Posted by usmlemate
    A 40-year-old HIV-infected man with a CD4 count of 337 cells/mm3 and an undetectable HIV RNA level presents for routine follow-up. He is currently asymptomatic and is taking highly active antiretroviral therapy (HAART). He states that his partner whom he is living with was recently diagnosed with active pulmonary tuberculosis (TB) and is currently undergoing treatment.

    Regarding the exposure to his partner, which of the following statements describes appropriate subsequent management of this 40-year-old HIV-infected man?

    A. After excluding active TB with a symptom review and a chest radiograph, you should treat him with 9 months of isoniazid (INH).

    B. You should ask him about current symptoms that would suggest active TB and obtain a chest radiograph. If his chest radiograph is negative, he does not require further treatment.

    C. You should discontinue his HAART and start him on four-drug TB treatment.

    D. You should test for latent TB infection with a tuberculin skin test and for anergy with a mumps control. If, 50 hours later, he has 0 mm of induration for both of the tests, you should inform him he does not require further treatment.

    The answer is A. Prior to giving isoniazid (INH) for latent TB infection, active TB should be excluded by symptom review and by chest radiograph. If this patient has no evidence of active TB, they should be treated for latent TB infection. This patient is presumed to have latent TB infection based on the close exposure to his partner with active pulmonary TB. In this situation, the patient is considered to have latent TB infection regardless of his tuberculin skin test result. For HIV-infected persons, 9 months of INH is appropriate therapy for latent TB infection.

    Answer B is wrong. The patient may not have current active pulmonary TB, but, based on his exposure to a person with active TB, he should be treated for latent TB infection. Although it is correct to perform a symptom review and obtain a chest radiograph for all patients who have been exposed to someone with active TB, this is not adequate for this patient. This patient has HIV infection, which increases his risk of reactivation TB, and he has had an exposure to TB. He should be treated with isoniazid (INH) once active TB is excluded.

    Answer C is wrong. This patient has no evidence of active TB and, therefore, does not require four-drug therapy. He should be treated for latent TB infection with 9 months of isoniazid (INH) due to his significant exposure to his partner with active pulmonary TB. Discontinuing HAART is also not recommended in order to start INH. Although there are important drug-drug interactions between some TB medications and antiretroviral medications, INH is generally free of significant interactions.

    Answer D is wrong. Anergy testing is no longer recommended for HIV-infected patients receiving the tuberculin skin test. Although this patient may be anergic, this finding would not alter your decision to treat him. In this situation, the patient has had close contact with a person who had active pulmonary TB. Therefore, after excluding active TB, he should be treated for latent TB infection regardless of his tuberculin skin test result.

  3. #3
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    Asclepius1 is offline Ultimate Member 537 points
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    My answer is A. After excluding active TB with a symptom review and a chest radiograph, you should treat him with 9 months of isoniazid (INH).

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