Flu 'n' TB

Y'all play Red Dead Redemption 2??? What y'all know bout consumption??

orthomyxovirus

What type of virus causes influenza?

Droplet

How is influenza transmitted?

A, B, C

Which influenza viruses infect humans?

Hemaggluttinin (H), neuroaminidiase (N)

What are the forms of influenza A?

Antigenic drift

small changes in the genes of the virus that change surface proteins where the body can still recognize (maybe)

Antigenic shift

ONLY flu A that is a abrupt change in the virus such as new H or N proteins and creates a new subtype that has limited immunity (Swine flu 2009)

1-4 days

What is the incubation time for influenza?

Supportive care, maybe oseltamivir (tamiflu)

33 y/o Patient presents to the ER with fever, chills, rigors, and muscle pain that started this morning. Patient also reports a sore throat, HA, malaise, rhinorrhea, nasal congestion, and cough. Patient’s medical history is negative for any major conditions/illness. He states his entire family was at a party 3 days ago and everyone is feeling sick. On a physical exam you note cervical lymphadenopathy, mild pharyngeal injection, facial flushing, and conjunctival injection. What is your treatment plan?

N/V/D, stomach discomfort

What symptoms of influenza are more common with flu B?

hypothermia, AMS

What symptoms of influenza are more common with geriatric populations?

beginning and end of flu season

Influenza rapid test are most useful when?

Tamiflu or zanamivir

65 y/o Patient presents to the ER with fever, chills, rigors, and muscle pain that started this morning. Patient also reports a sore throat, HA, malaise, rhinorrhea, nasal congestion, and cough. Patient’s medical history shows a recent liver transplant and DM. On a physical exam you note cervical lymphadenopathy, mild pharyngeal injection, facial flushing, and conjunctival injection. A flu swab is positive for flu A. What is your treatment plan?

baloxavir

What medication can we give prophylactically to immunocompromised peeps during flu season?

COPD, Asthma

Zanamivir is C/I in peeps with

peramivir

77 y/o patient is admitted to the hospital for influenza A. Patient reports fever, chills, rigors, and muscle pain that started this morning. As well as a sore throat, HA, malaise, rhinorrhea, nasal congestion, and cough. The patient is unable to tolerate PO/inhaled meds. What is your treatment plan?

Admitted patients, nursing home/LTC, progressive illness, asthma, COPD, CF, pregnant patients (or within 2 weeks postpartum), patients 65+, patients under 19 on long term asthma care, immune deficiency, BMI 40+, comorbid conditions

Which patients with the flu require treatment and cannot thug it out?

viral pneumonia, secondary bacterial infection, MI, Cerebrovascular insults, encephalitis, seizures

Complications of the flu

intiated necrosis of respiratory epithelium, ciliary dysfunction

Why does the flu lead to secondary bacterial infections?

strep pneumoniae

Most common secondary bacterial infection after the flu?

staph aureus

Most deadly secondary bacterial infection after the flu?

Vaccination, hand hygiene, facemask

How can you prevent the flu?

mycobacterium tuberculosis

What bacteria causes TB and is a rod-shaped bacterium with a waxy capsule?

airborne droplets

How is TB transmitted

caseating granulomas

Primary lesion of pulmonary TB

Primary TB

The original infection where M. tuberculosis is ingested by macrophages which take them to the lymph nodes leading to the spread of infection to apical portion of lungs, epiphyses of long bones, kidneys, vertebral bodies, and meninges that is hard to find on X-ray and granulomas are created to contain the infection - generally not contagious

fever, fatigue, cough, central consolidation on imaging

What symptoms of primary TB may pop up in someone immunosupressed?

Latent TB

After the primary infection where a majority of TB becomes dormant and can be found in the granulomas - no symptoms, not contagious (catch it on PPD)

Reactivation TB

If the immune system becomes weakened, latent TB can reemerge and develops in 5-10% of untreated latent TB

Ghon complex

What is specific to TB and consist of granulomas in the lung parenchyma and enlarged regional lymph nodes that usually head spontaneously by calcifications but can be reactivated

reinfection, reactivation (most common)

How does secondary TB develop?

apex, granulomatous lobular pnuemonia

In secondary TB, bacteria typically spread to the _______ of the lungs, causing a ________________________________.

cavernous TB

Characterized by confluent granulomas the produce cavities (causes hemoptysis)

Immune suppression (DM, HIV, meds, substance abuse, malnutrition), household contacts, birth in endemic area, crowded living facilities

Risk factors for TB

mild pulmonary disease, low grade fever (looks like an URI)

Quirks of primary TB

dry cough, low-grade fever, loss of appetite, malaise, night sweats, weight loss

Quirks of secondary TB

dyspnea

What may indicate that TB has spread through parenchyma of the lungs, pulmonary destructive lesions, and pleural effusions?

miliary pattern, upper lobe cavitary lesions (classic)

What are you going to see on a CXR positive for TB?

TST, quantiferon gold

How can you diagnose latent TB

HIV peeps, recent contact with TB, fibrotic changes on CXR, transplants, immunosupression

A lesion of greater than 5 mm is a positive TST in

IV drug users, high prevalence areas, you work in a hospital/healthcare, children under 4, comorbidities

A lesion of greater than 10 mm is a positive TST in

Peeps with no risk factors

A lesion of greater than 15 mm is a positive TST in

Yes

Will someone with the BCG vaccine have a positive TST?

quantiferion Gold (IGRA)

What has a higher sensitivity than the TST

BCG vaccine, high risk of infection

When do we use the quantiferon Gold

CXR (determine if active or latent)

If a patient has a positive PPD or Quantiferon gold, what’s our next step

obtain sputum, AFB smear, culture, NAAT, quarantine, treat

If a patient has an abnormal CXR and a positive PPD or Quantiferon gold, what’s out next step

treat (it’s latent and can reemurge)

If a patient has a normal CXR and a positive PPD or Quantiferon gold, what’s out next step

Nucleic acid amplification testing (NAAT)

What test for DNA Mycobacterium TB?

culture and sensitivity

What is the gold standard microbiological testing and provides a 100% confirmation you’re dealing with TB?

Maybe AFB smear, TB likely start treatment pending culture results

If a patient has an abnormal CXR and a positive PPD or Quantiferon gold, NAAT +, what’s out next step

AFB smear

If a patient has an abnormal CXR and a positive PPD or Quantiferon gold, NAAT -, what’s out next step

Repeat NAAT, culture, TB not likely

If a patient has an abnormal CXR and a positive PPD or Quantiferon gold, NAAT -, AFB +, what’s out next step

TB not fully excluded, culture

If a patient has an abnormal CXR and a positive PPD or Quantiferon gold, NAAT -, AFB -, what’s out next step

report it!

If TB is likely what do we need to do fam?

Rifampin daily 4 months (1st line), Isoniazid and rifampin 3 months, Isoniazid and rifampin weekly for 3 months, Isoniazid for 9 months

Treatment plan for latent TB

CBC, CMP with LFTs and billi, visual acuity, vision color testing, uric acid, add vitamin B6 to diet

What do you need to do before you start the treatment for TB

6-9 month RIPE regimen

How are we treating active TB?

isoniazid, rifampin, pyrazinamide, ethambutol

What is included in the intensive phase (2 month) of the RIPE regimen?

isoniazid, rifampin

What is included in the continuation phase (4-7 months) of the RIPE regimen?

multiple medications, directly observed therapy (DOT)

How can we prevent the emergence of drug resistance with TB?

non adherence to therapy

What is the main cause of treatment failure with TB?