A homeless 50 yr old male presents to the Emergency Department with weight loss,

Question

A homeless 50 yr old male presents to the Emergency Department with weight loss, lethargy, a low grade fever, and a productive cough. He is also HIV positive and has a history of schizophrenia but has never complied with treatment for either disease process. His chest x-ray indicates a suspicious area in his right middle lobe, and sputum cultures come back positive for mycobacterium tuberculosis. He will be treated with a combination of antimycobacterial drugs. Here is what is needed for quality care of this patient:

Explanation / Answer

Chest X-ray. Increased density over the left upper lung and right middle lobe suspicious for infiltrate/fibrotic change.

Routine testing for TB is not indicated but testing is indicated on patients who need prompt treatment such as immunosupressed patients, because they are at high risk of progression to active TB. Testing for LTBI preferred. . If there are no risks for progression of LTBI, wait three months postpartum to test and treat latent TB.

Tools for diagnosis are tuberculin skin testing (TST) and interferon-gamma release assays (IGRAs). . If the test results are positive further clinical evaluation including clinical features, radiological, microbiological, and immunological investigations should be performed to rule out active TB.

First choice of the treatment of latent TB is Isoniazid (INH) for nine-month duration with daily pyridoxine supplement. However in one of the following circumstances four-month treatment with Rifampin is indicated. (1) INH resistance, (2) intolerance to INH, and (3) poor medication compliance.

Infection-Control Practices to Prevent and Detect M. tuberculosis Transmission in Health-Care Settings

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