Kieth Roland Paloso

1. When screening for tuberculosis, what are the four cardinal signs and symptoms that
you should ask for?

Cardinal signs/symptoms of TB are cough, unexplained fever, unexplained weight loss, and night
sweats.

2. How would you classify a patient with the cardinal signs and symptoms of TB for at
least 2 weeks but without any laboratory tests?

Presumptive pulmonary tuberculosis – refers to any person having: i) two weeks or longer of any of
the following – cough, unexplained fever, unexplained weight loss, night sweats; or ii) chest X-ray
finding suggestive of TB.

3. Household and close contacts of all ages of a diagnosed TB case shall be screened for
TB using symptoms and what test?

Household and close contacts of all ages of a diagnosed TB case shall be screened for TB using
symptoms and chest X-ray.

4. Is a history of a fully documented and completed course of anti-TB treatment

considered a risk factor for tuberculosis infection?

No. Risk factors for TB infection include:

a. contacts of TB patients;
b. those ever treated for TB (i.e. with history of previous TB treatment);
c. people living with HIV (PLHIV);
d. elderly (> 60 years old);
e. Diabetics;
f. Smokers;
g. health-care workers;
h. urban and rural poor (indigents); and
i. those with other immune-suppressive medical conditions (silicosis, solid organ transplant,
connective tissue or autoimmune disorder, end-stage renal disease, chronic corticosteroid
use, alcohol or substance abuse, chemotherapy or other forms of medical treatment for
cancer).

5. How do you classify a patient with both pulmonary and extrapulmonary TB?

Pulmonary TB (PTB) refers to a case of tuberculosis involving the lung parenchyma while
Extrapulmonary TB (EPTB) refers to a case of tuberculosis involving organs other than the lungs (e.g.
larynx, pleura, lymph nodes, abdomen, genito-urinary tract, skin, joints and bones, meninges). A
patient with both pulmonary and extrapulmonary tuberculosis should be classified as a case of
pulmonary TB.

6. True or False. Diagnosis made by the attending physician on the basis of clinical findings
and X-ray abnormalities shall be classified as Radiologically-diagnosed PTB.

False. No such thing as Radiologically diagnosed TB, rather, clinically diagnosed TB (CDTB) – refers
to a patient for which the criterion for bacteriological confirmation is not fulfilled but diagnosis is made
by the attending physicians on the basis of clinical findings, X-ray abnormalities, suggestive histology
and/or other biochemistry or imaging tests.

7. Unavailability of Xpert MTB/RIf test shall not be a deterrent to diagnose TB disease

bacteriologically. What 2 other tests can alternatively be used to bacteriologically diagnose
tuberculosis?

Unavailability of Xpert MTB/RIF test shall not be a deterrent to diagnose TB disease bacteriologically.
Smear microscopy (whether brightfield or fluorescence microscopy) or loop mediated isothermal
amplification (TB LAMP) and culture shall be the alternative diagnostic test if Xpert is not accessible.

8. True or False. For Xpert, testing should be performed on any collected spot sputum sample
(i.e. a coughed-out sample) regardless whether it is sputum or saliva.

True. For Xpert, testing should be performed on any collected spot sputum sample (i.e. a coughed-out
sample) regardless whether it is sputum or saliva.

9. What laboratory test do you request to bacteriologically confirmed tuberculosis in biopsy

tissues and fine needle aspiration biopsy specimens?

Other fluid aspirates and biopsy specimens can only be submitted to specifically designated RTD
laboratories equipped with certified biosafety cabinets such as in TB culture laboratories. Blood, urine
and stools are currently not accepted specimens for Xpert MTB/RIF testing.

10. How do you register these TB patients?

a. previously treated for TB but failed most recent course based on a positive smear microscopy
follow-up at 5 months or later: or, a clinically-diagnosed 18 patient who does not show clinical
improvement anytime during treatment

Treatment after failure

b. previously treated for TB and declared cured or treatment completed, but is presently
diagnosed with active TB disease

Relapse

c. previously treated for TB but did not complete treatment and lost-to-follow up for at least?
months in most recent course

Treatment after lost to follow-up

11. What do you call the two phases of the first line anti-TB treatment?

Standard regimens are divided into an intensive (bactericidal) phase and a continuation (sterilizing)
phase. During the intensive phase, the majority of tubercle bacilli are killed, symptoms resolve, and
usually the patient becomes noninfectious. Intensive phase refers to the initial part of a standardized
regimen which usually consists of four or more anti-TB drugs. The continuation phase is required to
eliminate persisting mycobacteria and prevent relapse. Once some of the drugs are discontinued
according to the schedule of the standard regimen, this is now referred to as continuation phase.

12. What is the duration of first line treatment for drug susceptible tuberculosis in these
patients?
 a. Extrapulmonary tuberculosis or the cervical node only

6 months

b. Pulmonary tuberculosis with Gastrointestinal tuberculosis

6 months

c. Miliary tuberculosis only

6 months

d. Cavitary tuberculosis with pleural effusion

6 months

e. Tuberculous brain abscess only

12 months

F. Pott's disease only

12 months

13. How many HRZE tablets per day do you prescribe to patient with a weight of
a. 70kg

5 tabs

b. 38kg

3 tabs

c. 30kg

2 tabs

d. 55kg
4 tabs

14. What is the drug Dosage per Kg Body Weight in Adults for all the first-line anti-TB drugs?
15. Of all the first line anti-TB drugs that are known to cause hepatitis, which is the LEAST
hepatotoxic and which is the MOST hepatotoxic?

Isoniazid, rifampicin and pyrazinamide are all associated with hepatitis. Of the three drugs, rifampicin
is least likely to cause hepatocellular damage, although it is associated with cholestatic jaundice. Of
the three agents, pyrazinamide is the most hepatotoxic.

16. What is the most common cause of optic neuritis in ALL of the 18 drugs?

Linezolid is by far the most common cause of optic neuritis among all of the TB drugs. Mostly after
four months of treatment.

17. Patients with diabetes are at risk for what complication due to anti-TB drugs?

Patients with diabetes are at increased risk for optic neuritis. They should be managed with tight
glucose control as a means of prevention.

18. What vitamin is given to patients to prevent complications? Complications to which drug?
Given to prevent what complication?

For individuals who are given isoniazid and at risk for peripheral neuropathy (e.g. malnutrition, chronic
alcohol dependence, HIV infection, renal failure or diabetes, or who are pregnant or breastfeeding),
prescribe 10–25 mg/day of pyridoxine (vitamin B6). Supplemental pyridoxine of 5–10 mg/day should
be given to the infant who is taking isoniazid or whose breastfeeding mother is taking isoniazid (H).

19. Which first line anti-TB drugs is/are known to cause mild or localized skin reactions?

Any of the first line anti-TB drugs (HRZE).

20. Which first line anti-TB drugs is/are known to cause severe skin rash?

Any of the first line anti-TB drugs (HRZE).

21. Which first line anti-TB drugs is /are known to cause a burning sensation in the feet?

Isoniazid

22. Which first line anti.TB drues is/are known to cause arthralgia due to hyperuricemia?
Pyrazinamide

23. Which first line anti-TB drugs is/are known to cause flu-like symptoms?

Rifampicin

24. Which first line anti-TB drugs is/are known to cause psychosis and convulsion?

Isoniazid

25. Which first line anti-TB drugs is/are known to cause thrombocytopenia, anemia and shock?

Rifampicin

26. Which first line anti-TB drugs is/are known to cause ototoxicity?

None. Only second line anti tb drugs (Streptomycin) cause ototoxicity.

27. When monitoring a patient that you started on HRZE you noted that his SGPT is >5x the
upper limit of normal but he is asymptomatic and feels fine. What is the next best thing to do
with regards to the treatment regimen?

Stop all drugs, including anti-TB drugs; measure LFTs weekly. Treatment may be reintroduced after
toxicity is resolved.

28. True or False. It is necessary to wait for the liver function tests to revert to normal and
clinical symptoms (e.g., nausea, abdominal pain) to resolve before reintroducing the anti-T8
drugs.

True. It is necessary to wait for the liver function test (LFT) to revert to normal and clinical symptoms
(e.g. nausea, abdominal pain) to resolve before reintroducing the anti-TB drugs. If it is not possible to
perform an LFT, it is advisable to wait an extra two weeks after resolution of jaundice and upper
abdominal tenderness before restarting TB treatment. Once drug-induced hepatitis has resolved, the
drugs are reintroduced one at a time, beginning with rifampicin. After three to seven days, isoniazid
may be reintroduced. In patients who have experienced jaundice but tolerate the reintroduction of
rifampicin and isoniazid, it is advisable to avoid pyrazinamide. If symptoms recur or LFTs become
abnormal as the drugs are reintroduced, the last drug added should be stopped.

29. When reintroducing anti-TB drugs after hepatitis, how long should you wait before
reintroducing isoniazid after rifampicin?

Once drug-induced hepatitis has resolved, the drugs are reintroduced one at a time, beginning with
rifampicin. After three to seven days, isoniazid may be reintroduced. In patients who have
experienced jaundice but tolerate the reintroduction of rifampicin and isoniazid, it is advisable to avoid
pyrazinamide. If symptoms recur or LFTs become abnormal as the drugs are reintroduced, the last
drug added should be stopped.

30. What treatment should be prescribed for patients with established chronic liver disease?

Patients with chronic liver disease should not receive pyrazinamide. Alternative regimens are
2SHRE/6HR, 9RE or 2SHE/10HE.
31. Which of the first line anti-TB drugs are biliary excreted and thus can be given in normal
doses in patients with renal failure?

Isoniazid and rifampicin are eliminated by biliary excretion. These drugs, therefore, can be given in
normal dosages to patients with renal failure. Patients with severe renal failure should receive
isoniazid with pyridoxine to prevent peripheral neuropathy.

32. A 28-year-old G1P0 28 4/7 week pregnant patient was referred to your service for 2 weeks
cough with hemoptysis, chronic inflammatory infiltrates in the right upper lung and Xpert MTB
detected without Rit resistance. What treatment regimen do you prescribe?

Most anti-TB drugs are safe for pregnant women, except streptomycin, which is ototoxic to the fetus.
Advise a pregnant woman that successful treatment of TB with the recommended standardized
treatment regimen (i.e. 2HRZE/4HR) is important for a successful outcome of pregnancy. Pregnant
women taking isoniazid should be given pyridoxine (vitamin B6) at 25 mg/day.

33. In lactating mothers on treatment, most anti-tuberculosis drugs will be found in the breast
milk in concentrations equal to only a small fraction of the therapeutic dose used in infants.
What regimen should be prescribed for lactating mothers who are bacteriologically confirmed
without rifampicin resistance?

A breastfeeding woman afflicted with TB should receive a full course of TB treatment. Timely and
properly applied chemotherapy is the best way to prevent transmission of tubercle bacilli to the baby.
In lactating mothers on treatment, most anti-TB drugs will be found in the breast milk in concentrations
equal to only a small fraction of the therapeutic dose used in infants. However, effects of such
exposure on infants have not been established. It is recommended that lactating mothers feed their
infants before taking medications.
Supplemental pyridoxine (i.e. vitamin B6) should be given to the infant who is taking INH or whose
breastfeeding mother is taking INH.

34. Should mothers who are breastfeeding, but with sputum positive MDR TB discontinue
breastfeeding? Why or why not?

Mothers who are breastfeeding, but with sputum-positive MDR-TB should discontinue breastfeeding if
possible. Both bedaquiline and delamanid are excreted in breast milk in animal studies and, therefore,
the decision to discontinue the drug or nursing, as an alternative, should consider the benefits and
risks with clinical consideration.

35. Rifampicin interacts with oral contraceptive medications with a risk of decreased
protective
efficacy against pregnancy. What advice would you give?

Rifampicin interacts with oral contraceptive medications with a risk of decreased protective efficacy
against pregnancy. Advise a woman receiving oral contraceptives while on rifampin treatment that she
has the following options: 1) take an oral contraceptive pill containing a higher dose of estrogen (50μ),
following consultation with a clinician; or 2) use another form of contraception.

36. What is the follow up schedule for patients who are clinically diagnosed with tuberculosis?
What test do you order?
37. What is the follow up schedule for patients who are bacteriologically-diagnosed with
tuberculosis? What test do you order?

38. What is the follow up schedule for patients who are categorized as retreatment with
tuberculosis? What test do you order?

For 36-38,

39. What level of CD4 count should you start antiretroviral treatment in TB patients living with
HIV?

Antiretroviral treatment (ART) should be started in all TB patients living with HIV, regardless of CD4
cell count. TB treatment should be initiated first, followed by ART as soon as possible within the first
eight weeks of treatment. If with profound immunosuppression (e.g. CD4 counts less than 50
cells/mm3), HIV-positive TB patients should receive ART within the first two weeks of initiating TB
treatment.

40. In newly diagnosed HIV patients with TB, how long should anti-TB treatment be given prior
to starting antiretroviral treatment?

Antiretroviral treatment (ART) should be started in all TB patients living with HIV, regardless of CD4
cell count. TB treatment should be initiated first, followed by ART as soon as possible within the first
eight weeks of treatment.

41. How do you classify a patient as having bacteriologically-confirmed Multidrug-resistant TB

(BC-MDR-TB]?

42. How do you classify a patient as having bacteriologically-confirmed extensively

drug-resistant TB (BC-MDR-TB]?

43. How do you classify a patient as having bacteriologically-confirmed tuberculosis with

resistance to ethambutol and pyrazinamide but not rifampicin and isoniazid?

For 41-43,
44. Which of the following is not a drug used to treat MDR/XDR TB? Bedaquiline. Delamanid,
Levofloxacin, Clofazamine, Linezolid, Cycloserine, Prothionamide

None of the above. All are used to treat MDR TB

45. When do you inform clinically diagnosed TB patients if they are really cleared for
school/work?

After one week of uninterrupted treatment for clinically diagnosed TB cases.

46. When do you inform bacteriologically-confirmed TB patients if they are really cleared for
school/work?

After a negative follow-up SM for bacteriologically confirmed TB cases. If a patient wishes to return to
work sooner, SM may be repeated (outside of the regular schedule) at least two weeks after treatment
initiation.

47. A patient scheduled to undergo elective surgery under general anesthesia is found to have
tuberculosis, when is it safe to schedule for surgery?

Elective surgery should be delayed until the patient is no longer infectious. The American Society of
Anesthesiologists defines this as having been on treatment for 2-3 weeks, clinically getting better, and
having had three negative sputum smears on different days.

48. How do you manage these patients who interrupted their treatment?
a. Stopped HRZE more than 1 month but less than 2 months. Smear negative.

Continue treatment and prolong to compensate for missed doses

b. Stopped HRZE more than 1 month but less than 2 months. Smear positive. On treatment for
less than 5 months.

Continue treatment and prolong to compensate for missed doses

c. Stopped HRZE for more than 1 month but less than 2 months. Smear positive. On treatment
for less than 5 month or more

Continue treatment and prolong to compensate for missed doses

d. Stopped HRZE less than 1 month

Continue treatment and prolong to compensate for missed doses

e. Stopped HRZE more than 2 months

Lost to follow-up. Exert all efforts to trace patient, perform Xpert MTB/RIF test and refer to DR-TB
treatment center if needed.

49. How do vou classify these patients based on treatment outcome?

a. Treatment terminated because of evidence of additional acquired resistance (e.g., Rif
resistance on Xpert at 2nd month)?
Treatment failed

b. A patient whose treatment was interrupted for at least 2 consecutive months

Lost to follow-up

c. A patient who completes treatment without evidence of failure but with no sputum smear
negative results in the last month of treatment and on at least one previous occasion because
tests were not done or results were unavailable

Treatment completed

d. A patient with bacteriologically-confirmed TB at the beginning of treatment and who was

smear or culture-negative in the last month of treatment and on at least one previous
occasion in the continuation phase

Cured

e. A patient for whom follow-up sputum examination was not done (e.g. child of EPTB) and who
does not show clinical improvement anytime during the treatment

Treatment failed

f. A patient who dies for any reason during the course of treatment

Died

50. You are screening for individuals eligible for TB preventive treatment who are all
asymptomatic. Do you perform tuberculin skin testing for these individuals? Yes or no
a. Household contacts of bacteriologically-confirmed pulmonary TB case who are 5 years and
older but with no other risk factor for TB

Yes

b. Close contacts of bacteriologically-confirmed pulmonary TB

Yes

c. Patients receiving dialysis,

Yes

d. Patients preparing for an organ or hematological transplantation

Yes

e. Patients initiating anti-INF treatment

Yes

f. Patients with silicosis

Yes

51. What is considered a positive tuberculin skin test?

An induration of > 5 mm in children with immunosuppressed conditions, such as HIV or severe
malnutrition, or >10 mm in other children regardless of BCG vaccination status is defined as TST
positive.
52. How do you classify asymptomatic patient who are positive for TST? Do you start
treatment?

Latent TB Infection. Yes, start treatment as LTBI

53. When do you start preventive treatment in pregnant women with HIV who are already on
antiretroviral treatment?

For pregnant women with HIV who are already on ART, defer preventive treatment until three months
post-partum.

54. When do you start preventive treatment in patients with acute viral hepatitis?

Defer preventive treatment until the acute hepatitis has been resolved.

55. A mother who is now on her 3rd month on HRZE gave birth at the delivery room and is
asking if her newborn child should start preventive treatment. What do you say?

a. Assess the newborn. If the newborn is not well, refer it to a specialist/pediatrician.

b. If the newborn is well (absence of any signs or symptoms presumptive of TB), do not give
BCG first. Instead give TB preventive treatment. Give Pyridoxine at 5–10 mg/day. Preventive
treatment is not necessary if the mother has received more than two months of anti-TB
treatment and is not considered infectious.
c. At the end of treatment, perform TST. If TST is negative or not available, give BCG.
d. If the mother is taking anti-TB drugs, she can safely continue to breastfeed.
e. Mother and baby should stay together and the baby may be breastfed while on TB preventive
treatment.

56. Most first line anti-TB drugs are safe to give to pregnant women except which drug?

Isoniazid and rifampicin can be used in pregnant or breastfeeding women. Rifapentine should be
avoided due to lack of data on safety in pregnant or breastfeeding women. Advise a pregnant woman
that successful treatment of TB with the recommended standardized treatment regimen (i.e.
2HRZE/4HR) is important for a successful outcome of pregnancy. Pregnant women taking isoniazid
should be given pyridoxine (vitamin B6) at 25 mg/day.

Identify physical exam findings

● Phlyctenular conjunctivitis
● Gibbus deformity
● Cervical Tuberculous lymphadenitis
● Tuberculosis-Associated Erythema nodosum

Interpret the following GeneXpert results: