Question of the Week # 247

247 )  A 32 year old  hispanic woman with past medical history of HIV infection on Anti-retroviral therapy evaluated in your office because she is concerned about her potential exposure to Tuberculosis. Her father has come to visit her from Mexico and he was diagnosed with cavitary tuberculosis of left lung three week ago. He is currently receiving multi-drug anti-tuberculosis therapy. The patient says she has been taking care of her father at home since the diagnosis was made. A Tuberculin skin test is administered and is negative after 72 hours. Patient denies any fever, cough, chest pain or weight loss. Which of the following is most appropriate management ?

A) Re-assurance

B) Repeat PPD in 3 months

C) Start Isoniazid

D) Chest X-ray

E) Repeat PPD in one year

13 Responses

  1. C) Start Isoniazid is my vote

  2. Answer B

  3. b

  4. Reassurance is the answer(A)

  5. I would like to change my answer to “C”. Since he is an HIV + patient, he should be provided with prophylaxis with INH ASAP when there is an exposure to cavitatory TB patient. The TB + pt is a close contact, is a family member, living in the same house.

    good luck.

  6. c

  7. i agree.. C.. patient is immunocompromised.. though she is on Antiretroviral therapy we do not know her cell count.. if its low patient may not be positive on PPD even after 3 months.. so i say be safe give INH..

  8. Ans.C.
    recent guidelines from the CDC, which suggest that among persons who are HIV-positive and PPD-negative, isoniazid should be given only to those with recent or ongoing exposure to active tuberculosis.

  9. C…
    HIV-infected individuals who are close contacts of persons with infectious tuberculosis should receive treatment for LTBI regardless of the results of the tuberculin skin test, as long as active tuberculosis has been ruled out. In addition, because exogenous reinfection has been demonstrated in patients with AIDS, treatment should be given even if a prior course of therapy for tuberculosis or LTBI has been completed. Contacts of known cases of INH-resistant tuberculosis should be treated with rifampin (600 mg/day) instead of INH. Close contacts to MDRTB cases should be treated with at least two drugs to which the source isolate is susceptible.

  10. ccc

    • The father may not positive of HIV, He may be the old case of pulmonary tuberculosis.

  11. C) Start Isoniazid

    PPD may be negative due to anergy in HIV Pt

  12. C)
    “Window prophylaxis” is the practice of treating TB skin test (TST) negative individuals exposed to a contagious pulmonary or laryngeal TB case with isoniazid (INH).
    Patients exposed to active TB should be evaluated by TST, history and physical exam. If the TST is negative and there are no symptoms of active tuberculosis, consideration should be given to treating the patient with isoniazid prophylaxis.
    Individuals at high risk of progressing rapidly to active TB after infection (children less than 5 years of age and immunocompromised individuals) should also have a normal radiograph documented before starting treatment.
    The purpose of window prophylaxis is to abort an early TST negative TB infection and prevent progression to active tuberculosis (it can take up to three months for the TST to become positive after infection).

    SOURCE – UCSF

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