Question of the Week # 322

322)  A 45 year man is evaluated in emergency department for severe cough accompanied by bloody expectoration. Cough is of 4 month duration associated with sputum production but he is worried because of the new change in the character of his sputum which is now frankly bloody. He reports a weight-loss of 10 lbs in the past two months.  He has intermittent nigh-sweats and low grade fever on a daily basis. On examination, his temperature is 100F, Pulse 98/min, RR 20/min and Blood Pressure 100/60 mm HG.  He appears cachectic and in moderate distress due to cough. On auscultation, high-pitched bronchial breath sounds are heard in the right upper chest.

A chest-x-ray is shown below:

The patient is admitted and is placed on respiratory, negative-pressure isolation. HIV rapid test is positive. Sputum smears for Acid Fast Bacilli (AFB) are positive. A CD4 count is 155/μl ( Normal = 650 to 1150/µl). Which of the following is the most appropriate next step in management at this time?

A) Bronchoscopy and send bronchial washing for clutures

B) Start Multi-Drug anti-tuberculosis Therapy alone

C) Start Highly Active Antiretroviral Therapy (HAART) plus Multi-drug Anti-TB therapy

D) Start HAART and await sputum for AFB identification and sensitivity testing

E) Start Clarithromycin for Mycobacterium Avium Intracellulare (MAC)

39 Responses

  1. D

  2. ccccccccccccccccc

  3. c.start HAART therapy plus multi drug Anti-TB Therapy

  4. C) Start Highly Active Antiretroviral Therapy (HAART) plus Multi-drug Anti-TB therapy

  5. bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb

  6. c) Start HAART plus multi-drug anti-TB therapy. Early initiation of HAART along with TB treatment in co-infected patients boosts survival of these patients.

  7. OOPS…looks like im the only one thinking B…I though HAART was not started when an acute illness is going on to prevent Immune Reconstitution syndrome or something…please correct me if I am wrong…thanks! Waiting for the right answer…

  8. C

  9. d

  10. it’s ‘c’

  11. its c

  12. cccccccccccccccccccc

  13. answer is cccccccccccc

  14. C….

  15. cccc

  16. start multi drug anti TB regimen….and add HAART therapy after 2 weeks…inorder to have minimum adverse effects

  17. C Start HAART an Multi tb regimen

  18. B) Start Multi-Drug anti-tuberculosis Therapy alone
    and then HAART should be started a few weeks later to prevent Immune reconstitution inflammatory syndrome.

  19. c. When CD count is > 50 and < 500, ART and ATT can be started simultaneously

  20. B……..It is generally advised that when patients have low initial CD4 T cell count and opportunistic infection at the time of their HIV diagnosis, they receive treatment to control the opportunistic infections before HAART is initiated.

  21. Cd4 count>200 – delay haart for 6 months
    cd4 count 100-200 – delay haart for 2 months

    So, B

  22. Ans B

    As dr. redz said think about IRIS . Starting HAART with a coexisting active TB infection will lead to worsening of symptoms when the CD4 starts to go up .

    There’s no need wait for Sputum culture or sensitivity before initiating tx . Patient is in severe condition . go ahead and tx while wait .

  23. The tx is first the tb for 1 or 2 month before the recontitutional synd that appear with the use of hasty and can b dangerous, Meny time when the Pt came with this u have to stop the haart, never is indicated to stop the tb medication.

  24. IRIS:is a condition in aids where the immunesystem begins to recover but the system begins to respond to a previously acquired opportunistic infection with an overwhelming inflammatory response that makes the symptoms of infection worse.
    infections associated with iris :mycobacterium tb and cryptococcus meningitis
    treatment:administer antibiotic or antiviral agents to eliminate the infection and in severe cases add steroids to suppress inflammation till the infection is resolved .

  25. B
    Treatment guidelines recommend initiating antiretroviral therapy (ART) within two weeks for most opportunistic infections
    An exception to this recommendation is cryptococcal meningitis and possibly tuberculous meningitis, in which the benefits of ART are outweighed by induction of a potentially serious immune reconstitution inflammatory syndrome.
    Ref: Uptodate.

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