Question of the Week # 393

393)  A 36 year old homeless man is evaluated in the Emergency Room for intermittent fever, cough, night sweats and weight-losss. He also reports having chronic cough with progressively increasing bloody expectoration for the past 1 month. He has lost about 10lbs weight over the past 3 months. He smokes 1 pack per day and has a history of intravenos drug abuse. On examination, he is cachectic.  He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%.  Reminder of the physical examination is unremarkable. Which of the following is the most appropriate initial step in managing this patient?

A) Sputum samples for Acid Fast Bacilli

B) Start Multi-drug therapy for Tuberculosis

C) Obtain a Chest X-ray

D) Tuberculin Skin test

E) Air-Borne Isolation

F) Test for HIV

11 Responses

  1. C) Obtain a Chest X-ray – always the first step when u suspect Pulm Tb then sputum sample for acid fast bacilli – if positive
    E) Air-Borne Isolation —>B) Start Multi-drug therapy for Tuberculosis
    —->F) Test for HIV since he has a h/o iv drug abuse.

    • he has hemoptysis! What causes hemomptyis if this were to be TB (which is what he most likely has given his very high pre-test probability) ?

      • Primary focus?

    • If we were to choose CXR option, if he has cavitary TB or sputum +ve TB ; we would be putting radiology personnel and other ER staff at risk for TB exposure until CXR is obtained! Hence, these simple concepts can be still be difficult unless we know the accurate step by step approach and the rationale for such approach.

      • So isolate the patient first when there a high pre test probability of Pulmonary Tb?

        E) Air-Borne Isolation

      • Yes, until three sputum samples are negative for AFB. If three sputum samples are negative, isolation can be discontinued even if he has positive chest x-ray findings. Sputum AFB smears determine infectivity. If they are negative , infectivity is very low. Remember negative AFB smear does not rule out TB ( most often they are negative even in active pulmonary TB therefore, we start empiric TB therapy and wait cultures which takes about 6 weeks) . The only thing that negative sputum smears exclude is infectivity so, giving you a green signal to discontinue airborne isolation

      • But the person who collects the sputum sample as well as examines it is also equally exposed to TB !! so considering the same precautions one takes to examine a sputum sample, the same precautions can be taken by the Xray tech and ER guys !!! And by the way he has progressively increasing hemoptysis which can be suddenly massive,,,!! In all probability the sputum test will remain in negative and considering we find signs of pulmonary TB i feel we practically go chest x ray first !!!

  2. in my country, since most of the hospital stuff and population are already infected withTB, we do X-ray first; cos there is not much risk getting active TB. but i guess for the literature answer should be isolation 🙂

  3. chest x-ray

  4. C

  5. EEE

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