DIP Episode 262 - The Clutch TB Podcast

Okay, welcome. I am divine. This is episode 262 of the Divine Intervention Podcast. This podcast should be relatively short. It's the Clutch TV Podcast. And again, if you listen to this, you should pretty much be able to hopefully get all your TV questions right on the test. And again, just a reminder from the 21st to the 23rd of this month, that's the next week Monday to Wednesday. On the 21st, I have a test against strategies class on the 22nd and 23rd. I have a comprehensive step to seek your review class, right? So if you want more details on that, so you want to sign up, there's still a few spots remaining. Just shoot me an email via the website and then we'll go from there. Okay, let's jump right into it. So the thing is, if you suspect that a person has TB, right? Or if they need to get, if they are trying to get you to pick a diagnostic test for TB on your exam. Always like, if you want to like screen, right, let's put it this way, right? If you want to screen, you can do one of two things on your test, right? You can do the TB skin test or you can do the interferon gamma release assing. Either one is perfectly acceptable on exams, right? Either one is perfectly acceptable on exams. Now, let me tell you something. If they give you a specific situation where the person, right? So this is like one specific scenario, right? Usually they won't give you both as answer choices like, oh, TB skin test and the interferon gamma release assing.

But let me tell you one specific scenario, let me show you an exam, right? If they give you a scenario for a person that's coming from a foreign country, right? Like an immigrant or something, especially someone that came from a foreign country less than five years ago. And then they're trying to get you to screen that person for TB. And in the answer choice, you see an answer choice that says, especially if the person has got in the BCG vaccine, right? They'll throw in this thing. The person has got in the BCG vaccine. I want to screen the person for TB, the hotel, they'll give you an answer choice, they'll say, TB skin test. And then they give you another answer choice that says interferon gamma release assing. If you see that, big interferon gamma release assing, right? So the person has received the BCG vaccine back in the day. They give you both answer choices, the TB skin test of interferon gamma release assing. Take the answer choice that says to do the interferon gamma release assing, right? It's just more helpful in those people. Also, they give you a question where the person doesn't follow up with the physician regularly. The last time they saw the physicians like five years ago, something crazy, right? Those are the kinds of people you know, they will very likely not come back in 70 to 72 hours to have their TB skin test results read. For those people, administered interferon gamma release assing in those specific populations.

And the thing though, I will say though, is whether a person has got in the BCG vaccine or not, it doesn't matter. The TB skin test results are always interpreted the exact same way. They are always interpreted the exact same way. And again, don't forget your millimeters of duration for the TB skin test. So if a person, remember, five millimeters of duration is positive in a person that is, I think the big thing you want to keep in mind here is a person that is immunocompromised, right? A person that is immunocompromised, right? So what are examples of who is an immunocompromised? What are different veneers they can create on the test, right? Can be a person that has HIV, that's the classic one, right? But it can also be a little more exotic, especially on this new NBA me exams, right? It will give you something about a person that has had a transplant of some sort and the person is an immunosuppression, right? Or the person is getting like chronic pregnancy therapy for some autoimmune disease, right? Or if you're a person that recently contacted someone that is known to have active TB, you definitely fall under that five millimeter in duration category, right? And then the 10 millimeters of duration, right? This one are, I think of like, high risk people and people in groups, right? So high risk people and people in groups, what do I mean by that? So let's say you're an immigrant and you just came from a foreign country again less than five years ago.

That's usually like the cut off, right? If you're an IV drug user, right? You fall in this 10 millimeter category, right? If you're a person that lives in a crowded environment, right? Prison, jail, right? Nursing home, right? Hospital person, something like that, right? Those people also again go that 10 millimeter category and again, if you're a healthcare worker, right? If you're a healthcare worker, you definitely fall within this 10 millimeter purview, right? And then 15 millimeters is positive in every person, right? It's positive in every person. Now, one thing I want to say is, and again, unfortunately, you do actually need to commit this stuff to memory, right? Now, let me tell you one thing right over the bat. You can never, if you remember this really, you'll see from a lot of pain and heartache on your test, you can never differentiate between active TB and latent TB by virtue of a TB skin test, one interferon gamma release assay. Fix this fact in your mind permanently. You can absolutely never differentiate between active TB or latent TB by a TB skin test, one interferon gamma release assay, right? Now, one thing I would say here is, really, there are two diagnoses of TB you want to essentially make on your test. You want to make the diagnosis of a person having active TB or a person having latent TB, because those people get different kinds of treatment, right? So, for example, if a person has latent TB, they need to meet three conditions on an MBM exam.

I'll say this again, for a person to be diagnosed with latent TB, they need to meet three conditions on an MBM. One, they must have a positive TB skin test or interferon gamma release assay. That's criteria one, they must have a positive TB skin test or a positive interferon gamma release assay. That's one, two, the chest x-ray must be negative. Three, they must not have any systemic manifestations of TB. They shouldn't be having cough, he might twist, we could also need that crap, okay? They need to meet those three criteria to be diagnosed with latent TB on an MBM. For a person who has latent TB on an MBM, guess what? You treat it with this regimen. This is the regimen that will probably cover 99% of your basis. But just for completeness sake, I'll talk about the other regimen, right? The primary regimen used on an MBM exam for latent TB is isozonaiazid for nine months. I don't care what you read in another Q-Bank or whatever, right? This is what the MBM goes after. Isozonaiazid for nine months plus vitamin B6, right? Isozonaiazid plus B6 for nine months, right? But one other thing you can do in some select cases, right? Especially people that don't have like HIV or you know, pretty normal people. You can actually do isozonaiazid for six months plus B6, right? You can even do rifamping for four months, just straight up rifamping for four months or INH for six months. But usually people that I you know compromise HIV folks, you do that nine months of INH plus B6.

But again, with that said, on an MBM exam, what I want you to pick, which will be correct like 99.9% of the time isozonaiazid for nine months plus vitamin B6, right? And then what tells you that the person has active TB, right? It's going to be a person that again has symptoms, right? The big, big, big thing is symptoms, right? Cough, right? Chess pain, hemoptysis, right? Fever chills, night sweats, those B symptoms. And they will have you for a long period of time, right? It can be like a TSA agent, it can be a person that is an immigrant, right? Or it can be a person that just traveled out of the country recently, like you know, over the last couple months or couple years and just came back not too long ago, right? Those people can have active TB, right? Those people can have active TB. And in general, if you suspect the person has active TB, right? You know, you typically want to do, you want to get something, you want to get some kind of sputum, right? You can do a bronchi of Yolala Vash to get that sputum, we can do an induced sputum sample, right? You can do an induced sputum sample, right? And typically when you do that, right, you're going to subject that sputum sample to the AFB smear, right? Like the acid phosphacylysmear, right? You're going to culture those things, right? In fact, remember, if you have a negative AFB smear, it doesn't roll out TB, right? Remember the gold standard for diagnosing TB, believe it or not, is actually a sputum culture, right?

But it takes weeks for TB to grow, right? It takes weeks for TB to grow, right? It takes weeks for TB to grow. And one thing I would say is, if for some reason they give you a question about a person that has a negative AFB smear, right? And they say for your next best step, right? And you don't see an answer that says to do a culture, go ahead and do like PCR testing, right? You know, the another thing for PCR and NV Me exams, right, is NEAT, right? Like a nucleic acid amplification test. Go ahead and do that on the sputum to diagnose a TB, right? To diagnose a TB, right? And how do we treat active TB? Easy, right? Active TB will usually treat it, right, with a combination of ripe, right? So, right, fanping, isonize it, pair of xenomite and ethambutol, right? You give these four agents plus vitamin B6 for the first two months. And then after that, for the remaining four months, because these six months of therapy total, right? So, first two months, right, fanping isonize it, pair of xenomite and ethambutol, right? Plus B6 for two months, and then for the remaining four months, you give right, fanping and isonize it, plus B6. Basically, whenever you're on a sonyis it, you've got to be on B6, right? You've got to be on B6, okay? And one weird, bizarre thing that your friends at the NV Me are beginning to go after these days, they're beginning to worry, especially again, the newer exams, right? There are some weird things they are beginning to touch on these days, right?

So, like, for example, right, like, you don't want you to know criteria that means that, oh, this person no longer has infection, you know, they can be exposed to other human beings, even if they are still being treated. Obviously, you're not going to be quarantined that person for a month, right? That's ridiculous, right? So, basically, you must have been on adequate therapy for two weeks, for at least 14 days, right? Just kind of think of the coronavirus guidelines, right? Like, oh, be quarantined for two weeks, right? And you see the person is getting clinically better, right? And then, they must have had, like, three negative sputum smears, right? Like, consecutive sputum smears, AFB smears, three must be negative. You need to meet those criteria for you to say, okay, this person doesn't need to be pleased in quarantine, this person doesn't need to be isolated anymore. We can go ahead and let this person out into the wild, right? Now, some preventive medicine things that they love to test on exams, right? Are things you're supposed to do before you start certain TB regimens, right? So, the thing is, before you start putting a person on parasyneamide, you need to check their levels of urethaceptic, right? Because remember, parasyneamide can trigger gout, right? It can trigger gout. That's one of those weird, high-yield things you want to know, right?

And then, people that have been studied on a thambutal, remember, those people need some kind of ophthalmologic testant, right? So, you need to check their visual acuity, check for call, check their color vision and all that stuff, right? Before you start them on a thambutal, right? Just one of those weird, bizarre things. You want to keep in mind, for example, right? Then remember, TB can, many times on in-beaming exams, if you show you a chest x-ray or TB, you can see the cavitary lesion, right? The person can have like a unilateral plural of fusion, right? Remember, people can also have like, like unilateral hyalurgylomyphadenopathy, right? They can even have this miliary TB, right? Where you see all these dots, right? In their, in their, in their lungs, right? These are things you'll want to be able to identify on imaging, on an NBME, on an NBME exam, right? Those are things you'll want to be able to identify. And then remember, TB can also cause problems in the brain, right? Like TB meningitis, right? Remember, people that have TB meningitis, you check the CSF, right? The CSF, classically, right? The thing that will happen is, you'll notice that they have a ton, like, elevated, very, very elevated pressures, right? So, high CSF opening pressures, you see a ton on an lymphocyte, right? So, the white cells will be up, proteins will be up, proteins will be up, and the white cells will be predominantly lymphocytes, right?

And again, the way you treat TB meningitis is exactly where you treat a regular TB, right? And again, remember, the glucose will be low, protein will be high, stuff like that, right? And usually, the way you treat, the way you diagnose, the way you deal with that CSF, where you suspect the person has TB meningitis, is to just do PCR of the CSF. That's actually the best test in diagnosing a TB meningitis. But if they say, do an AFB smear of the CSF, that's also acceptable on NBME exams as well, right? And then, don't forget that TB can also cause osteomyelitis, right? So, if they tell you about a person that has, like, back pain, right? And they have all these TB risk factors, right? Think about POTS disease, right? Remember, TB can cause a vertebral kind of osteomyelitis, right? It can cause a vertebral kind of osteomyelitis. And then one last thing I want to say, I guess, that may help you on an exam with regards to these microbiota-term species, right? Don't forget microbiota-term avium, right? Again, remember, if your CD4 count is less than 50, back in the day, we used to prophylax against those, but we don't do that anymore, right? Mac prophylaxis is no longer recommended, right? But the thing is, Mac can show up in non-HIV people on NBME exams, right? And usually, it'll be the classic presentation, right, of Mac in a non-HIV person, on especially the newer NBME exam, right? It'll be like an old woman, old white female, right? Very thin, right?

And they'll usually have something that tells you that they have, like, a connective tissue thing going on, right? Or they may have, like, some chest wall anomaly, right? They can have, like, pectosexcavaron, they can have, like, scoliosis. Or if you see a person that has, like, TB-stalk symptoms, and the person has my trovault prolapse, I want you to think about a Mac infection. And really, the way we treat Mac infections on exams is with macrolets, right? So, you treat Mac with a macrolet, right? So, you can give them, like, erythromycin, clarythromycin, or whatever, right? Make sure those people's cutie intervals are not super prolonged, right? Make sure they're cutie intervals are not super prolonged. Okay, so I'm going to go ahead and stop here. Please subscribe to this podcast. It's an Apple podcast. It's on Google, please, on Spotify, please subscribe. I also have a You Tube channel, Divine Intervention, USM-Eli podcast, and videos. And then, also have a website, right? Divine Intervention Podcast.com. So, please subscribe. I wish you all the very best. Thank you for listening. Thank you for all the support. And God bless you. Have a wonderful weekend. I'll see you next time.

1) Positive TST or IGRA; 2) Negative chest X-ray; and 3) Absence of systemic symptoms (e.g., cough, fever).

Sputum culture.

High opening pressure, predominantly lymphocytes, low glucose, and high protein.

Urate levels, because PZA can trigger gout.

IV drug use, living in crowded environments (prisons/nursing homes), or being a healthcare worker.

Macrobetol; Erythromycin or Clarithroam.

An ophthalmologic examination (checking visual acuity and color vision).

RIPE + B6 (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) plus Vitamin B6.

Multiple small dots scattered throughout the lungs.

History of tracheal prolapse or symptoms resembling TB-stalk syndrome.

PCR testing on the Cerebrospinal Fluid (CSF).

An ophthalmologic examination (checking visual acuity and color vision).

RIPE + B6 (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) plus Vitamin B6.

Multiple small dots scattered throughout the lungs.

History of tracheal prolapse or symptoms resembling TB-stalk syndrome.

PCR testing on the Cerebrospinal Fluid (CSF).