A 27-year-old woman comes to the outpatient clinic for evaluation. She says her father, who came from India 3 months ago and is living with her, was recently diagnosed with pulmonary tuberculosis and began a 4-drug treatment regimen. The patient has had no cough, weight loss, night sweats, chills, or fevers. She has a history of type 1 diabetes mellitus but no history of lung disease. She does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits. Cardiac and pulmonary examinations are normal. A tuberculin skin test is read 48 hours later as 7-mm induration and 12-mm erythema. Chest x-ray shows no abnormalities.
What is the best next step in management of this patient?

Question

A 27-year-old woman comes to the outpatient clinic for evaluation.  She says her father, who came from India 3 months ago and is living with her, was recently diagnosed with pulmonary tuberculosis and began a 4-drug treatment regimen.  The patient has had no cough, weight loss, night sweats, chills, or fevers.  She has a history of type 1 diabetes mellitus but no history of lung disease.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits.  Cardiac and pulmonary examinations are normal.  A tuberculin skin test is read 48 hours later as 7-mm induration and 12-mm erythema.  Chest x-ray shows no abnormalities.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_985c_aad5_853d_bd4f23af28c4_MD0002_00 Close contacts of individuals with active pulmonary tuberculosis (TB) must be screened for TB exposure. In this population, a tuberculin skin test (TST) reaction of ≥5-mm induration is considered positive. Patients with positive screening then require chest x-ray and symptom review to differentiate between latent and active disease. ≥5-mm induration This patient has a positive TST with no symptoms or chest x-ray findings, indicating latent TB infection (LTBI). Several LTBI treatment regimens are available; short-course (eg, 3-4 months), rifamycin-based regimens (eg, 3 months of weekly isoniazid [INH] plus rifapentine; 4 months of daily rifampin; 3 months of daily INH plus rifampin) are preferred over daily INH for 6-9 months. Some patients need to be on prolonged, daily INH therapy due to drug-drug interactions or hypersensitivity to rifampin; major side effects of INH therapy include: Peripheral neuropathy - can be prevented by pyridoxine supplementation. However, pyridoxine should only be added for those at greatest risk including patients who are pregnant, those who have other conditions associated with neuropathy (eg, diabetes, uremia, alcohol use disorder, HIV), and individuals with seizure disorder.Hepatitis - cannot be prevented with pyridoxine supplementation. Patients should be advised to abstain from alcohol. Liver function tests should be monitored at baseline and every 3 months. INH should be discontinued immediately if serum transaminase levels are >3 times the normal limit in symptomatic patients or >5 times the normal limit in asymptomatic patients. Peripheral neuropathy - can be prevented by pyridoxine supplementation. However, pyridoxine should only be added for those at greatest risk including patients who are pregnant, those who have other conditions associated with neuropathy (eg, diabetes, uremia, alcohol use disorder, HIV), and individuals with seizure disorder. Peripheral neuropathy - can be prevented by pyridoxine supplementation. However, pyridoxine should only be added for those at greatest risk including patients who are pregnant, those who have other conditions associated with neuropathy (eg, diabetes, uremia, alcohol use disorder, HIV), and individuals with seizure disorder. Hepatitis - cannot be prevented with pyridoxine supplementation. Patients should be advised to abstain from alcohol. Liver function tests should be monitored at baseline and every 3 months. INH should be discontinued immediately if serum transaminase levels are >3 times the normal limit in symptomatic patients or >5 times the normal limit in asymptomatic patients. Hepatitis - cannot be prevented with pyridoxine supplementation. Patients should be advised to abstain from alcohol. Liver function tests should be monitored at baseline and every 3 months. INH should be discontinued immediately if serum transaminase levels are >3 times the normal limit in symptomatic patients or >5 times the normal limit in asymptomatic patients. (Choice A) Patients with positive TB screening who have symptoms or chest x-ray findings concerning for active TB require further evaluation with sputum samples for acid-fast bacillus and mycobacterial culture. This patient has a normal chest x-ray and no symptoms. (Choice C) TST induration ≥5 mm is considered a positive result in close contacts of a known TB case. The 10-mm cut-off is used for recent immigrants from endemic areas, injection drug users, residents/employees of high-risk settings, and those at greater risk for TB reactivation (eg, prolonged glucocorticoid use, leukemia, end-stage renal disease). (Choice D) A positive TST indicates exposure and does not need to be repeated. Close contacts who have a negative initial TST should have a repeat TST done at 8-12 weeks. (Choice E) The combination of rifampin and pyrazinamide was shown to result in severe liver injury and is no longer recommended as treatment. Educational objective: A tuberculin skin test reaction of ≥5 mm is considered positive in a patient with recent exposure to an individual with active pulmonary tuberculosis. Short-course, rifamycin-based regimens are recommended as treatment for latent tuberculosis infection. __________ References: Current concepts in the management of tuberculosis. (http://www.ncbi.nlm.nih.gov/pubmed/21454737)

A 27-Year-Old Woman Comes to the Outpatient Clinic for Evaluation