PPD 8 mm before starting steroids ... what next ? EXPLANATION!!!! ??? - USMLE Forums
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  #1  
Old 06-06-2012
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Default PPD 8 mm before starting steroids ... what next ? EXPLANATION!!!! ???

A 39-year-old woman is evaluated in the office for a malar rash, arthralgias, and serositis. Complete blood count and renal and liver chemistry studies are normal. Assays for antinuclear antibodies, anti-double-stranded DNA antibodies, and anti-Smith antibodies are positive. Serologic studies for HIV are negative.

Chest radiograph is normal. Tuberculin skin testing reveals 8 mm of induration.

Before initiating prednisone, which of tahe following is the most appropriate next step in this patient's management?

A Isoniazid for 9 months
B Isoniazid, pyrazinamide, rifampin, and ethambutol for 12 months
C Rifampin and pyrazinamide for 2 months
D No antituberculous therapy
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Old 06-06-2012
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these PPD question have no end
since the pt will be start (no yet) and steroid though immunosupressive but dont directly accused of reactivating TB like (anti-TNF). i think at this time NOthing is needed.
however if the pt has been taking steroid for prolonged time and PPD is 8mm, know what is the ans ?
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Quote:
Originally Posted by bisho View Post
these PPD question have no end
since the pt will be start (no yet) and steroid though immunosupressive but dont directly accused of reactivating TB like (anti-TNF). i think at this time NOthing is needed.
however if the pt has been taking steroid for prolonged time and PPD is 8mm, know what is the ans ?
Those on steroids for long time PPD of 5mm and above is positive, and they should have CXR done
if CXR is negative then INH for 9 months
If CXR is positive then complete treatment (RIPE)
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No antituberculous therapy as pt is not on steroids.


Quote:
Originally Posted by tyagee View Post
A 39-year-old woman is evaluated in the office for a malar rash, arthralgias, and serositis. Complete blood count and renal and liver chemistry studies are normal. Assays for antinuclear antibodies, anti-double-stranded DNA antibodies, and anti-Smith antibodies are positive. Serologic studies for HIV are negative.

Chest radiograph is normal. Tuberculin skin testing reveals 8 mm of induration.

Before initiating prednisone, which of tahe following is the most appropriate next step in this patient's management?

A Isoniazid for 9 months
B Isoniazid, pyrazinamide, rifampin, and ethambutol for 12 months
C Rifampin and pyrazinamide for 2 months
D No antituberculous therapy
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Old 06-06-2012
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Quote:
Originally Posted by cytokine View Post
Those on steroids for long time PPD of 5mm and above is positive, and they should have CXR done
if CXR is negative then INH for 9 months
If CXR is positive then complete treatment (RIPE)
i thought you had to confirm by doing sputum staining if xray was positive before you start prophylaxis/tx?

And i would answer D aswell, the values of > 15mm is stuck in my head fr some reason.
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Old 06-06-2012
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Quote:
Originally Posted by tyagee View Post
A 39-year-old woman is evaluated in the office for a malar rash, arthralgias, and serositis. Complete blood count and renal and liver chemistry studies are normal. Assays for antinuclear antibodies, anti-double-stranded DNA antibodies, and anti-Smith antibodies are positive. Serologic studies for HIV are negative.

Chest radiograph is normal. Tuberculin skin testing reveals 8 mm of induration.

Before initiating prednisone, which of tahe following is the most appropriate next step in this patient's management?

A Isoniazid for 9 months
B Isoniazid, pyrazinamide, rifampin, and ethambutol for 12 months
C Rifampin and pyrazinamide for 2 months
D No antituberculous therapy
D No antituberculous therapy
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Old 06-07-2012
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Default source is authentic !!!

ans is INH * 9 months

qbank uncle...

Isoniazid therapy for 9 months is recommended for this patient. Immunosuppressed patients have an increased risk for developing primary or reactivation tuberculosis. Prednisone may cause false-negative tuberculin skin test results. Therefore, tuberculin skin testing in immunosuppressed patients is recommended before initiation of prednisone therapy. The American Thoracic Society recommends that patients who use prednisone, ≥15 mg/d, or any other immunosuppressive agent and who have ≥5 mm of induration on tuberculin skin testing begin prophylactic therapy with isoniazid, 300 mg/d, for 9 months.

Concomitant administration of rifampin and pyrazinamide is associated with substantial hepatic toxicity and is not indicated for patients with latent tuberculosis unless the benefits of this treatment outweigh the risks or other regimens cannot be used. Since this patient has no evidence of active tuberculosis, four-drug treatment for 1 year is not needed. Compared with isoniazid, rifampin for 4 months may be associated with better compliance and fewer side effects and therefore may be used as alternative therapy for latent tuberculosis.
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So we are considering this SLE pt as being immunosuppresed!!!
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Quote:
Originally Posted by bisho View Post
So we are considering this SLE pt as being immunosuppresed!!!
I think the take home point from last two questions on PPD is --- INH prophylaxis for any patient who either is on immunosuppressive therapy or starting immunosuppressive therapy.
If you think about it it makes perfect sense. You will give INH for 9 months to a patient on immunosuppressive therapy with a PPD of > 5mm. If the same patient is going to start immunosuppressive therapy and has a PPD of > 5 mm then that patient is in the same situation as before.
So, starting immunosuppressive therapy is clinically equivalent to being on immunosuppressive therapy with a PPD > 5mm for the purpose of starting INH prophylaxis.
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