THG18-001
A 7-year-old boy who presented with frequent cough was subjected to this investigation.
a. What is shown in the given image and table? What to look for in these?
b. Name any four indications of this test?
c. Name any four diseases where this type of lung function needs to be monitored.
d. Name any four contraindications for this test.
Answer
| a. | Flow volume loop (FVL) and pulmonary function test (PFT) reading |
| Shape of FVL—expiration and inspiration | |
| Readings: FEV1/forced vital capacity (FVC), FEV, FEF 25–75, and peak expiratory flow rate (PEFR) | |
| b. | Chronic cough, persistent wheezing, asthma, cystic fibrosis, and interstitial lung disease |
| c. | Transfusion-dependent thalassemia major, sickle cell anemia, connective tissue disorders, ataxia telangiectasia, and chest deformities such as pectus excavatum |
| d. | Pulmonary embolism, hemoptysis of unknown origin, recent pneumothorax, cerebral/thoracic aneurisms, recent eye/thoracic/abdominal surgery, and severe respiratory distress |
THG18-002
An 8-year-old child was referred for evaluation of activity-induced cough and cough on exposure to incense sticks.
a. What could be the possible diagnosis in this child and what parameters one would look at in the given table
b. What are forced expiratory volume in 1 second (FEV1) and forced expiratory flow between 25th–75th% of vital capacity (FEF 25–75) and their importance?
Answer
| a. | FEVI, FEV1/FVC, FEF 25–75, and PEFR |
| b. | Forced expired volume in 1 second (FEV1) |
| • | The amount of air that can be blown in the first second in the FVC maneuver. Normal is above 90% |
FEF 25–75 (maximal mid expiratory flow rate)
| • | Forced expiratory flow rate between 25–75% of FVC |
| • | Represent small airway disease |
THG18-003
Q18.3
a. Interpret this spirometry.
b. What is the diagnosis?
c. What is the next step?
Answer
| a. | Shape: Scooped out appearance in expiration after the peak |
| Decreased FEV1/FEF 25–75/PEF | |
| b. | Obstructive airway disease |
| c. | Bronchodilator test |
THG18-004
Q18.4
a. Interpretation of this spirometry reading—image A and arrive at a diagnosis.
b. What does the arrow point out in the inner FVL in image B?
Answer
| a. | Shape of the FVL—scooped out appearance—obstruction during expiration |
| FEV1/FEF 25–75/PEF—pre and post | |
| (34 vs. 51)/(15 vs. 24)/(41 vs. 70)—obstructive airway disease—asthma | |
| b. | Cough in between |
THG18-005
Q18.5
a. Identify the device?
b. What do green, yellow, and red zones indicate?
c. What is the next step after getting red zone in flow meter?
Answer
| a. | Peak flow meter |
b. • Green zone: 80–100% of usual or “normal” peak flow rate—signals—asthma is under reasonably good control
| • | Yellow zone: 50–80% of usual or “normal” peak flow rate—signals—airways are narrowing and may require short action beta 2 agonist treatment |
| • | Red zone: <50% of usual or “normal” peak flow rate—signals—severe airway narrowing may be occurring |
| c. | Take rescue medications right away |
THG18-006
A 7-year-old boy with recurrent cough and wheeze has been diagnosed to have persistent asthma. His pediatrician has planned to start inhalation therapy.
a. Expand these acronyms used in asthma—GINA, ICS, MART, and ART
b. What is the recent change in GINA guideline as far as management of children between 6 and 11 years with intermittent wheeze is concerned?
Answer
| a. | Global initiative for asthma, inhaled corticosteroid, maintenance and reliever therapy, and anti-inflammatory reliever therapy |
| b. | Give inhaled corticosteroid whenever inhaled short acting beta 2 agonist is given |
THG18-007
A 7-year-old boy with recurrent cough and wheeze has been diagnosed to have persistent asthma. His pediatrician has planned to start inhalation therapy.
a. What are the drugs used in MART therapy?
b. What is the rationale behind it?
c. Ideal way to give inhaled corticosteroid medication in less than 3 years, 4–6 years and above 6 years.
Answer
| a. | Use of inhaled steroid combination with long-acting beta 2 agonist formoterol in the same pressurized meter dose canister is MART therapy |
| b. | Other long-acting beta 2 agonist do not have shorter time of onset of action like formoterol and hence MART therapy is always only with formoterol with inhaled steroid in the same canister. |
| c. | Up to 3 years: pMDI + spacer + mask or nebulizer |
| 4–6 years: pMDI + spacer ± face mask | |
| 6 years: pMDI ± spacer/dry powder inhaler |
THG18-008
A 7-year-old boy with recurrent cough and wheeze has been diagnosed to have persistent asthma. His pediatrician has planned to start inhalation therapy.
a. What is the composition of very low dose ICS-formoterol/low dose ICS-formoterol in MART therapy for relieving symptoms?
b. What is the maximum dose of ICS/formoterol in adolescent when used as reliever and in children 6–11 years?
Answer
| a. | Very low dose: Formoterol 6 µg + 100 µg of ICS either budesonide or beclomethasone |
| Low dose: Formoterol 6 µg + 200 µg of ICS either budesonide or beclomethasone | |
| b. | MART therapy—reliever in adolescent—maximum 12 doses/day |
| MART therapy—reliever in children 6–11 years—maximum 8 doses/day |
THG18-009
Name and elaborate the components of scoring system for the following conditions:
a. Acute tonsillitis
b. Acute croup
Answer
| a. | Modified Centor Criteria (McIsaac)—fever, tonsillar exudate, absent cough, anterior cervical lymphadenopathy, age 15–44 years, age >44 years |
| b. | Westley croup score: Inspiratory stridor, intercostal recession, air entry, cyanosis, and level of consciousness |
THG18-010
Expand these acronyms—CT, HRCT, MDCT, and CECT.
Answer
Computed tomography, high-resolution computed tomography, multidetector computed tomography, and contrast-enhanced computed tomography
THG18-011
In CT chest, what etiology should one suspect if there is predominant involvement of:
a. Bilateral upper lobe
b. Unilateral upper lobe
c. Lower lobe
Answer
| a. | Bilateral upper lobe—cystic fibrosis/allergic bronchopulmonary aspergillosis (ABPA) |
| b. | Unilateral upper lobe—TB |
| c. | Lower lobe—sequela of pulmonary infection |
THG18-012
8-year-old girl has cough lasting for more than 6 months with increased severity on waking up with expectoration of copious sputum with occasional tinge of blood and referred for evaluation. The senior resident has made a diagnosis of bronchiectasis based on history and chest X-ray.
a. Name any four CT findings in bronchiectasis.
b. Name any four syndromes associated with bronchiectasis.
Answer
a. • Retained bronchial secretions: Bronchial mucoid impaction/centrilobular nodules and tree in bud when affecting small airways
| • | Bronchial wall thickening |
| • | Bronchus visualized within 1 cm of pleural surface |
| • | ↑ Bronchoarterial ratio: >0.8–bronchiectasis (signet rings) |
| • | Lack of tapering of bronchus |
| • | Atelectasis and/or mosaic pattern secondary to air trapping |
b. • Young syndrome
| • | Mounier–Kuhn syndrome (congenital absence of bronchial muscle) |
| • | Williams–Campbell syndromes (congenital absence of cartilage) |
| • | Yellow nail syndrome |
| • | Nail patella syndrome |
THG18-013
8-year-old girl has cough lasting for more than 6 months with increased severity on waking up with expectoration of copious sputum with occasional tinge of blood and referred for evaluation. The senior resident has made a diagnosis of bronchiectasis based on history and chest X-ray.
a. Identify the abnormality in the right eye and CT chest findings?
Answer
a. • Telangiectasia—right eye
| • | Air trapping left lung |
| • | Bronchial wall thickening |
| • | Mucus impaction in bronchus |
THG18-014
A 5-year-old girl was referred for recurrent cough and wheeze. Chest X-ray done as part of evaluation showed this finding necessitating further imaging.
a. Identify the imaging procedure done.
b. What are the findings in this imaging?
Answer
| a. | MRI |
| b. | Fluid filled cystic lesion in right side superior mediastinum—duplication cyst—bronchial duplication cyst—no connection with esophagus |
THG18-015
A 2-year-old boy referred for evaluation of recurrent respiratory tract infection. As the chest X-ray showed a small lung volume on the right side further imaging was done.
a. What is this imaging?
b. Mention one common finding in images A and B.
c. Where does the pulmonary vein drain into—image C and D?
d. Where does the lower lobe receive the arterial supply from—image E?
e. What is the diagnosis after looking at all the images of the same child?
Answer
| a. | CT chest |
| b. | Decreased lung volume right |
| c. | Pulmonary vein drains into IVC |
| d. | Arterial supply from celiac axis/abdominal aorta |
| e. | Diagnosis: Right pulmonary venolobar syndrome—Scimitar syndrome |
THG18-016
CT done for recurrent acute wheeze in a 1-year-old child is given in below images.
a. What are the findings?
b. What is the possible diagnosis?
Answer
| a. | Mediastinal shift, collapse of the right lower lobe and right upper lobe, and thinning of vessels in right middle lobe with air trapping |
| b. | Congenital lobar emphysema—right middle lobe |
THG18-017
A 4-year-old child admitted for pneumonia who on treatment with co-amoxyclav did not show response but deteriorated.
a. Mention four findings in this CT for a child admitted for pneumonia.
b. What is the diagnosis?
Answer
| a. | (i) Cavity, (ii) destruction of lung parenchyma, (iii) fluid inside the cavity, and (iv) no mediastinal shift |
| b. | Necrotizing pneumonia right upper lobe |
THG18-018
Contrast CT chest of a 10-year-old child with fever and loss of appetite of 1 month duration is given in below images.
a. What are the findings?
b. What is the most probable diagnosis?
Answer
| a. | Multiple lymph nodal enlargement—paratracheal, hilar, mediastinal, subcarinal with central necrosis |
| b. | TB |
THG18-019
An 8-month-old child admitted for recurrent episodes of pneumonia which resolves with intravenous antibiotics was evaluated further as child had recurrent vomiting.
a. Name the investigation in Fig. B.
b. What are the findings?
c. What will be the common symptoms?
d. What is the treatment modality?
Answer
| a. | Barium study |
| b. | Gross dilatation of esophagus with smooth narrowing at lower end—achalasia cardia |
| c. | Vomiting food taken 24–48 hours earlier |
| d. | Heller’s cardiomyotomy |
THG18-020
An 8-year-old child presented with increasing severity of snoring, sleep disturbance and difficult to wake up in the morning everyday and was evaluated.
a. What is the investigation?
b. What are the parameters recorded (any four)?
c. What are the abnormalities?
d. What are the indications for this test?
e. What is the treatment for this problem?
Answer
| a. | Polysomnography |
| b. | Parameters—electroencephalogram (EEG), electrooculogram (EOG), electrocardiogram (ECG), electromyogram (EMG), oxygen saturation (SpO2), capnometry, airflow through nostril and mouth, respiratory effort through chest movement, and abdominal wall movement by plethysmography belt |
| c. | Apnea/hypopnea |
| d. | Sleep disordered breathing |
| e. | Children—adenotonsillectomy |
THG18-021
A 3-year-old child with persistent pneumonia was subjected for scopy. Under procedural sedation the flexible bronchoscope was passed through this tube for bronchoalveolar lavage procedure.
a. Name the device and what are the parts in the device?
b. When should one use it?
c. From which age it can be used?
Answer
| a. | ProSeal laryngeal mask airway—wire reinforced airway, drain tube for nasogastric (NG) tube passage, and inflatable cuff/pilot balloon |
| b. | Rapid and easily achieved patent airway—permits positive pressure ventilation |
| c. | Newborn |
THG18-022
A 5-year-old child with fever for 7 days and worsening respiratory distress had tachypnea, decreased breath sounds on right side with few crackles. Chest X-ray taken showed pneumonia right lung with moderate pleural fluid right side.
a. Difference between uncomplicated and complicated parapneumonic effusion (PPE)?
b. What are the most common organisms associated with empyema?
c. What are the stages of empyema and the most appropriate management at each stage?
Answer
a.
| Uncomplicated PPE (UPPE) | Complicated PPE (Empyema) |
|---|---|
| Pleural pH >7.2 | Pleural pH <7.2 |
| Pleural fluid glucose >2.2 mmol/L | Pleural fluid glucose <2.2 mmol/L |
| Pleural LDH <1,000 IU/L | Pleural LDH > 1,000 IU/L |
| Gram stain—negative | Gram stain—± |
| Culture—no growth | Culture—± |
b. • Streptococcus pneumoniae
| • | Staphylococcus aureus |
| • | Streptococcus pyogenes |
| • | Haemophilus influenzae |
| • | Mycoplasma pneumoniae |
| • | Pseudomonas aeruginosa |
c. • Stage 1 or exudative: Antibiotics
| • | Stage 2 or fibrinopurulent stage: Antibiotics + pleural drainage with fibrinolytics/video-assisted thoracoscopic surgery (VATS) |
| • | Stage 3 or organizing stage: VATS/decortication |
THG18-023
An 8-year-old child came with purulent rhinorrhea, nasal block for 10 days with increasing headache in the last 3 days had maxillary sinus tenderness on examination on both sides. A diagnosis of bilateral maxillary sinusitis was made.
a. Classify sinusitis by duration.
b. What is the initial therapy in uncomplicated mild to moderate acute bacterial sinusitis?
c. Name any four conditions wherein recurrent or chronic sinusitis occurs.
d. What are the indications for high-dose amoxicillin-clavulanate (80–90 mg/kg/day of amoxicillin) in sinusitis?
Answer
| a. | <30 days—acute,1–3 months—subacute, >3 months—chronic |
| b. | Amoxicillin (45 mg/kg/day divided bid), alternative treatments—penicillin allergic patient: cefdinir, cefuroxime axetil, cefpodoxime, and cefixime |
| c. | Immune deficiencies particularly of antibody production [immunoglobulin G (IgG), IgG subclasses, and IgA], cystic fibrosis, ciliary dysfunction, gastroesophageal reflux, and anatomic defects (cleft palate) |
| d. | Children with risk factors (antibiotic treatment in the preceding 1–3 months), age younger than 2 years, children who fail to respond to initial therapy with amoxicillin within 72 hours, and severe sinusitis |
THG18-024
An 8-year-old child came with purulent rhinorrhea, nasal block for 10 days with increasing headache in the last 3 days had maxillary sinus tenderness on examination on both sides. A diagnosis of bilateral maxillary sinusitis was made.
a. What are the two distinct patterns suggestive of sinusitis?
b. What organism causes fungal sinusitis often with intracranial extension?
c. Name some predisposing factors.
Answer
| a. | Persistence of nasal congestion, rhinorrhea (of any quality) and daytime cough ≥10 days without improvement (OR) severe symptoms-temperature ≥39°C (102°F) with purulent nasal discharge for 3 days or longer |
| b. | Organisms: Aspergillus and Mucor |
| c. | Immunosuppression for bone marrow transplantation, Malignancy with profound neutropenia and lymphopenia, and coronavirus disease (COVID) infection |
THG18-025
A 5-month-old child presents to ER with refusal to take feeds, vomiting, cough for >4 weeks, and increased frequency of urine. Examination reveals dehydration, malnutrition, hypokalemia, hyponatremia, hypochloremia, and metabolic alkalosis with a normal urine analysis.
a. What is this syndrome called?
b. What is the most probable etiology?
c. What body fluid is used for diagnosing this condition before genetic testing and what is the cutoff level of the electrolyte to suspect the disease?
d. Which newborn screening test can make one suspect this condition?
Answer
| a. | Pseudo–Bartter syndrome |
| b. | Cystic fibrosis |
| c. | Sweat, sweat chloride above 60 mEq/L |
| d. | Immunoreactive trypsin |
TUBERCULOSIS
THG18-026
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago.
a. What is presumptive pediatric tuberculosis (TB)?
b. Initial specific investigation?
Answer
a. • Persistent fever without a known cause
| • | Unremittent cough for >2 weeks |
| • | Loss of weight—definite weight loss (>5% loss in the past 3 months) or failure to gain weight in the past 3 months despite adequate nutrition with no other apparent cause with/without history of contact with pulmonary TB in past 2 years |
| b. | CXR anteroposterior/posteroanterior (AP/PA) |
THG18-027
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray was ordered.
a. In a child with presumptive TB, what CXR findings considered?
i. Highly suggestive of TB
b. In a child with presumptive TB which CT findings highly suggestive of TB?
c. In a child with presumptive TB after CXR what will you do if:
Answer
a. i. Specific: Miliary shadows, intrathoracic lymphadenopathy ± parenchymal involvement, and chronic fibrocavitary shadows
| ii. | Nonspecific: Consolidations, in-homogenous shadows, and bronchopneumonia |
| b. | Necrotic mediastinal lymphadenopathy, centrilobular nodules with tree-in-bud pattern, cavities with surrounding consolidations |
| c. | If highly suggestive—nucleic acid amplification test—sputum/gastric aspirate (GA)/induced sputum |
| Nonspecific—treat with antibiotics—correct dose and duration—avoid linezolid and fluoroquinolone | |
| If normal—look for extrapulmonary TB |
THG18-028
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. Induced sputum sample was taken and sent for microbiological exam.
a. Fill up the blanks.
i. Sample for microbiological testing for TB to be collected in ______
b. How many numbers of bacilli can be detected with each of these methods and time taken for result?
i. Direct smear
c. What are the body fluids in which newer rapid NAAT tests perform very poorly compared to respiratory specimens?
Answer
a. i. Falcon tube
| ii. | Refrigerator |
| iii. | 7 days |
b.
| Method | Direct smear | Culture | CBNAAT | CBNAAT ultra |
|---|---|---|---|---|
| 10,000 bacilli/mL | 100 bacilli/mL | 131 | 16 | |
| Time to get result | 1 hour | 42 days | 2 hours | 2 hours |
| c. | Pleural fluid, ascitic fluid, lymph node (LN) aspirates, pus, and CSF |
THG18-029
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. Chest X-ray revealed consolidation in right upper lobe.
a. Tuberculin skin test (TST)—what is it?
b. What is recommended strength?
c. What is positive test in non-human immunodeficiency virus (HIV) children?
d. What is positive test in HIV affected children?
e. What is inference of positive test?
Answer
| a. | Intradermal injection of purified protein derivative (PPD) |
| b. | 2TU PPD RT23 |
| c. | Induration 10 mm or more |
| d. | HIV coinfected cases, 5 mm as the cutoff |
| e. | Indicates present or past infection with Mycobacterium tuberculosis. but cannot distinguish infection from disease |
THG18-030
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. Mantoux
a. C-Tb test—what is it?
b. What is the size taken for cutoff for positive result?
c. What antigens are used?
d. Is it affected by Bacillus Calmette–Guérin (BCG) vaccination?
Answer
| a. | Next-generation skin test for the detection of (TB infection) TBI developed by SSI Copenhagen (Statens Serum Institute, Copenhagen, Denmark) |
| b. | Universal 5 mm cutoff to differentiate the infected from the uninfected |
| c. | Test is based on ESAT-6 and CFP-10 antigens (same as those used in IGRA) specific for Mycobacterium tuberculosis |
| d. | Unaffected by BCG vaccination |
THG18-031
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. Four days after admission child had was becoming more drowsy with vomiting and responding to voice calls only.
a. Mention contrast-enhanced computed tomography (CECT) findings in central nervous system (CNS TB)—any four.
b. Mention any four conditions mimicking imaging findings of CNS TB.
c. Mention cerebrospinal fluid (CSF) findings in CNS TB.
d. What are the differentiating features of tuberculoma from neurocysticercosis?
Answer
| a. | Basal meningeal enhancement, hydrocephalus, tuberculoma, infarcts in different areas, especially the basal ganglia, and precontrast basal hyperdensity |
| b. | Cryptococcal meningitis, cytomegalovirus encephalitis, toxoplasmosis, sarcoidosis, meningeal metastases, and lymphoma |
c. • Fluid mostly clear
| • | Leukocyte count—ranges from 10 to 500 cells/mm3 |
| • | Majority—usually lymphocytes |
| • | CSF glucose—remains below 40 mg/dL |
| • | CSF glucose/blood glucose below 0.5 |
| • | Protein elevated (often > 100 mg/dL) |
| • | Rapid NAAT—positive in about 30–40% of cases |
d. • Size >2 cm, irregular thick outline, marked perilesional edema, infratentorial or supratentorial
| • | Midline shift more likely, T2—usually hypointense core in contrast, MRS—lipid peak present |
| • | T2 relaxation time shorter |
THG18-032
A 3-year-old child referred by family physician as child’s father was diagnosed to have microbiologically confirmed pulmonary TB a week earlier. Child had no symptoms. Investigations were normal.
a. What is TB preventive therapy in drug-susceptible TB (DS-TB)?
b. What are fixed-dose combination (FDC) composition of isoniazid (INH) and rifapentine?
Answer
a. • Weekly INH and rifapentine (3HP) in persons older than 2 years for 3 months (totally 12 doses) or
| • | Daily INH (6H) for 6 months. INH 10 mg/kg for <10 years and 5 mg/kg >10 years |
| b. | INH + rifapentine FDC (150 mg/150 mg) |
THG18-033
What are the imaging findings in abdominal TB-CT enterography/US abdomen (any 5)?
Answer
| ■ | Ileocecal area—most common involved region |
| ■ | Uniform and concentric bowel thickening |
| ■ | Contracted and pulled up caecum |
| ■ | Ileocecal angle is distorted and often obtuse |
| ■ | Short strictures of <3 cm |
| ■ | Mesenteric thickening of >15 mm |
| ■ | Loculated ascites |
| ■ | Caked omentum |
THG18-034
A 9-year-old boy comes with pain in the back of chest of 5 months duration with poor appetite. Examination reveals tenderness at D 10, 11, 12 spinous process. His younger brother 6 years old has a swelling in the middle phalanx of his index finger slowly increasing in size over 4 months.
a. Another name for dactylitis and spinal TB.
b. What are the common bones involved in dactylitis and spinal TB?
c. How much bone loss should be present to be seen in X-ray?
d. Which imaging investigation is most sensitive for picking up abnormalities?
e. Mention the MRI findings in spine TB.
Answer
| a. | Spina ventosa and Pott spine |
| b. | Short tubular bones of hands and feet and thoracic vertebrae |
| c. | 30–50% |
| d. | MRI |
e. • MRI findings in spine TB
| • | Marrow edema |
| • | Destruction of adjacent vertebral bodies and opposing endplates |
| • | Destruction of the intervening disc |
| • | Occurrence of prevertebral, paravertebral, and epidural abscesses |
THG18-035
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT.
a. What are the types of bacillary population present in every child with TB disease?
b. Antitubercular therapy (ATT) drugs—INH, RMP, and PZA act against which population of bacilli?
c. What is the standard treatment regimen for DS-TB?
d. What is the recommended duration of continuation phase (CP) in CNS and spinal TB?
Answer
| a. | Extracellular and intracellular, slow and rapidly growing |
b. • INH—fast-growing bacilli
| • | RMP—fast-growing bacilli and extracellular slow-growing bacilli |
| • | PZA—intracellular organisms in an acidic medium |
| c. | 2HRZE/4HRE |
| d. | 10 months |
THG18-036
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT.
a. Why more drugs are given in the initial stage of TB?
b. Why ethambutol is added?
c. What is the aim of intensive phase (IP)?
d. What is the aim of CP?
Answer
| a. | Chances of naturally occurring mutations are higher if the bacillary load is more |
| b. | Due to high INH resistance (around 13% in new cases) |
| c. | Early and rapid killing of Mycobacterium tuberculosis, prevent deterioration and death, and reduce infectivity |
| d. | CP eliminates most residual bacilli and thus reduces failures and relapses |
THG18-037
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT.
a. Name the first-line drugs, dose per kg, range, and maximum daily dose.
b. What does dispersible pediatric fixed drug combination contains?
c. What are the constituents of nondispersible adult fixed drug combination?
Answer
a.
| Drug | Average mg/kg/day | Range | Maximum (mg) |
|---|---|---|---|
| INH (H) | 10 | 7-15 | 300 |
| Rifampicin (R) | 15 | 10-20 | 600 |
| Pyrazinamide (Z) | 35 | 30-40 | 2,000 |
| Ethambutol (E) | 20 | 15-25 | 1,500 |
| b. | For IP: dispersible three drug combination H 50, R 75, Z 150 |
| For CP: dispersible two drug combination H 50 R 75 | |
| c. | For IP: Four drugs FDC: H 75, R 150, Z 400, E 275 |
| For CP: Three drug FDC: H 75, R 150, E 275 |
THG18-038
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT.
a. How many weight bands and drug treatment for the same?
b. Pyridoxine—why it is used and dose?
Answer
a. • Pediatric formulation: H 50, R 75, Z 150, E 100 (separate tablet)
| • | Adult formulation: H 75, R 150, Z 400, E 275 |
| Weight band (kg)* | Dose (0-18 years) |
|---|---|
| 4-7 | 1P + 1E |
| 8-11 | 2P + 2E |
| 12-15 | 3P + 3E |
| 16-24 | 4P + 4E |
| 25-29 | 3P + 3E + 1A |
| 30-39 | 2P + 2E + 2A |
*Children up to the weight of 39 kg would be managed as per the various weight bands available for children/children >40 kg would be managed as per the various weight bands available for adults >40 kg.
| b. | Increase in INH dose-related adverse effects and high prevalence of malnutrition in children with TB, dose—10 mg/day |
THG18-039
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT.
a. What are the indications of steroids in TB as per the National Tuberculosis Elimination Programme (NTEP)
b. Name any four types of TB where steroids may be used.
c. What steroids can be used—what is the dose and duration?
Answer
a. • TB meningitis
| • | Pericarditis |
| • | Addison’s disease |
| • | Miliary TB with alveolar-capillary block |
| • | TB uveitis |
b. • Endobronchial TB
| • | Bronchial compression |
| • | Mediastinal compression syndrome |
| • | Pleurisy with severe distress |
| • | Laryngeal TB |
| • | TB immune reconstitution inflammatory syndrome (IRIS) |
| c. | Prednisolone 1–2 mg/kg/day or dexamethasone 0.6 mg/kg/day for 2–4 weeks, then tapered over next 4 weeks |
THG18-040
When is it called severe TB disease? Mention any four scenarios.
Answer
| ■ | Cavities or bilateral disease on chest radiography |
| ■ | Extrapulmonary forms of disease other than lymphadenopathy (peripheral nodes or isolated mediastinal mass without compression) |
| ■ | Occurrence of advanced malnutrition |
| ■ | Advanced immunosuppression |
THG18-041
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT. Anti TB drugs were started and after three months mother stopped treatment as child’s appetite improved.
a. How to manage treatment interruption in intensive phase and continuation phase
Answer
a. • If <4 weeks interruption—resume therapy
| • | If beyond 4 weeks interruption—investigate for DR-TB—if rifampicin resistance not detected—start DS-TB regimen but test for INH resistance—if detected modify to INH mono-resistance therapy |
THG18-042
A 10-year-child with microbiologically confirmed pulmonary TB with mediastinal adenopathy developed sudden onset of new onset neck swellings – lymphadenopathy bilaterally with breathlessness two months after starting treatment.
a. What are paradoxical upgrading reactions (PURs)?
b. When does it occur?
c. Mention manifestation of PUR—any four.
d. What is the treatment for PUR?
Answer
| a. | Enlargement of existing lesions or unexpected appearance of new lesions during apparently adequate ATT |
| b. | Occurs 3–12 weeks after beginning therapy and lasts for approximately 2 months |
c. • Increase in size of mediastinal LNs or areas of pulmonary infiltration in pediatric patients with primary TB
| • | Appearance of new lung infiltrates in patients with extrapulmonary TB |
| • | Development of TB pleural effusion |
| • | Increase in size of effusion/appearance of effusion on the contra lateral side |
| • | Appearance of new LNs/enlargement of original nodes |
| • | Increase in size or number of tuberculoma/infarctions/hydrocephalus on treatment of intracranial TB |
| d. | Generally self-limiting and resolve without serious sequelae |
THG18-043
A 3-year-old child on evaluation for TB disease was found to have only a positive Mantoux test. Answer the following questions regarding TB infection.
a. What is the cutoff for underweight in TB?
b. What is tuberculosis infection (TBI)?
c. What is tuberculosis preventive treatment (TPT)?
Answer
| a. | In adults and adolescents, body mass index <18.5 kg/m2, in children <10 years weight-for-age <–2 Z-scores |
| b. | State of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifest TB disease |
| c. | Treatment of TB infection—offered to individuals who are at risk of developing TB disease to reduce that risk |
THG18-044
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT. Anti TB drugs were started and after three months mother stopped treatment as child’s appetite improved. Social worker was able to trace the child after 2 months and was brought for evaluation. Investigation reveals CBNAAT positive for M TB with rifampicin resistance detected.
a. What is second-line drug in TB?
b. Streptomycin: Is it a first-line or second-line drug?
c. When does one uses it?
d. Mention the dose and side effects?
Answer
| a. | Agent reserved for the treatment of DR-TB |
| b. | Now considered a second-line TB drug |
| c. | Used only as a substitute for amikacin when amikacin not available/confirmed resistance to it |
| d. | 15–20 mg/kg, side effects: ototoxicity and nephrotoxicity |
THG18-045
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT. Anti TB drugs were started and after three months mother stopped treatment as child’s appetite improved. Social worker was able to trace the child after 2 months and was brought for evaluation. Investigation reveals CBNAAT positive for M TB with rifampicin resistance detected.
a. Isoniazid-resistant TB (HR-TB)
b. Mono-resistant TB (MR-TB)
c. Multidrug-resistant TB (MDR-TB)
d. Extensively drug-resistant TB (XDR-TB)
e. Rifampicin-resistant TB (RR-TB)
Answer
| a. | TB patient with biological specimen resistant to INH but susceptibility to rifampicin is confirmed |
| b. | TB patient whose biological specimen is resistant to one first-line anti-TB drug only |
| c. | TB patient whose biological specimen is resistant to both H and R with or without resistance to other first-line anti-TB drugs |
| d. | MDR/RR-TB with resistant to any fluoroquinolone (levofloxacin or moxifloxacin) and at least one additional group A drug (presently to either bedaquiline or linezolid, or both) |
| e. | TB patient whose biological specimen is resistant to R and detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs |
THG18-046
A 4-year-old child comes with fever for 3 weeks and persistent cough a week after fever started. General examination reveals weight below 3rd centile with anemia. Paternal grandmother died due to tuberculosis one month ago. A chest X-ray reveals consolidation right lung while induced sputum showed positive result in CBNAAT. Anti TB drugs were started and after three months mother stopped treatment as child’s appetite improved. Social worker was able to trace the child after 2 months and was brought for evaluation. Investigation reveals CBNAAT positive for M TB with rifampicin resistance detected.
a. WHO and NTEP approved test to detect additional drug resistance in MDR-TB and XDR-TB patients—name the test.
b. What is prerequisite for using the test?
c. What is turnover time?
d. Which drug resistance does it detects?
Answer
| a. | Line probe assay test (Hain test/MTBDRplus, MTBDRsl) |
| b. | Smear-positive/sputum specimens or culture isolates for genotypic drug susceptibility testing (DST) |
| c. | 72 hours |
| d. | H, R, fluoroquinolones, and second-line injectables |
THG18-047
For treating this MDR-TB child, second line drugs are used. How to classify them?
Answer
| ■ | Three groups—group A, B, and C |
| ■ | Group A—three drugs—levofloxacin or moxifloxacin, linezolid, and bedaquiline |
| ■ | Group B—two drugs—clofazimine, cycloserine or terizidone |
| ■ | Group C—seven drugs—ethambutol, delamanid, pyrazinamide, imipenem cilastatin or meropenem, amikacin or streptomycin, ethionamide or prothionamide, and para-aminosalicyclic acid (PAS) |
THG18-048
Mention doses of group A drugs in management of MDR TB in this child.
Answer
| ■ | Lfx: <5 years: 15–20 mg/kg—two divided dose/>5 years: 10–15 mg/kg—once daily |
| ■ | Mx: 7, 5–10 mg/kg/high dose 10–15 mg/kg |
| ■ | Linezolid: <6 years age: 10–12 mg/kg/>6 years age: 15 mg/kg |
| ■ | Bedaquiline: 200 mg daily for 2 weeks; then 100 mg thrice weekly for 22 weeks for weight bands 16–30 kg, approved for only age >12 years |
THG18-049
Mention treatment of INH mono/poly DR-TB and dose.
Answer
| ■ | 6 Lfx, R, Z, E—no separate IP/CP—may extend up to 9 months |
| ■ | Lfx: <5 years: 15–20 mg/kg—two divided dose/>5 years: 10–15 mg/kg—once daily |
| ■ | R: 10–20 mg/kg |
| ■ | Z: 30–40 mg/kg |
| ■ | E: 15–25 mg/kg |
THG18-050
What is shorter oral bedaquiline containing regimen for MDR-TB/RR-TB—duration and drug regimen?
Answer
| ■ | 9–11 months (4–6 months—IP followed by 5-month CP) |
| ■ | (4–6) Lfx, Cfz, Z, E, Hh, Eto (6) Bdq (5) Lfx, Cfz, Z, E |
THG18-051
What is longer oral MDR/XDR TB treatment—duration and drug regimen?
Answer
| ■ | 18–20 months—no separate IP and CP |
| ■ | (18–20) Lfx, Lzd*, Cfz, Cs (6) Bdq (6 m or longer) |
| • | After 6 months patient reviewed based on 5th month culture result |
| ■ | Lzd*: Decision to taper dose of linezolid from 15 mg/kg body weight to 10 mg/kg body weight based on the month four culture result if 5th month culture not available at 6 months review |
THG18-052
ATT drugs with:
a. Prolonged QT
b. Hepatotoxicity
c. Ototoxicity
Answer
| a. | Bdq, FQ, Cfz |
| b. | Z, H, R, Eto, PAS, Bdq |
| c. | Amikacin |
THG18-053
What is TB preventive therapy in MDR-TB and H-mono resistance?
Answer
| ■ | 6 months levofloxacin for contacts of R-resistant fluoroquinolone sensitive patients |
| ■ | 4 months rifampicin for contacts of H-resistant R-sensitive patients |
THG18-054
Can BCG vaccine given to:
a. HIV exposed infants at birth?
b. HIV infected older infants and children?
Answer
| a. | Yes |
| b. | No |
THG18-055
A 10-day-old neonate was referred as baby’s mother who had chronic cough (past 3 months) and recurrent fever on evaluation showed cavitory lesions on chest X-ray with CBNAAT positive for M TB.
a. Primary focus in perinatal TB in transplacental route: (i) ______, (ii) ______, or (iii) ______.
b. Which criteria used for congenital TB and components of the criteria?
c. What is treatment of perinatal TB?
Answer
a. i. Liver
| ii. | Lungs |
| iii. | Gastrointestinal tract (GIT) |
b. • Modified Cantwell’s criteria
Proven tuberculous lesion and at least one of the following:
| • | Lesions in first week of life |
| • | Primary hepatic complex or caseating hepatic granuloma |
| • | TB infection of placenta or maternal genital tract |
| • | Exclusion of postnatal transmission by thorough contact investigation |
| c. | 2HRZE/4HRE |
THG18-056
A 10-day-old neonate was referred as baby’s mother who had chronic cough (past 3 months) and recurrent fever on evaluation showed cavitory lesions on chest X-ray with CBNAAT positive for M TB.
a. Can pulmonary TB mother breastfeed her child?
b. Can BCG vaccine given to baby if uninfected and is on TB preventive therapy?
Answer
| a. | Yes—if mother has DS-TB and follows cough hygiene |
| b. | BCG has to be given |
THG18-057
List the treatment outcomes in TB as given in 'NIKSHAY' app.
Answer
| ■ | Cured |
| ■ | Treatment completed |
| ■ | Treatment success |
| ■ | Failure |
| ■ | Failure to respond |
| ■ | Lost to follow-up |
THG18-058
Mention the findings and treatment of the given images.
Answer
| ■ | Highly placed BCG scar—incorrect placement of BCG vaccine |
| ■ | Axillary adenopathy—BCG adenitis |
| ■ | No FNAC/no ATT/no antibiotics |
| ■ | If on the verge of breaking down—aspiration/excision |
THG18-059
What is the name of the TB portal where TB patients are to be registered?
Answer
Nikshay [NI-KSHAY-(Ni=End, Kshay=TB)]
THG18-060
What are the findings in given CT and any five causes?
Answer
| ■ | Miliary shadows in lung |
| ■ | Infections: Miliary TB, histoplasmosis, Mycoplasma, Nocardia, blastomycosis |
| ■ | Immune and inflammatory disorders—sarcoidosis, tropical pulmonary eosinophilia, hypersensitivity pneumonitis (HP), Langerhans cell histiocytosis, pulmonary hemosiderosis |
| ■ | Malignant disorders—bronchoalveolar carcinoma, hematogenous metastases—carcinoma of thyroid, kidney or lymphangitic carcinomatosis |
| ■ | Occupational lung diseases: Pneumoconiosis especially silicosis and pulmonary siderosis |
| ■ | Miliary nodules—unusual causes—ABPA, leiomyoma, pulmonary alveolar microlithiasis. |