Endgames OnExamination quiz

Tuberculosis

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5082 (Published 03 December 2009) Cite this as: BMJ 2009;339:b5082

The answers to this question, and more questions on this topic, are available from www.onexamination.com/endgames until midnight on Wednesday.

This week’s quiz is on tuberculosis and is taken from the OnExamination revision questions for the MRCP parts 1 and 2 and the MRCGP exams.

A 21 year old Asian medical student presented to the emergency department with a month long history of fever, night sweats, and a cough that produced purulent sputum.

On examination, he was febrile (38.5°C), and his pulse was 110 beats/min and respiratory rate was 22 breaths/min. Coarse crackles were heard over the right lung apex. Chest radiography showed right upper lobar consolidation with a single cavitating lesion. Investigations showed:

  • Haemoglobin 115 g/l (normal range 130-180)

  • White cell count ×12.5 109/l (4-11)

  • Platelets 425 ×109/l (150-400)

  • Serum sodium 140 mmol/l (137-144)

  • Serum potassium 4.2 mmol/l (3.5-4.9)

  • Serum urea 3.1 mmol/l (2.5-7.5)

  • Serum creatinine 76 µmol/l (60-110)

  • Serum C reactive protein 254 mg/l (<10)

  • A sputum sample showed acid-alcohol fast bacilli

He was started on anti-tuberculous therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. Within seven days his fever had settled, he was feeling better, and his inflammatory markers were going down.

He lived with his parents and two sisters. His older sister, who had always lived in the United Kingdom, subsequently had a strongly positive Mantoux test. She felt well; had no symptoms of anorexia, weight loss, fever, night sweats, or cough; and her chest radiograph was normal.

Which one of the following is the most appropriate management for his sister?

  • A Arrange to see her in clinic in one month with a repeat chest radiograph and clinical assessment

  • B Ignore the Mantoux test because she is physically well and has no signs of active tuberculosis

  • C Prescribe a three month course of rifampicin and isoniazid

  • D Prescribe quadruple tuberculosis treatment

  • E Repeat her Mantoux test after one month

Notes

Cite this as: BMJ 2009;339:b5082

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