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Rifampin only
45%
9/20
No management indicated
25%
5/20
Quantiferon gold
10%
2/20
Repeat PPD in 1 week
Rifampin, isoniazid, pyrazinamide, and ethambutol
5%
1/20
Select Answer to see Preferred Response
This patient with a positive PPD skin test, a negative chest radiograph, high-risk occupational exposure for TB, who has never lived outside the US (and thus never received the BCG vaccine) is most likely suffering from latent tuberculosis (TB). The most preferred treatment for latent tuberculosis is rifampin monotherapy for 4 months. Latent tuberculosis is an asymptomatic and nontransmissible infection that carries the risk of progression to active TB. Latent TB is most commonly seen in immigrants from high-incidence countries, health care professionals, institutionalized patients, and homeless individuals. Risk factors for conversion of latent to active TB include immunodeficiency, re-exposure to tuberculosis, or chronic kidney disease. PPD is the preferred screening test for tuberculosis. If it is positive, a patient should have a chest radiograph performed. If the radiograph is negative, the patient only needs a regimen of rifampin monotherapy for 4 months to decrease the risk of latent tuberculosis progressing to an active infection. Alternative therapies include isoniazid and rifampin for 3 months, isoniazid and rifapentine for 3 months, or isoniazid monotherapy for 9 months. Incorrect Answers: Answer 2: No management may be indicated in the setting of a positive PPD and a normal chest radiograph if a patient has the BCG vaccine, which will make them positive on PPD for life (just like a previous infection). These patients may receive the Quantiferon gold test to rule out TB infection. Answer 3: Quantiferon gold would also be positive in this patient at high risk for infection and thus would not change management. It is an alternative to a PPD as an initial test, especially for patients with prior BCG vaccine. Answer 4: Repeat PPD in 1 week is unnecessary because this patient will have a positive PPD for life now. Answer 5: Rifampin, isoniazid, pyrazinamide, and ethambutol is the full treatment for active tuberculosis and would be indicated in a symptomatic patient with a positive chest radiograph. Bullet Summary: A patient who has never received the BCG vaccine who presents with a positive PPD and a normal chest radiograph with a high risk of TB infection needs treatment for latent TB with rifampin monotherapy.
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