REVIEW TOPICS

The signs of multiple myeloma can be remembered using the mnemonic CRAB for Calcium (hypercalcemia), Renal failure, Anemia, and Bone lesions (lytic)

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Staging of sarcoidosis (on CXR) a. Stage I: bilateral hilar adenopathy without parenchymal infiltrates (highest rate of remission)

. Stage II: hilar adenopathy with parenchymal infiltrates

c. Stage III: diffuse parenchymal infiltrates without hilar adenopathy (least favorable prognosis)

d. Stage IV: pulmonary fibrosis with honeycombing and fibrocystic parenchymal changes

Treatment . Most cases resolve or significantly improve spontaneously in 2 years and do not require treatment. b. Systemic corticosteroids are the treatment of choice.

Know the side effects very well.

Induration ≥5 mm: Patients with HIV infection

recent close contact to person with known active tuberculosis (TB), patients with chest x-ray consistent with prior TB,

patients with organ transplants and other immunosuppressed patients (receiving the equivalent of prednisone ≥15 mg/day for ≥1 month or those taking TNF-α antagonists).

Induration ≥10 mm: Patients with clinical conditions that increase risk of TB infection,

people born in countries where TB disease is common,

IV drug users, residents and employees of high-risk congregate settings,

Mycobacte-riologylaboratory workers,

people <90% of ideal body weight,

children <5 years of age, or infants, children, and adolescents exposed to adults at high risk

Induration ≥15 mm: Patients who do not meet any of the above criteria (no risk factors for TB)

For a positive TB exposure and a positive PPD test (but no active disease), treatment is INH only. •

 If the patient has active TB, multiagent therapy is indicated.

Patients with active TB must be isolated until sputum is negative for AFB. 

a. First-line therapy is a four-drug regimen: isoniazid (INH), rifampin, pyrazinamide, and ethambutol or streptomycin. 

b. The initial treatment regimen consists of 2 months of treatment with the four drug regimen. After this initial 2-month phase, a phase of 4 months is recommended using INH and rifampin. 

2. Prophylactic treatment for latent (primary) TB (i.e., positive PPD skin test): consists of 9 months of INH after active TB has been excluded (negative CXR, sputum, or both).

There are two major types of tests for identification of TB infection: the tuberculin skin test (TST) and the interferon-gamma release assay (IGRA) blood test. (IGRA does not give false-positive results because of prior BCG vaccination. IGRA test results are available within 24 hours at the earliest

The TST can give false-positive . This may be due to nontuberculous mycobacteria infection and Bacillus Calmette-Guérin (BCG) vaccination.

The TST consists of intradermal injection of tuberculin material, which stimulates a delayed-type hypersensitivity response mediated by T lymphocytes and, in patients with prior mycobacterial exposure, causes induration at the injection site within 48 to 72 hours.

Tuberculosis infection is the newer term for latent TB (TBI; newer term for latent tuberculosis)

Tuberculosis disease is the newer term for active TB (newer term for active tuberculosis)

Primary TB is a term that describes new TB infection or active disease in a previously naïve host

Treatment of TBI before the development of TB disease kills the organisms, thereby reducing the risk of developing TB disease (termed reactivation TB) by as much as 90 percent

Clinical features

Symptoms

• Insidious onset—headache, sore throat, fatigue, myalgias

• Dry cough (no sputum production)

• Fevers (chills are uncommon)

Signs  normal pulse in the setting of high fever is suggestive of atypical CAP