00:00
Let's move on to a question.
00:03
A woman from a first nations
reserve in western Alaska
presents with cough with flecks
of blood in her green sputum.
00:10
She has a three month history
of fatigue, weight loss
and poor appetite.
00:15
Her sputum is identified with
microbaterium tuberculosis.
00:18
There has been one historical
case from her reserve without
resistance patterns.
00:24
The appropriate course
of action would be
A. Initiate isoniazid, rifampin,
pyrazinamide and streptomycin.
00:33
B. Initiate rifampin to treat for 9 months.
00:37
C. Initiate isoniazid
for 18 months.
00:41
D. Initiate isoniazid, rifampin and pyrazinamide.
00:46
If the organisms are fully susceptible,
pyrazinamide can be stopped
in two months.
00:51
Or E. Initiate pyrazinamide for 18 months.
00:57
Okay you chose D
and that's correct.
01:01
Now this is a hard question
but let's just go through it
so that you understand
the concept.
01:07
And when you to the exam you'll
feel much more confident
answering these
kinds of questions.
01:12
So in areas with less than 4%
resistance isoniazid,
a three drug combination
is actually reasonable.
01:21
Now the questions on TV will
not focus on your intimate
knowledge of each of it's
drugs, but on the uses
and indications.
01:29
If the patient had come from
say an area of high endemic
resistance, like South Asia
or South East Asia,
Somalia or China, a 4 drug
regimen is appropriate.
01:39
Now some people are advocating
the 2 drug approach with
just isoniazid and rifampin
for 9 or 18 months.
01:47
This is not unreasonable
and could be correct.
01:50
But the reality is that we use
the 3 drug combination in almost
all cases.
01:55
So if you are caught with a
question that gives you this
choice and no other,
then the 2 drug approach
would be the answer.
02:02
But in most cases you're going
to be given an option for 3 drug
approach.
02:06
And that would probably be
the right answer unless they
specifically mention resistance.
02:11
Single drug treatment of active
TB is never a reasonable choice
on exams or in the TB clinic.
02:20
Now let's go on to
the next question.
02:24
The woman from question one
received the appropriate
treatment as part of
the regimen, the CDC consultant
also added pyridoxine
or vitamin B6 to her regimen.
02:35
What was the purpose
of pyridoxine?
Now if you're not sure what
the first question was,
it's just dealing with a woman
from a reserve in Alaska
who is found to have TB
in the sputum.
02:49
Let's take a look
at our choices.
02:51
A. Pyridoxine will reduce
the risk of pulmonary scarring
during treatment.
02:55
B. Pyridoxine will reduce
the risk of hepatotoxicity
during treatment.
03:01
C. Pyridoxine will reduce
the risk of dental erosions
during treatment.
03:07
D. Pyridoxine will reduce
the risk of arrhythmia
during treatment.
03:11
or E. Pyridoxine will reduce
the risk of neurotoxicity
during treatment.
03:17
And the answer of course is E.
03:22
This is a third question
in the a string of two.
03:28
The woman from question 1
was on oral contraceptives.
03:30
If you've lost two questions,
just be aware that she was
started on 3 drug regiment for
TB and she lives on a reserve
with no worrisome
resistance patterns.
03:40
She does not wish
to get pregnant.
03:43
Which drug is most likely
to interfere with the oral
contraceptive agent?
Is it A. Ethambutol,
B. Isoniazid,
C. Rifampin,
D. Pyridoxine
or E. Pyrazinamide.
03:59
Good for you, you chose
rifampin.
04:02
Now rifampin is an important
thing to think about.
04:06
Because rifampin is
the prototypical
cytochrome inducer.
04:10
And it is the drug that we talk
about, when we're talking about
multidrug interactions.
04:15
So rifampin is going to be
the answer in that case.
04:22
Let's go on to
the next question.
04:24
A 36 year old HIV positive
male is tachypneic and hypoxic.
04:30
His chest X-ray shows right
middle lobe infection.
04:33
He was diagnosed with
microbaterium avium complex
or MAC.
04:38
The appropriate treatment
is one of the following.
04:41
Is it A) Clarithromycin
with rifabutin.
04:44
Is it B) Azithromycin
with rifabutin.
04:47
Is it C) Isoniazid
with rifabutin.
04:51
Is it D) Azithromycin or
Clarithromycin with ethambutol
and rifabutin.
04:57
Or is it E) Ethambutol,
streptomycin, rifampin,
isoniazid and penicillin.
05:04
Good, you chose D.
05:07
You can choose either
azithromycin or clarithromycin
with ethambutol and rifabutin
as the second and third agents
in the treatment.
05:18
Microbaterium avium complex
or MAC
was actually first described
as Lady Windermere syndrome.
05:26
Now who is Lady Windermere.
05:28
She was a character
in Oscar Wilde's play.
05:30
She was one of these very proper
people who wouldn't cough
or wouldn't expectorate.
05:35
And actually it was surprisingly
common in these women to see
right middle lobe pneumonia
because it is cough of the junk
that was in their lungs.
05:43
MAC made a come back
in the post-AIDS era.
05:46
It is treated with a 3 drug
regimen that includes
a macrolide, ethambutol
and rifabutin.
05:52
Infections from other bacteria
like microbacterium ulcerans
or microbacterium marinum are
treated with similar drugs
or other antibiotics that
are usually not a horribly
symptomatic disease.
06:05
That's it.
06:07
You completed a
very tough section.
06:09
I'm really proud of you.
06:11
Now go up to that exam
and show them what you know.