+PPD, -CXR, INH or not??

[raine91]

I'm an MS III who had a positive PPD for the first time a week ago (no known exposure, contact, travel, etc... yes... it sucks). i had my cxr which was negative. So the question now is whether or not to take the 9 months of INH.... if I weren't applying to residencies in about 6 months, I wouldn't take it. But... I am wondering if not having taken it will prevent me from being able to go to some programs (i mean university programs that might be more anal??). Any help?? Part of the reason I don't want to take it is that I'm going to be out of the state for 3-4 of the next 9 months doing away electives, so I won't be able to have liver enzymes drawn, etc. So what do people think about whether or not some residency programs will give me a hard time about this? Thanks very much.

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[inositide]

forget about the residency programs. for your own health, assuming you have no prior liver problems, take inh. it is true that only a small % of ppd+ people will develop active tb, but it is good to take inh.

 

[AJM]

I think you should take the INH. The CXR is primarily to ensure that you don't have evidence of active TB so that you won't have to take the 4-drug therapy (which is much more toxic and difficult to take than plain INH, by the way). INH for latent TB is very easy to take and has a very low risk of side effects, plus you will greatly diminish your chance of getting reactivation TB in the future. You can always get your LFTs drawn at the hospitals you're rotating at and get the results sent to your PCP -- it's quite easy.

Besides, you don't want to be like that Boston resident who was in the news last year because they had active TB for 6 months and exposed thousands of patients.....

Also - being a clinical medical student, you're automatically at high risk of getting TB and have had plenty of high-risk exposures at the hospital, most of which you are probably not aware of. Thinking that you have not had any exposures is deluding yourself and giving you a false sense of security.

 

[usnavdoc]

I'm an MS III who had a positive PPD for the first time a week ago (no known exposure, contact, travel, etc... yes... it sucks). i had my cxr which was negative. So the question now is whether or not to take the 9 months of INH.... if I weren't applying to residencies in about 6 months, I wouldn't take it. But... I am wondering if not having taken it will prevent me from being able to go to some programs (i mean university programs that might be more anal??). Any help?? Part of the reason I don't want to take it is that I'm going to be out of the state for 3-4 of the next 9 months doing away electives, so I won't be able to have liver enzymes drawn, etc. So what do people think about whether or not some residency programs will give me a hard time about this? Thanks very much.

Dude what are you thinking. Take the Inh and be done with it.

 

[Mumpu]

double post. Buhleted.

 

[Mumpu]

There are things that can cause a false-positive PPD. There's some sort of cross-reactivity I'm blanking on and of course BCG vaccination which people still get (I've had it and I probably will test positive if you tested me although some BCG-vaccianted people do turn negative with time). Nine months of INH therapy is not harmless, make sure you rule out false positives first.

 

[Smurfette]

there was a case of a resident who converted to a positive PPD whose friend (read: fellow resident) read as a negative PPD who actually had caught Tb from a pt at the VA. 90 staff members ultimately seroconverted that the ID service traced back to him...as well as then having to bring in EVERY patient he had seen in the previous 6 months for testing (many pts converted too, but no one got active Tb). Thankfully he was in a field with less of a patient load than most. Ultimately about 200 people had to be put on meds for prophylaxis/treatment. True story. The lesson? Take the meds, who knows what can happen in a couple months if you don't take the meds.

And, many residency programs/hospitals may INSIST on documented treatment for a PPD conversion, depending on where you are and what pt population you work with.

 

[deleted87716]

So the question now is whether or not to take the 9 months of INH.

The CDC recommendations for latent TB may be found here.

This article (abstract only) in the NEJM may also be helpful.

Most doctors would probably recommend that you receive prophylaxis, as you fall into one of the higher-risk groups (hospital worker).

By the way...you're not supposed to post a question in more than one forum.

 

[usnavdoc]

There are things that can cause a false-positive PPD. There's some sort of cross-reactivity I'm blanking on and of course BCG vaccination which people still get (I've had it and I probably will test positive if you tested me although some BCG-vaccianted people do turn negative with time). Nine months of INH therapy is not harmless, make sure you rule out false positives first.

Sure there are things that can give you a false positive. The two most common reasons for false positive PPD reactions are infection with nontuberculous mycobacteria and vaccination with BCG, which Americans rarely get. Im sure the op would not be posting if he had recieved the vaccine.

INH can cause liver toxicity but is successfully tolerated by most when the patients are educated regarding side effects and lifestyle choices and are followed closely by the supervising medical provider.

It is likely that your medical school will not allow further contact with patients if you refuse treatment through student health. It is also a big screening deal when you match next year. Programs will want proof of treatment for a positive rx.

Weigh your decision carefully. You are in an at risk profession. If you dont take inh and expose other patients, health care workers, friends, and family because you didnt want to take INH, what will that make you.

There are certain prophylaxis treatments you just do because the consequences are horrific. This is one of them. Going on HIV treatment for a needle stick is another. Do it.

 

[highball]

I converted last spring (during MSIII) and started taking INH after my wedding in July. I'm on month 8 right now and have had no problems with the INH. As if I'm taking a sugar pill. Liver enzymes were checked after 1 month and again this month because it is my last. I went in for a 10 minuted check up every month to get my refills. Absolutely not a big deal. Take the meds. NEJM suggests that 6 months is a reasonable length of time if 9 months is not preferable. Also, as far as residencies and interviews, there are lots of people who don't drink at the events (if that's what you're worried about)

 

[Ruban]

Medical question about TB:
Let's say a person is PPD+ and works in health care. They then go on INH for 9 months and eradicate all the latent TB. The next month the person is exposed to a TB patient.

Can the person get TB again after having eradicated it with 9 months of INH? Basically, it seems like it would suck if you were on INH your whole life because you get kept getting recurrent latent TB from your patients!

Anyone know?

 

[deleted87716]

Let's say a person is PPD+ and works in health care. They then go on INH for 9 months and eradicate all the latent TB. The next month the person is exposed to a TB patient.

Can the person get TB again after having eradicated it with 9 months of INH?

Yes. However, it is believed that once a person is PPD positive, they will have some weak antibody protection against reinfection. The exception is if they're immunosuppressed (HIV, etc.)

 

[southerndoc]

I took INH when my PPD converted in 1998. Just remember to take pyridoxine with it or you will develop a peripheral neuropathy from the INH.

I was presented with hard data: 10% of patients with positive PPD's develop TB. That number os 0.1% if you take the INH.

 

[Mumpu]

So what happens once you convert (or get a false positive from BCG or non-TB mycobacteria... MAC is a very common colonizer in places like Florida per my ID fellow)?

I'm BCG-vaccinated and when I was screened at the TB clinic before starting med school I was basically told "no PPDs, no xrays, nothing unless you develop symptoms." I guess false positive reactions tend to be smaller than true positives...

What's interesting is that back in the Old Country (former Evil Empire), where everybody my age was BCG vaccinated, they did routine mantoux screenings at school (annually, as I recall) which means they could differentiate BCG response from true positive. Perhaps the US practitioners read on a different scale?

 

[deleted87716]

back in the Old Country (former Evil Empire), where everybody my age was BCG vaccinated, they did routine mantoux screenings at school (annually, as I recall) which means they could differentiate BCG response from true positive.

Generally, TB prophylaxis should be considered for BCG-vaccinated healthcare workers who have a PPD reaction >/=10mm. The CDC guidelines concerning BCG may be found here.

 

[raine91]

What's the incidence of hepatic failure (the kind requiring liver transplant and/or leading to death, not liver enzyme elevation) in INH given for latent TB infections? thanks.

 

[penguins]

I'm the same as the OP.
+PPD
-CXR
starting INH later this month
hope my residency doesn't care as long as I am taking the INH.
They don't do they????

 

[pgg]

I'm an MS III who had a positive PPD for the first time a week ago (no known exposure, contact, travel, etc... yes... it sucks). i had my cxr which was negative. So the question now is whether or not to take the 9 months of INH....

Here's something to consider, since you don't seem to be capable of making the correct decision regarding your own health.

What do you think your residency program director would do to a resident who was so incompetent, irresponsible, and reckless that he ignored his own +ppd, failed to take the CDC-recommended treatment, went on to develop active TB, and then proceeded to infect other residents, attendings, nurses, techs, admin staff, the janitor, and patients?

If it was me, I'd throw you out on your ass.

Take the ****ing drugs and be done with it, mkay?

starting INH later this month
hope my residency doesn't care as long as I am taking the INH.
They don't do they????

Of course not. Many, many, many health care workers convert every year, and they've certainly had residents taking INH before. Don't sweat it.

What's the incidence of hepatic failure (the kind requiring liver transplant and/or leading to death, not liver enzyme elevation) in INH given for latent TB infections? thanks.

Essentially zero, provided you cease taking INH if symptoms develop or LFTs are elevated (above 3x normal IIRC).

Again IIRC, about 10% of people who take INH will get slight transaminase increases which don't warrant discontinuing the drug, and about 10% of them will progress to liver failure if they keep taking it. But remember, liver failure is not symptom free so it's not like it's going to sneak up on you. No one dies if INH is discontinued promptly once symptoms appear.

As an aside, some people have told me that LFTs aren't even needed in young healthy people provided you do monthly in-office visits with them. (No symptoms? Normal exam? Here's your refill. See you next month.) However, in my young healthy patient population (military) I check them anyway just because so many of my young healthy patients are binge drinkers. Take away the EtOH ... I just spent 7 months in Iraq, with a couple guys on INH, and I didn't worry about them despite the fact that we couldn't do LFTs.

 

[CANES2006]

To the OP, just take the INH. Stop thinking of only yourself and help protect others from seroconverting.

 

[neutropenic]

Had a very similar question on step 2. I picked the isoniazid prophy answer.

 

[Mumpu]

So what happens next? You are still exposing yourself to TB patients but now you are PPD positive so there's no way to tell if you've been re-exposed after the 9 months of INH. You are likely also colonized with MRSA and, if you spent any time in the ICU, with multidrug resistant Pseudomonas and who knows what else.

Should every healthcare worker be placed on lifelong INH, mupirocin, and colistin?

 

[Solideliquid]

BUMP

Sorry to revisit this but, what is the Tx for PPD +, but immunocompromised pt?

 

[fomites]

I'm an MS III who had a positive PPD for the first time a week ago (no known exposure, contact, travel, etc... yes... it sucks). i had my cxr which was negative. So the question now is whether or not to take the 9 months of INH.... if I weren't applying to residencies in about 6 months, I wouldn't take it. But... I am wondering if not having taken it will prevent me from being able to go to some programs (i mean university programs that might be more anal??). Any help?? Part of the reason I don't want to take it is that I'm going to be out of the state for 3-4 of the next 9 months doing away electives, so I won't be able to have liver enzymes drawn, etc. So what do people think about whether or not some residency programs will give me a hard time about this? Thanks very much.

er, umm, my dear future doctor, you have what is called.... LATENT TB. And yes, it needs treatment. Or you could just let it fester in your body and maybe develop active TB and spread it like a banshee on your away electives.

DO you really not know this? ((visualize a swift backhand)). Seriously, are you a **** or what?? Um, I guess you should....probably READ THAT DAMN CHAPTER or check the CDC website!! or maybe you missed that day in school they taught that really rare unheard of disease called TB?

oh yeah, regarding residency programs...no worries, this will be a glimmering beacon of the magnitude of your ******edness.

toodles AFB boy/girl!

 

[KluverBucy]

er, umm, my dear future doctor, you have what is called.... LATENT TB. And yes, it needs treatment. Or you could just let it fester in your body and maybe develop active TB and spread it like a banshee on your away electives.

DO you really not know this? ((visualize a swift backhand)). Seriously, are you a **** or what?? Um, I guess you should....probably READ THAT DAMN CHAPTER or check the CDC website!! or maybe you missed that day in school they taught that really rare unheard of disease called TB?

oh yeah, regarding residency programs...no worries, this will be a glimmering beacon of the magnitude of your ******edness.

toodles AFB boy/girl!

it's not that i don't agree with you, but that i concur with you. quite a disgusting post to say the least. time to dole out the cocktail of sorts...