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Answered Review

1. Question

Which of the following diagnostics tests is intended for latent tuberculosis infection?

a) Sputum smear microscopy

b) Polymerase chain reaction (PCR)

c) Interferon-gamma release assay (lGRA)

d) ELISAfor TB antibodies

Incorrect
The correct answer is (c). Interferon-gamma release assays (e.g., TB Gold) are meant
for the diagnosis of latent TB infection. They should not be used for active TB diagnosis
because they cannot distinguish between latent TB and active disease. A 2011 World
Health Organization (WHO) policy discourages their use for active TB diagnosis. 
Reference: World Health Organization . Policy statement Use of tub erculosis interferon-
gamma re lease assays (IGRAs) in lowand middle-income countries. In. Geneva: World
Health Organization; 2011.

2. Question

Which of the following diagnostics tests can be used to diagnose drug resistant
tuberculosis?

a) Sputum smear microscopy

b) Liquid culture

c) Interferon-gamma release assay (IGRA)

d) Chest X-ray

Incorrect
The correct answer is (b). Liquid culture can be used to grow Mycobacterium
tuberculosis and also identify drug resistance (to rst and second line drugs). The use
of liquid culture is endorsed by the WHO.
Reference: World Health Organization . The use of liquid medium for culture and DSf. URL:
http://www.who.int/tb/laboratory/policy_liquid_medium_foc
(http://www.who.int/tb/laboratory/policy_liquid_medium_foc) culture_dst/en/index.html. In.
Geneva: World Health Organization; 2007.

3. Question

Which of the following tests are banned by the government of India?

a) Sputum smear microscopy

b) Polymerase chain reaction (PCR)

c) Interferon-gamma release assay (lGRA)

d) Serological (antibody) TB tests

Incorrect

The correct answer is (d). The Indian Government has banned the use, sale and
import of all commercial serological (antibody-detection) TB tests. This includes ELISA
as well as rapid antibody tests. The ban applies to domestic as well as imported
serodiagnostics kits. The ban is based on a WHO policy that strongly recommends
against the use of serological, antibody tests for TB. The International Standards for TB
Care also discourages the use of serological TB tests.
References:
World Health Organization. Policy statement Use of tuberculosis interferon-gamma re lease
assays (IGRAs) in low and middle-income countries. In. Geneva: World Health Organization;
2011.
World Health Organization. Policy statement Commercial serodiagnostic tests for diagnosis
of tuberculosis. In. Geneva: World Health Organization; 2011.

4. Question

The ideal clinical specimen for pulmonary TB diagnosis is:

a) Blood

b) Sputum

c) Urine

d) Tissue

Incorrect
The correct answer is (b). Sputum is the best clinical specimen for diagnosis of
pulmonary TB. There are no accurate, validated tests for specimens such as blood,
urine and tissue.

5. Question

Advantages of culture for TB compared to sputum microscopy alone include all of the
following EXCEPT:

a) Obtaining a positive culture can allow for drug-susceptibility testing

b) Culture can allow for identi cation of non-tuberculous mycobacterium species


c) Culture has a higher sensitivity than smear microscopy for diagnosing TB
 d) Culture, particularly by liquid media, can be faster than smear microscopy

Incorrect
The correct answer is (d). Culture is not faster than smear microscopy because even
liquid culture needs 10 -14 days for a result to be obtained. Sputum smear results are
usually available within 1-2 days.

6. Question

Which of the following statements is FALSE about chest X-rays for TB diagnosis:

a) Chest X-rays have good sensitivity, but poor speci city

b) Chest X-rays can help determine the severity of lung damage

c) Chest X-rays alone is su cient to diagnose pulmonary TB

d) Chest X-rays can look similar in patients with old, inactive TB and those with
currently active TB disease

Incorrect
The correct answer is (c). Chest X-rays alone is NOT su cient to diagnose pulmonary
TB) It needs to be followed by sputum testing. While chest X-rays have fairly high
sensitivity for pulmonary TB, its speci city is low. Many lung conditions and infections
can cause chest X-ray abnormalities. So, all patients with chest X-ray abnormalities
must be investigated with sputum smears, NAAT and/or culture.

7. Question

What is the ideal location for sputum collection?

a) Inside the doctor's clinic

b) Inside the laboratory

c) Outdoors or in a well ventilated area

d) The patient's bathroom with the door closed

Incorrect

The correct answer is (c). Sputum expectoration can release infectious aerosols,
which are diluted in the open-air or a well ventilated room and are inactivated by UV
light in the outdoors.

8. Question

Which of the following tests requires a blood sample for the diagnosis of active
pulmonary TB?

a) Sputum smear microscopy

b) Liquid culture

c) Interferon-gamma release assay (IGRA)

d) None of the above

Incorrect
The correct answer is (d). There is no approved blood test for the diagnosis of active
pulmonary TB) IGRAs are tested on blood but only give information on latent TB
infection, not active disease.
Reference: World Health Organization. Policy statement: Use of tuberculosis interferon-
gamma release assays (IGRAs) in low- and middle-income countries. In. Geneva: World
Health Organization; 2011.

9. Question

Which of the following constitutes a good sample for sputum microscopy?

a) 5 ml of muco-purulent sputum

b) 5 ml of clear saliva

c) 2 ml of sputum in a washed food container

d) All of the above

Incorrect
The correct answer is (a). Sputum quality and quantity are essential features of a
good specimen for TB testing. Five ml of muco-purulent specimen collected in a sterile 
laboratory approved container is the ideal specimen for sputum microscopy for TB).
10. Question

For a two year old child with suspected TB, the best clinical specimen for pulmonary TB
diagnosis is:

a) Blood

b) Sputum

c) Gastric aspirate

d) Bronchoalveolar lavage (BAL)

Incorrect
The correct answer is (c). Young children cannot expectorate sputum but it is often
swallowed overnight. The best specimen is, therefore, a series of two to three
consecutive, fasting gastric aspirates.
Reference: Marais BJ, Pai M. Specimen collection methods in the diagnosis of childhood
tuberculosis. Indian J Med Microbiol 2006;24:249-51.

11. Question

What is the minimum recommended number and timing of specimens for the diagnosis
of pulmonary TB?

a) Three early morning sputum specimens

b) Two sputum specimens collected one hour apart

c) Three sputum specimens taken on the same day

d) One early morning sputum plus one blood sample

Incorrect
The correct answer is (b). The minimum requirement for sputum testing is two
specimens taken one hour apart. Previously three consecutive early morning sputum
samples were recommended but research has shown that the 3rd sample does not
add much to the overall yield (and can increase the risk of patient drop-out).
Reference: Policy statement. Same-day diagnosis of tuberculosis by microscopy. World
Health Organization, 2011. (Accessed 2011, at http://whqlibdoc 
(http://whqlibdoc))who.int/publications/2011/9789241501606_eng.pdf.)
Mase SR, Ramsay A, Ng V, et al. Yield of serial sputum specimen examinations in the
diagnosis of pulmonary tuberculosis: a systematic review. Int J Tuberc Lung Dis 2007;11:485-
95.

12. Question

Which of the following specimens should be rejected by the culture laboratory?

a) An unlabeled sputum specimen

b) A lymph node received in xative

c) A specimen received without a request form

d) All of the above

Incorrect
The correct answer is (d). Specimens that are unlabeled or do not have a properly
lled out form, are rejected by the laboratory. Fixatives, such as formalin, will inactivate
any micro-organisms in a tissue sample, therefore, making it unsuitable for culture.

13. Question

In a woman with infertility, suspected to have genito-urinary TB, which of the following
specimens is important for diagnosis?

a) Venous blood

b) Menstrual blood

c) Endometrial tissue

d) Sputum

Incorrect
The correct answer is (c). Endometrial issue for culture and histopathology is critical
for diagnosing genito-urinary tract TB) Blood (venous or menstrual) is not the
appropriate sample as it is very di cult to isolate M. tuberculosis or detect MTB DNA
in such samples.


14. Question
Which of these statements is NOT true about chest radiology for TB diagnosis?

a) Chest x-rays are highly speci c for TB

b) All persons with radiographic abnormalities suggestive of TB should have

sputum specimens submitted for microbiological examination

c) Treatment of TB purely on the basis of x-rays can result in signi cant over-
treatment

d) HIV infection can alter the radiological appearance of TB

Incorrect
The correct answer is (a). Chest x-rays are not speci c for TB) Many lung infections
and conditions can cause radiological abnormalities. This is why all persons with
radiographic abnormalities suggestive of TB should have sputum specimens submitted
for microbiological examination. Only microbiological examination can con rm the
diagnosis of TB).
Reference:
Hopewell PC, Pai M, Maher D, Uplekar M, Raviglione MC) International standards for
tuberculosis care. Lancet Infect Dis 2006;6:710-25.
Pai M. Diagnosis of pulmonary tuberculosis: what every GP should know. GP Clinics
2013;3:22-8.

15. Question

The commonest radiologic nding in TB is:

a) Pleural e usion

b) Upper lobe consolidation with or without cavities

c) Pericardial e usion

d) Lung nodule

Incorrect
The correct answer is (b). Although TB can cause any of the radiologic ndings listed,
upper lobe disease with or without cavitation is the most common.
Reference:

Pinto L, Dheda K, Theron G, et al. Development of a Simple Reliable Radiographic Scoring
System to Aid the Diagnosis of Pulmonary Tuberculosis. PLoS One 2013;8(1): :e54235.
Pinto LM, Pai M, Dheda K, Schwartzman K, Menzies D, Steingart KR. Scoring systems using
chest radiographic features for the diagnosis of pulmonary tuberculosis in adults: a
systematic review. Eur Respir J 2012.

16. Question

TB cannot occur in the:

a) Upper lobes

b) Lower lobes

c) Lingula

d) RML

e) None of the above

Incorrect
The correct answer is (e). Although TB most commonly occurs in the upper lobes it
can occur in any part of the lung.

17. Question

A patient presents with a 10 day history of high fever, cough and purulent sputum. A CXR
shows a dense consolidation in the RUL. The next step is:

a) Obtain sputum specimens for AFB and start TB treatment

b) Start a course of moxi oxacin

c) Obtain sputum specimens for AFB and culture/sensitivity examination and

start azithromycin

d) Refer the patient to a TB hospital

Incorrect
The answer is (c). CXR’s must be interpreted in the clinical context. An acute
presentation suggests acute bacterial infection. Sputum specimens should be obtained

before starting conventional antibiotics. Fluoroquinolones should be avoided if TB is at
all suspected as they will result in temporary improvement because TB is sensitive to
this class of drugs, leading to delay in diagnosis.

18. Question

A 55 year old 40 pack year smoker consults with you for a 2 month history of cough and
blood tinged sputum (no fever). He reports that his sister had TB 10 years ago. The CXR
shows a cavitary mass in the RUL. What is the next step?

a) Obtain sputum AFB

b) Send sputum for cytology

c) Send patient for a bronchoscopy

d) Start treatment with an antibiotic

Incorrect
The answer is (c). Although TB must be suspected in anyone with an upper lobe
cavitary mass, in a heavy smoker with a 2 month history of cough and bloody sputum,
in the absence of infectious symptoms, lung cancer must be suspected) A
bronchoscopy can obtain specimens for AFB but at the same time, can make the
diagnosis of cancer.

19. Question

Which of the following is the correct drug regimen for a newly diagnosed patient with
pulmonary tuberculosis?

a) 2 months of Streptomycin, Rifampicin, Isoniazid, Pyrazinamide and Ethambutol

followed by 4 months of Rifampicin and Isoniazid

b) 8 months of Rifampicin, Isoniazid and Ethambutol

c) 2 months of Rifampicin, Isoniazid, Pyrazinamide and Ethambutol followed

by 4 months of Rifampicin and Isoniazid

d) 6 months of Rifampicin, Isoniazid, Pyrazinamide and Ethambutol

Incorrect 
The correct answer is (c). Injectable drugs are not part of the regimen for newly
diagnosed pulmonary tuberculosis. The standard regimen for the treatment of TB lasts
6 months, with 4 drugs (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol)
prescribed in the rst two months (intensive phase), and Rifampicin and Isoniazid
continued for another 4 months (continuation phase). In India, because of high levels
of INH resistance, the Standards for TB Care in India recommends the addition of
ethambutol to the continuation phase.

20. Question

Which of the following tests should be used to monitor the success of treatment for a
patient with pulmonary tuberculosis?

a) Chest radiograph

b) Sputum smear examination

c) TB IgG, IgM antibodies

d) TB Gold test (interferon-gamma release assay)

Incorrect
The correct answer is (b). Sputum smear examination is recommended at the end of
the intensive phase of treatment and at the end of treatment. Investigations for drug
resistant TB need to be performed if the smear continues to be positive at 3 months.
Treatment is considered to have failed if the smear at end of treatment is positive.
Improvements in chest radiographs, while reassuring in the clinical context, are not
speci c enough to be used to monitor disease. TB IgG and IgM are serological tests
that have been banned and have no role in the management of TB) IGRA (e.g., TB Gold)
is a test to diagnose latent TB, and has no role in the diagnosis or monitoring of active
disease.

21. Question

When should one suspect the possibility of drug-resistant TB?

a) When the patient has been treated for TB in the past

b) When the patient is in close contact with a patient who has drug-resistant TB 

c) When the patient has defaulted from treatment before the present illness
 d) All of the above

Incorrect
The correct answer is (d). Relapse, retreatment and having a close contact with drug-
resistant TB are important risk factors for drug-resistant TB, and questions pertaining
to these risk factors are very important in the initial assessment of patients with TB)

22. Question

Which of the following statements is true about intermittent treatment?

a) It is superior to daily treatment

b) It can be given twice a week

c) It should be prescribed only when treatment is supervised

d) When prescribed, it must include an injectable drug

Incorrect
The correct answer is (c). While intermittent treatment is an accepted modality of
treatment, it is recommended only when compliance is ensured through direct
supervision, and given for a minimum of three times a week. Twice-weekly regimens
are not acceptable. Injectable drugs are not part of a standard intermittent treatment
regimen for newly diagnosed pulmonary TB).

23. Question

Which of the following is false regarding adverse reactions to TB drugs?

a) Jaundice is a common adverse e ect and is self-limiting

b) Nausea is a common adverse e ect, is usually self-limiting and can be treated

with symptomatic management

c) Joint pains are an adverse reaction to pyrazinamide and usually respond well to
non-steroidal anti-in ammatory drugs

d) The elderly and those with pre-existing liver disease are more susceptible to
drug induced hepatitis 
Incorrect
The correct answer is (a). Jaundice is a sign of hepatitis and warrants stoppage of all
TB medications, and investigations for drug-induced hepatitis. It is more common in
the elderly and in patients with pre-existing liver disease.

24. Question

Which of the following samples is not appropriate for a case of suspected tuberculous
pleural e usion?

a) Blood

b) Pleural uid

c) Pleural biopsy

d) Sputum

Incorrect
The correct answer is (a). There is no validated blood test for pleural or any form of
extrapulmonary tuberculosis. Other samples listed are useful to collect.

25. Question

Which of the following diagnostics tests is endorsed by WHO for extrapulmonary TB?

a) Interferon-gamma release assay (IGRA)

b) Tuberculin skin test (Mantoux)

c) Xpert MTB/RIF

d) Serological (antibody) TB tests

Incorrect
The correct answer is (c). In 2013, WHO endorsed the use of Xpert MTB/RIF for
extrapulmonary TB.

26. Question 
Which of the following tests are banned by the government of India:
 a) Sputum smear microscopy

b) Polymerase chain reaction (PCR)

c) Interferon-gamma release assay (IGRA)

d) Serological (antibody) TB tests

Incorrect
The correct answer is (d). The Indian Government has banned the use, sale and
import of all commercial serological (antibody-detection) TB tests. This includes ELISA
as well as rapid antibody tests. The ban applies to domestic as well as imported
serodiagnostics kits. The ban is based on a WHO policy that strongly recommends
against the use of serological, antibody tests for TB) The International Standards for TB
Care, and Standards for TB Care in India also discourage the use of serological TB
tests.

27. Question

Interferon-gamma release assays (e.g., TB Gold) and Mantoux skin test cannot
distinguish between latent infection and active (pulmonary or extrapulmonary) disease.
True or False?

a) True

b) False

Incorrect
The correct answer is TRUE. Neither Mantoux nor TB Gold can separate latency from
active TB disease. Thus, they are discouraged for active TB diagnosis.

28. Question

Of the following tests, which has the highest sensitivity for TB?

a) Smear microscopy

b) Tuberculin skin test

c) Liquid cultures 

d) Interferon-gamma release assay (IGRA)

Incorrect
The correct answer is (c). Liquid cultures have the highest sensitivity.

29. Question

In which of the following specimens does Xpert MTB/RIF have the lowest sensitivity?

a) Lymph nodes

b) CSF

c) Gastric aspirates

d) Pleural uid

Incorrect
The correct answer is (d). Xpert does not have high sensitivity in pleural uid
samples, and therefore should not be used alone. It should be used in combination
with other tests such as pleural uid/tissue cultures and biopsy.

30. Question

What is the estimated prevalence of latent TB infection in India?

a) 5%

b) 10%

c) 40%

d) 80%

Incorrect
The correct answer is (c). An estimated 40% of the Indian population is estimated to
be latently infected, using tuberculin surveys.

31. Question

Which of the following tests can be used to screen for latent TB infection? 

a) GeneXpert (Xpert MTB/RIF)

 b) Sputum smear examination

c) TB IgG, IgM antibodies

d) Mantoux (tuberculin skin test)

Incorrect
The correct answer is (d). The tuberculin skin test, using Mantoux technique, is one of
the two accepted tests for latent TB infection screening. The other test is interferon-
gamma release assays (e.g., TB Gold)

32. Question

Which of these high-risk populations should be targeted for LTBI screening and
treatment?

a) People living with HIV/AIDS

b) Child contacts of pulmonary TB cases

c) Patients initiating anti-tumour necrosis factor (TNF-alpha) treatment

d) Patients with end stage renal failure on dialysis

e) All of the above

Incorrect
The correct answer is (e). Latent TB screening should be restricted to high-risk
groups. These include people living with HIV and AIDS, adult and child contacts of
pulmonary TB cases, patients initiating anti-tumour necrosis factor (TNF-alpha)
treatment, patients with end stage renal failure on dialysis, patients preparing for
organ or haematologic transplantation, and patients with silicosis.

33. Question

Which of the following statements is TRUE about interferon-gamma release assays (e.g.,
TB Gold)?

a) IGRAs cannot separate latent infection from active TB, and, therefore, not
recommended for active TB detection 

b) IGRAs are skin tests for latent infection

 c) IGRAs are useful for diagnosing active, pulmonary TB

d) IGRAs are banned in India

Incorrect
The correct answer is (a). IGRAs cannot separate latent infection from active TB, and,
therefore, not recommended for active TB detection. This is also true for Mantoux skin
test. Both IGRAs and TST should be restricted to LTBI screening, and should not be
used for active TB diagnosis. In children, Mantoux test may have some value as a test
for infection, in addition to chest x-rays, symptoms, history of contact, and other
microbiological investigations (e.g., gastric juice acid fast bacilli and Xpert MTB/RIF).

34. Question

Which of the following drug regimens are NOT recommended for latent TB infection?

a) 6 to 9 months of isoniazid

b) 3-month regimen of weekly rifapentine plus isoniazid

c) 3–4 months isoniazid plus rifampicin

d) 3–4 months rifampicin alone

e) Isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) for 2 months,

followed by isoniazid and rifampicin (HR) for 4 months

Incorrect
The correct answer is (e). The HRZE drug regimen is meant for treating active
tuberculosis. For latent TB infection, treatment options recommended by WHO include
6 to 9 months of isoniazid, 3-month regimen of weekly rifapentine plus isoniazid, or 3–
4 months isoniazid plus rifampicin, or 3–4 months rifampicin alone.

35. Question

Which of the following diagnostic tests is the recommended frontline test for PLWH
suspected of having active, pulmonary TB?

a) Smear microscopy 
b) Interferon-gamma release assay (e.g. TB Gold)
 c) Sputum culture

d) GeneXpert (Xpert MTB/RIF)

Incorrect
The correct answer is (d). The WHO and STCI recommendation is that GeneXpert
(Xpert MTB/RIF) be used as the frontline test for PLWH suspected of having active
pulmonary TB) This test is more sensitive than sputum smear microscopy. The
interferon-gamma release assay is a test for latent TB infection, it should not be used
as a diagnostic test for investigating suspected active pulmonary TB) Sputum culture is
highly sensitive and speci c for the diagnosis of active pulmonary TB; however,
GeneXpert is recommended as the frontline test because it provides results within a
few hours, whereas sputum culture can take weeks.

36. Question

You are seeing a 23 year old engineer who had sputum tested with GeneXpert, and the
test result was “MTB detected, Rifampin resistance not detected” Which of the following
statements is true:

a) This patient does not need to be tested for HIV infection because he denies risk
factors for HIV.

b) This patient should not be tested for HIV infection because he is not from a
population where HIV prevalence is elevated.

c) This patient should be tested for HIV infection because he has active
tuberculosis.

Incorrect
The correct answer is (c). The WHO and STCI recommend that all persons diagnosed
with active TB should be tested for HIV infection. This is because HIV is more common
amongst persons with active TB, and also because the management of active TB will be
di erent among patients that are PLWH.

37. Question

You are seeing a patient in your clinic who was recently diagnosed with HIV. Which of the
following is true about TB screening:
 a) This patient does not need to be screened for active TB

b) If the patient denies having a cough lasting more than 3 weeks, they do not need
any further evaluation for active TB

c) To screen them for active TB, you should ask about the presence of the following
symptoms: a cough of any duration, night sweats, fevers, and weight loss; if at least
one of these is present they need further diagnostic evaluation for TB)

d) To screen them for active TB, you should obtain a CXR, even if they are
asymptomatic; if any abnormality is present, further diagnostic evaluation for active
TB is indicated)

e) Both c and d are correct

Incorrect
The correct answer is (e). The WHO and the STCI recommend TB screening for PLWH
in high TB burden areas. The WHO recommendation is to use symptom-based
screening, and if resources are available, a CXR. The symptom-based screen
recommended by the WHO consists of asking about the presence of four symptoms:
fevers, coughs, night sweats, and weight loss; if any symptom is present, then active TB
should be suspected and the patient will require additional diagnostic work up. A CXR
should be used as a supplement to symptom-based screening to increase sensitivity.
The CXR should be performed even amongst PLWH that do not have any of the four
symptoms asked about in symptom-based screening; this will increase the sensitivity.
The presence of any abnormality on a CXR means that further diagnostic testing (e.g.,
GeneXpert) should be pursued in order to diagnose or exclude active TB).

38. Question

Which of the following interventions will lower the risk of active TB in PLWH?

a) Antiretroviral therapy

b) Isoniazid preventive therapy

c) Co-trimoxazole

d) Both a and b are correct


e) a, b & c are correct
Incorrect
The correct answer is (d). Antiretroviral therapy and isoniazid preventive therapy
both lower the risk of active TB in PLWH. All PLWH should be regularly assessed to
determine if they meet criteria for initiating antiretrovirals.

39. Question

Which of the following will lower the risk of mortality in PLWH who have active TB?

a) Antiretroviral therapy initiation within 8 weeks of starting TB treatment

b) Isoniazid preventive therapy

c) Co-trimoxazole

d) Both a and c are correct

e) a, b & c are correct

Incorrect
The correct answer is (d). Antiretroviral therapy and co-trimoxazole lower mortality in
PLWH who have active TB) Isoniazid preventive therapy is contraindicated when active
TB is suspected (or con rmed, of course)—as this will expose the M. tuberculosis to
isoniazid monotherapy which will lead to the development of isoniazid resistance.
Antiretroviral therapy should be initiated in all PLWH who have active TB, regardless of
their CD4 count, within 8 weeks of starting TB treatment.

40. Question

Which of the following is true about TB treatment regimens in PLWH?

a) The preferred regimen is 2 months of isoniazid, rifampin, pyrazinamide and

ethambutol, followed by 6 months of isoniazid and ethambutol; with treatment dosed
intermittently (three times weekly) throughout

b) The preferred regimen is 2 months of isoniazid, rifampin, pyrazinamide and

ethambutol, followed by 4 months of isoniazid and rifampin; with treatment
dosed daily throughout

c) The preferred regimen is 2 months of isoniazid, rifampin, pyrazinamide and 

ethambutol, followed by 4 months of isoniazid and rifampin; with treatment dosed
 daily in the intensive phase and intermittently (three times weekly) in the continuation
phase.

Incorrect
The correct answer is (b). The preferred regimen for the treatment of active TB in
PLWH is 2 months of isoniazid, rifampin, pyrazinamide and ethambutol, followed by 4
months of isoniazid and rifampin, with treatment dosed daily throughout. Regimens
that used rifampin only in the intensive phase (question 6. choice “a)”, where rifampin
is used for only 2 months) have been associated with worse TB outcomes in PLWH
(and also in HIV-uninfected TB patients). Intermittent TB therapy has also been
associated with worse TB treatment outcomes in PLWH—hence, all e orts should be
made to ensure PLWH who have active TB are treated with regimens in which dosing is
daily throughout treatment.

41. Question

Which of the following drugs has the highest potential to produce exfoliative dermatitis?

a) Isoniazid

b) Rifampicin

c) Pyrazinamide

d) Ethambutol

Incorrect
The correct answer is (c). The propensity of the drugs to cause erythroderma
(exfoliative dermatitis) are PZA >SM >EMB >RIF >INH with rates for PZA being 2.4 %. All
the drugs have to be stopped and reintroduction of the ATT is to be done with INH
followed by RIF, EMB and PZA with careful monitoring. To prevent monotherapy, 2 new
drugs which were not used previously should be added while introducing individual
drugs.

42. Question

Which of the following adverse events is a contraindication to rechallenge of the possibly

implicated drug during treatment with ATT? 

a) Hepatotoxicity
 b) Drug rash

c) Drug induced thrombocytopenia

d) Vomiting

Incorrect
The correct answer is (c). Drug induced thrombocytopenia is because of immune
mediated mechanisms because of production of autoantibodies or drug dependent
antibodies resulting in rapid destruction of platelets. It is a life threatening
complication and is an absolute contraindication to rechallenge as even minute
quantities of the drug can trigger immune mediated destruction of platelets leading to
severe hemorrhage.

43. Question

Which of the following ATT drugs has no hepatotoxicity potential?

a) Rifampicin

b) Pyrazinamide

c) Isoniazid

d) Ethambutol

Incorrect
The correct answer is (d). The propensity to produce hepatotoxicity is with PZA> INH>
RIF. Ethambutol, streptomycin and moxi oxacin do not have hepatotoxic potential and
they can be administered safely in patients with hepatotoxicity while discontinuing
those drugs with hepatotoxic potential and to accompany the individual drugs on
rechallenge to prevent monotherapy .

44. Question

Which of the following is a risk factor for ATT induced hepatitis?

a) Female gender

b) Advancing age 

c) Malnutrition
 d) All of the above

Incorrect
The correct answer is (d). Advancing age, female gender, chronic alcohol
consumption, pre existing liver diseases, hepatitis B, C and HIV coinfection,
malnutrition are some of the important risk factors for drug induced hepatotoxicity.
They have to be carefully sought prior to the initiation of ATT and their presence
warrant close monitoring of liver function tests every 2-4 weeks on therapy.

45. Question

Which of the following is false regarding adverse reactions to TB drugs?

a) Jaundice is a common adverse e ect and is always due to liver adaptation

which is self-limiting.

b) Drug induced neuropathy can be prevented by routine supplementation with

pyridoxine

c) Joint pains are an adverse reaction to pyrazinamide and usually respond well to
non-steroidal anti-in ammatory drugs

d) Females and those with pre-existing liver disease are more susceptible to drug
induced hepatitis

Incorrect
The correct answer is (a). Jaundice is a sign of hepatitis and warrants stoppage of all
TB medications, and investigations for druginduced hepatitis. However, it can also
occur rarely due to drug induced hemolysis which is a life threatening complication.
Liver function tests and complete blood counts are to be requested to di erentiate
drug induced hepatitis and hemolytic jaundice. Drug induced hepatitis is diagnosed
when serum aminotransferase level >5 times the upper limit of normal [ULN] without
symptoms or >3 times the ULN with symptoms.

46. Question

Mohan is a 53 year old man who visits your o ce with a month of productive cough, 8
kilograms of weight loss, and night sweats. He has type II diabetes, for which he takes 
glyburide 5mg twice a day. He has a pleasant demeanor and you learn he is an avid
cricket fan. In your initial investigation, you nd that a chest X-ray shows a right upper
lobe in ltrate, and sputum microscopy shows 2+ acid fast bacilli. He denies ever having
had TB previously. You diagnose Mohan with pulmonary tuberculosis (TB) and decide to
initiate him on once-daily treatment with isoniazid, rifampicin, pyrazinamide, and
ethambutol (AKT-4). He weighs 53 kilograms at the time of your initial evaluation.

As you start Mohan on TB therapy, what counseling should you provide to counter
potential medication adverse e ects and to minimize drug-drug interactions, so that he
is more likely to adhere and complete therapy?

a) Advise him that he should not worry if his urine or tears turn red-orange color
while on therapy

b) Tell him that his TB medications should only be taken at bedtime

c) Prescribe pyridoxine (vitamin B6) 50mg by mouth daily

d) Advise him to visit his diabetes doctor soon after starting TB therapy, due to a
risk of poorer blood sugar control while on TB therapy

e) Both A and C

f) A, C, and D

Incorrect
The correct answer is (F). Rifampicin often turns body uids a red-orange color.
Alerting patients ahead of time to this benign side e ect may help minimize
unnecessary concern or interruptions in therapy.

Pyridoxine should be considered for all patients starting TB therapy including isoniazid,
but Mohan is at particularly high risk for isoniazid-related peripheral neuropathy due
to his diabetes, which can also cause peripheral neuropathy. People living with HIV,
malnourished patients, and patients on other medications that can cause peripheral
neuropathy (e.g., multidrug resistant TB patients on ethionamide, cycloserine, or
linezolid) are also at higher risk for isoniazid-related peripheral neuropathy.

Rifampicin can decrease blood levels of sulfonylureas used to treat diabetes, including
glyburide, which can result in worsened blood sugar control in some patients.1,2 As
such, patients on sulfonylurea medications should have their diabetes monitored
closely, as they may require modi cations of their medications while on TB therapy.

There is no speci c requirement that patients should take their TB medications only at
bedtime. In general, for patients on standard therapy for drug-susceptible TB, it is
important that patients take their medications at the same time every day (whether in
the morning or at night). TB medications are best absorbed if taken on an empty
stomach; however, for patients with signi cant gastrointestinal side e ects, taking
medications with food may be considered to reduce these side e ects.

47. Question

You see Mohan again more than 6 weeks after starting TB therapy. His weight has
dropped from 53kg to 48kg, and he has evidence of temporal wasting. When you talk to
him, he endorses ongoing fatigue and night sweats. You worry that he does not seem to
be improving clinically after starting TB therapy. What should you do?

a) Order a GeneXpert MTB/Rif test, line probe assay, or other drug susceptibility
testing, if not sent already at the time of diagnosis

b) Carefully screen for poor medication adherence using questions about his pill-
taking

c) Empirically add injection streptomycin to his medication regimen

d) Inquire about the quality of his diet and refer him to a dietician

e. Start a rapid prednisone taper

f. A, B, and D

g. A, B, and C

Incorrect
The correct answer is (F). Ongoing weight loss after weeks of TB therapy should raise
concern for potential drug-resistance, poor medication adherence, and poor quality of
the patient’s diet. Per the Standards for TB Care in India, drug susceptibility testing
(DST) should be o ered to all diagnosed TB patients prior to starting therapy. however,
in cases where DST was not done at the initiation of therapy, failure to respond to
therapy as evidenced by ongoing weight loss should prompt GPs to send a DST.

Ongoing weight loss may also suggest that a patient is not taking his or her
medications, so screening for non-adherence using simple questions (such as the 
Morisky questions) is important.
Low caloric intake and poor protein intake may blunt replenishment of the patient’s
nutritional stores, especially in patients with food insecurity, vegetarian patients with
poor protein intake, and patients with a high catabolic state from other comorbidities
(e.g., HIV cachexia).

Streptomycin alone should not be added empirically to the patient’s medication

regimen. If there is high concern for drug-resistant TB, DST should be performed, and
empiric multidrug- resistant TB therapy (which would involve addition of multiple
medications) can be considered in some cases pending the DST result.

While a prednisone taper might brie y increase the patient’s weight and temporarily
improve symptoms, it would not improve the patient’s long-term response to TB
therapy.

48. Question

You look in his chart and see that a GeneXpert test sent at the start of therapy was
negative for rifampicin resistance. You ask the patient about his medication adherence,
and he admits to only taking his TB medications twice in the last week. Upon more
careful questioning using the Morisky questions, the patient notes that he experienced
some clinical improvement after taking his medications regularly for the rst 2 weeks,
but then he stopped taking his medications as frequently because he was starting to feel
better. He also notes that he often forgets to take his medications due to his busy work
schedule and confusion with his diabetes medications. What messages can you share
with Mohan to ensure that he takes his TB medications every day?

a) Tell Mohan to stop taking his TB medications if he has acid re ux or mild nausea
for the hour immediately after taking his medications

b) Remind Mohan of the consequences of poor medication adherence or stopping

TB therapy early, including risk of treatment failure, disease relapse, development of
drug-resistant TB, and transmission of TB to family members

c) Recommend that Mohan set a daily alarm on his phone to remind him to take his
pills

d) Advise him to stop taking his diabetes medications because curing TB is more
important in the short term

e) Advise Mohan to involve his wife or other family members in his care (if he has
disclosed his diagnosis to them) to help remind him to take his pills and observe him 
taking them
 f) Ask him to repeat back your instructions about how and when he should take his
TB and diabetes medications

g) A, B, and D

h) B, C, E, and F

Incorrect
The correct answer is (H). Unfortunately, evidence-based data about the best
approaches for ensuring adherence to TB medications are lacking. However, some
common-sense strategies for improving medication adherence include improving the
patient’s treatment literacy (by educating about the consequences of non-adherence),
setting daily reminders to facilitate pill-taking, involving close family members in the
patient’s TB care, and implementing a “talk back” strategy at each visit, in which the
patient repeats back your recommendations to con rm his or her understanding.

Patients should not stop TB medications for acid re ux or mild nausea, though they
should get in touch with their GP. GPs can then check LFTs to rule out hepatotoxicity
and recommend therapies to reduce these GI side e ects, such as antacids.

Maintaining good glycemic control is important during TB therapy, and patients should
not be advised to stop their diabetes medications while on TB therapy.

49. Question

On follow-up visits for the next two months, Mohan reports improved medication
adherence, and his weight increased and symptoms improved. However, he misses his
fth month visit. You call him and Mohan comes into your clinic one week later with his
wife. He looks disheveled, does not make eye contact, and provides terse answers
during your interview. He smells of alcohol. His wife notes that he becomes
intermittently tearful at home and stopped going to work three weeks ago. He stopped
taking his TB medications completely at that time. What should you do?

a) Tell him that he has nished four and a half months of TB therapy, so it is OK to
stop

b) Screen for clinical depression using simple questions and consider referral to a
mental health specialist

c) Screen for alcohol use disorder using simple questions and consider referral to a
mental health specialist
 d) Discuss Mohan’s family and social support system with him and his wife

e) B, C, and D

Incorrect
The correct answer is (E). Depression and alcohol use disorder are two common
barriers to TB medication adherence. Simple questionnaires—such as the Patient
Health Questionnaire- 2 (for depression) and the AUDIT-C (for alcohol use disorder)—
can be easily implemented during brief patient visits to screen for these problems.
Ideally, patients should be referred to mental health specialists to help with these
problems; however, nding a quali ed specialist can be di cult in many areas of India.
Encouraging compassionate, non-judgmental involvement from a patient’s family
members can sometimes provide the social support needed to get through TB
therapy.
The patient should not be advised to stop TB therapy, because premature termination
of therapy will increase the risk for relapse of TB.

50. Question

Before the visit is nished, the patient’s wife notes that the patient has started drinking
alcohol heavily again (around 7 or 8 drinks a day) after years of sobriety and asks for you
to provide advice about the patient’s alcohol use disorder. What should you advise?

a) Warn the patient about the increased risk of hepatotoxicity of TB medications

when taken with alcohol, and encourage him to contact you quickly for any intractable
vomiting or jaundice

b) Identify triggers of his alcohol use (including peer pressure from friends) and
recommend strategies for minimizing contacts with these triggers

c) Tell him that he is at fault for his drinking and state that you will no longer see
him at follow-up visits unless he stops drinking

d) Advise him to eat before drinking to blunt the e ects of the alcohol

e) A, B, and D

Incorrect

The correct answer is (E). Patients with alcohol use disorder should be reminded
about the increased risk of hepatotoxicity from TB medications. Identifying triggers
that lead the patient to use alcohol heavily may help patients to re ect upon how they
can avoid these triggers and cut down on drinking. For heavy drinkers, eating before
drinking may improve nutritional status and blunt the e ects of alcohol. It is important
to have a non-judgmental approach to patients with substance use disorders. Patients
are more likely to have ongoing engagement with healthcare providers who are open
and compassionate. Recent studies suggest that supportive engagement of patients
with alcohol use disorder can improve their TB treatment outcomes.

51. Question

Which of the following is true of undernutrition and TB?

a) Undernutrition is a risk factor for TB

b) Tuberculosis can lead to undernutrition

c) Undernutrition worsens severity of tuberculosis

d) Undernutrition is associated with adverse outcomes in TB patients

e) All of the above

Incorrect
The correct answer is (e).

52. Question

A patient with a height of 170 cm has a weight of 45 kg. His calculated BMI would
indicate

a) Normal body weight

b) Mild undernutrition

c) Severe undernutrition

d) Moderate undernutrition


Incorrect
 The correct answer is (c). BMI is calculated as weight in kg/(height in metre). The BMI in
this patient would be 45/(1.7)2= 15. 57 kg/m2. This is less than 16.0 kg/m2 and
indicates severe undernutrition.

53. Question

Which of the following drug/s should be given on an empty stomach for better
bioavailability?

a) Isoniazid

b) Rifampicin

c) Ethambutol

d) Isoniazid as well as rifampicin

Incorrect
The correct answer is (d). The bioavailability and peak serum concentrations of both
isoniazid and rifampicin is a ected by food.

54. Question

A labourer with TB has signs of hypoproteinaemia. What would be an appropriate

dietary advice?

a) Take 4 teaspoons of a commercial supplement, which has 40 gm protein in 200

gms

b) Eat mutton, chicken (if he is non-vegetarian)

c) Eat additional quantity of pulses or eggs (if he is non-vegetarian)

d) Take 2 tsp of a tonic containing amino acids daily

Incorrect
The correct answer is (c): The commercial protein supplement may contain 40 gm
protein in a 200-gm pack, but is costly and inappropriate, as are tonics with amino
acids. Mutton and chicken are more expensive than eggs and the labourer is more
likely to a ord additional pulses or eggs, than eat chicken or mutton on a daily basis. 
The protein content per 100 gm, does not di er between eggs and chicken.
55. Question

Pyridoxine de ciency can occur due to treatment of which anti-TB drug?

a) Rifampicin

b) Isoniazid

c) Ethambutol

d) Pyrazinamide

Incorrect
The correct answer is (b). Isoniazid interferes competitively with pyridoxine
metabolism by inhibiting the formation of the active form of the vitamin, and hence
often results in peripher¬al neuropathy. This is especially marked in malnutrition,
pregnancy, lactation, HIV infection, diabetes and hypertension. This e ect can be
prevented by giving pyridoxine 10 mg per day.

56. Question

The following are true for inpatient care of patient with red- ag features in the rst
week, except

a) Feed vigorously with the daily requirement of calories and protein

b) Give adequate quantities of potassium, magnesium

c) Correct dehydration

d) Give thiamine and B-complex vitamins during this phase

Incorrect
The correct answer is (a). In a patient with very low BMI and who has probably been
eating little for many days, vigorous feeding may result in refeeding syndrome which
can be danger¬ous. The feeding should start at 50% of the dietary requirement or
even lower in the rst few days, along with the other measures mentioned.

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