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A 77-year-old man comes to your office for a PPD reading. The patient recalls being told he was PPD-negative thirty years ago. The patient has a history of hypertension, ischemic bowel disease, and gastric cancer, and his medications are prednisone 10 mg daily, multivitamins, and losartan. The patient denies exposure to anyone with active tuberculosis and has lived in Queens, New York, his whole life. He is a retired stockbroker and now works in a homeless shelter. He denies drinking alcohol or smoking tobacco but admits to occasional prostitute relations. You measure an area of erythema of 18 mm and an area of induration of 11 mm. His chest x-ray is normal. What would your next course of action be?
(A) Nothing further is necessary
(B) Isoniazid for six months
© Isoniazid for nine months
(D) Repeat the PPD in one year
(E) Check three sputum acid-fast stains
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aaa pros doesnt spread it!
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pt is immunocompromissed (due to prednisone).. the PPD is significant
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nice job CD45
Answer:
© Isoniazid for nine months
Explanation:
This patient has a positive PPD skin test because his level of induration is >5 mm and he uses steroids. Five millimeters is the cutoff for a positive test in HIV-positive patients, those who use steroids, close contacts, organ transplant recipients, and in those who have abnormal chest x-rays consistent with previous tuberculosis. Even though he is older than 35 years, he should receive nine months of isoniazid anyway. The age cutoff of 35 years as a criterion for whether or not to treat latent tuberculosis was eliminated several years ago. He is a good example of exactly who should undergo screening for tuberculosis with a PPD test. He is immunocompromised because of the steroid use, as well as the previous gastrectomy. In addition, he has potentially been exposed because he works in a homeless shelter. The ideal length of therapy was raised to nine months from six months several years ago. All of these recommendations are regardless of whether or not the patient has had a previous vaccination with BCG.
