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PE31.1-14 | Tuberculosis and Febrile Infections — Graded Quiz
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A 3-year-old child living with a smear-positive TB parent has no symptoms. Mantoux is 6 mm. Chest X-ray is normal. According to NTEP guidelines, what is the most appropriate management?
Correct. All children under 5 years who are household contacts of smear-positive TB patients must receive IPT (isoniazid 10 mg/kg/day, max 300 mg for 6 months), irrespective of Mantoux result. This prevents progression to active TB.
NTEP IPT protocol: isoniazid 10 mg/kg/day × 6 months for ALL under-5 household contacts of smear-positive TB, regardless of Mantoux result or BCG status.
Full treatment is for active disease. Under-5 contacts always receive IPT regardless of Mantoux. BCG does not treat latent infection. Watchful waiting delays necessary prevention.
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A 9-year-old presents with 4 weeks of fever, night sweats, and weight loss. CXR shows right hilar lymphadenopathy with a small calcified focus. Mantoux is 14 mm. CBNAAT is ordered. What does CBNAAT simultaneously detect?
Correct. CBNAAT (GeneXpert MTB/RIF) is a cartridge-based nucleic acid amplification test that simultaneously detects M. tuberculosis complex AND rifampicin resistance (as a surrogate for MDR-TB) in a single 2-hour run. It does not test isoniazid, ethambutol, or pyrazinamide resistance.
CBNAAT/GeneXpert MTB/RIF: detects M. tuberculosis AND rifampicin resistance in 2 hours from sputum/gastric aspirate/CSF. Rifampicin resistance = surrogate marker for MDR-TB. For full DST: BACTEC MGIT liquid culture.
CBNAAT specifically detects rifampicin resistance (rpoB gene mutations), not isoniazid or ethambutol resistance. It does not cover atypical mycobacteria's full DST profile.
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An 8-year-old girl with febrile illness develops a pruritic vesicular rash starting on the trunk and spreading centrifugally, with lesions in multiple stages (macules, papules, vesicles, pustules, crusts). She has no previous varicella vaccination. What is the specific antiviral treatment recommended for a non-immunocompromised child with moderate disease?
Correct. This is varicella (chickenpox). For non-immunocompromised children with moderate or secondary household cases, oral acyclovir 20 mg/kg/dose (maximum 800 mg) four times daily for 5 days is recommended. It reduces duration and severity if started within 24 hours of rash onset.
Varicella: rash in multiple stages simultaneously, centripetal distribution (trunk > face > extremities). Treatment: oral acyclovir 20 mg/kg/dose (max 800 mg) QID × 5 days (start within 24 h). Immunocompromised: IV acyclovir. Secondary household cases are more severe — treat.
Oseltamivir treats influenza. IV ganciclovir is for CMV. Ribavirin inhalation is for RSV. Varicella requires acyclovir.
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A 5-year-old unvaccinated child presents with high fever, sore throat, and a tough greyish membrane in the throat that bleeds on attempted removal. There is a bull-neck appearance and muffled voice. Which is the correct immediate priority management?
Correct. Diphtheria management priority: (1) Diphtheria antitoxin (DAT) — the specific treatment that neutralizes unbound toxin; administer WITHOUT waiting for culture results (clinical diagnosis is sufficient). (2) Antibiotics — penicillin G or erythromycin to eliminate the organism and reduce toxin production. The antitoxin must be given promptly as bound toxin cannot be neutralized.
Diphtheria: greyish adherent membrane + bull-neck + toxin complications (myocarditis in week 1, neuropathy later). Priority: Diphtheria Antitoxin (DAT) immediately (clinical diagnosis; don't wait for culture) + penicillin/erythromycin. Notifiable disease.
Antibiotics alone are insufficient — they kill the bacteria but do not neutralize the toxin already released. Antitoxin must be given first. Corticosteroids have limited evidence. Emergency intubation may be needed for airway compromise but is not the priority over DAT.
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During a primary TB infection work-up, a haematology report shows: Hb 10.2 g/dL, TLC 9,800/mm³, lymphocytes 45%, ESR 78 mm/hr, CRP elevated. Which combination of blood findings is most consistent with active tuberculosis?
Correct. Active TB typically shows: relative lymphocytosis (in children), elevated ESR (>40 mm/hr), elevated CRP, and anaemia of chronic disease (normocytic normochromic). Neutrophilia suggests bacterial superinfection. Eosinophilia and thrombocytopenia are not characteristic of TB.
TB blood picture: lymphocytosis, elevated ESR (>40 mm/hr), elevated CRP, normocytic normochromic anaemia of chronic disease. No single blood marker is diagnostic — combine with clinical and radiological findings.
Active TB causes an elevated inflammatory response (ESR/CRP) and lymphocyte-predominant picture in children. Normal or low ESR/CRP argues against active TB. Eosinophilia is more consistent with parasitic infections.
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A 12-year-old returning from a malaria zone develops fever with rigors on alternate days (48-hour cycle). Peripheral blood smear shows banana-shaped (crescent) gametocytes. What is the correct first-line treatment?
Correct. Banana/crescent-shaped gametocytes are pathognomonic of Plasmodium falciparum. First-line treatment is ACT (e.g., artemether-lumefantrine or artesunate-amodiaquine) for 3 days. Chloroquine resistance is widespread for falciparum. Additionally, a single dose of primaquine (0.75 mg/kg) is given as gametocytocidal agent to reduce transmission.
P. falciparum identifiers: crescent/banana-shaped gametocytes, ring forms only in peripheral smear, potentially severe malaria. Treatment: ACT (3 days). Never chloroquine for falciparum. Add single-dose primaquine (0.75 mg/kg) to reduce gametocyte transmission.
Chloroquine resistance in P. falciparum is near-universal in India. Banana-shaped gametocytes confirm falciparum, which requires ACT. Quinine + doxycycline is for multidrug-resistant falciparum. Primaquine monotherapy has no blood-stage activity for falciparum.
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A 10-year-old child presents with fever, rash, and arthralgia. His mother reports the rash began behind the ears and then spread to the face. Cervical lymph nodes are enlarged posteriorly (post-auricular and sub-occipital). The rash is a fine pink maculopapular rash lasting less than 3 days. She had the first dose of MMR vaccine but not the second. What is the primary concern regarding a pregnant woman in the household?
Correct. This is rubella (German measles) — post-auricular/sub-occipital lymphadenopathy + fine maculopapular rash lasting <3 days + arthralgia. Congenital Rubella Syndrome (CRS) occurs when a pregnant woman (especially in first trimester) is infected: causes cataracts, congenital heart disease (PDA, pulmonary artery stenosis), sensorineural deafness, microcephaly — the classic triad. Risk is highest in first trimester (>85% risk).
Rubella: post-auricular lymphadenopathy + 3-day rash + arthralgia. CRS risk highest in first trimester: cataracts + PDA + sensorineural deafness. Live MMR vaccine CONTRAINDICATED in pregnancy. Pregnant contacts: check immunity, advise isolation, give Ig if non-immune.
Rubella in pregnancy is very dangerous for the foetus, especially in the first trimester. Measles does not cause CRS. Live rubella vaccine is CONTRAINDICATED in pregnancy.
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A 6-year-old is brought in with fever, severe abdominal pain, and 3 loose stools with mucus but no blood. Stool microscopy shows cysts with 4 nuclei (quadrinucleate). The child is treated with metronidazole. Which additional drug is required to eliminate intestinal cyst carriage?
Correct. Quadrinucleate cysts on stool microscopy = Entamoeba histolytica (amoebiasis). Metronidazole is the tissue amoebicide (kills trophozoites in the gut wall and liver). To eliminate luminal cysts and prevent ongoing transmission, a luminal amoebicide — diloxanide furoate — must be added after the metronidazole course.
Amoebiasis: E. histolytica quadrinucleate cysts in stool. Treatment: metronidazole (tissue amoebicide) THEN diloxanide furoate (luminal cyst eliminant). Always complete both stages. Albendazole is for helminths, not amoeba.
Albendazole is for helminths (ascariasis, giardiasis). Chloroquine is for malaria (and occasionally hepatic amoebiasis as an adjunct). Another tinidazole course does not specifically target luminal cyst carriage.
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An 8-year-old child with dengue fever has platelet count 18,000/mm³ on day 5 of illness. He has no active bleeding and haemodynamics are stable. Which statement about platelet management is correct?
Correct. WHO and NVBDCP guidelines clearly state that prophylactic platelet transfusion in dengue is NOT recommended, even for platelet counts <10,000–20,000/mm³, in the absence of significant active bleeding. Unnecessary transfusions risk volume overload, transfusion reactions, and do not improve outcomes.
Dengue platelet management: NO prophylactic transfusions regardless of count. Transfuse ONLY for significant active bleeding. Watch for warning signs (abdominal pain, rapid BP drop, altered mental status). Aspirin/NSAIDs = absolutely contraindicated.
Prophylactic platelet transfusion is not recommended in dengue regardless of platelet count, unless there is significant active bleeding. Aspirin and NSAIDs are contraindicated. Corticosteroids are not proven effective for dengue thrombocytopenia.
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A 5-year-old child presents with a tetanic spasm after stepping on a nail. He has never been immunized. Which combination of immediate interventions is correct?
Correct. Tetanus management requires: (1) Human Tetanus Immunoglobulin (TIG) 3000–6000 IU IM for passive protection against unbound toxin; (2) Active immunization with DPT; (3) Wound debridement — remove dead tissue and foreign material to eliminate anaerobic environment; (4) Metronidazole (or penicillin) to kill Clostridium tetani; (5) Supportive care for spasms (benzodiazepines).
Tetanus management: TIG (3000–6000 IU, different site from toxoid) + DPT vaccine + wound debridement + metronidazole/penicillin + benzodiazepines for muscle spasm. Risus sardonicus + opisthotonos = clinical diagnosis. Notifiable disease.
Toxoid alone provides no immediate protection (takes weeks to generate immunity). Diphtheria antitoxin is for diphtheria, not tetanus. TIG alone without antibiotics and wound care is insufficient.
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