Q2: September 2019 PLAB 1 Exam Style Question
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A 53-year-old male, a long-term resident of the UK, is diagnosed with pulmonary tuberculosis after a prolonged cough, low-grade fevers, and night sweats. Sputum smears are positive for acid-fast bacilli. He has a past medical history of hypertension managed with lisinopril and atenolol, as well as type 2 diabetes mellitus controlled with metformin. He also mentions he occasionally consumes alcohol but denies any other substance abuse. What is the SINGLE most appropriate initial investigation to perform before commencing anti-tuberculosis treatment?
A. Hemoglobin A1c
B. Serum creatinine and electrolytes
C. Ophthalmic examination
D. Chest X-ray
E. Liver function tests
Answer: E. Liver function tests
Explanation
Diagnosis:
This patient has been diagnosed with pulmonary tuberculosis (TB), confirmed by a positive sputum smear for acid-fast bacilli. He also has comorbid conditions, including hypertension and type 2 diabetes, and reports occasional alcohol consumption.
Management Options:
A. Hemoglobin A1c: While diabetes control is important, it is not the immediate concern before starting anti-TB therapy.
B. Serum creatinine and electrolytes: Although renal function is important and should be monitored, especially considering this patient's history of hypertension and diabetes, it is not the initial investigation to perform prior to anti-TB treatment.
C. Ophthalmic examination: This would be considered if the patient were starting ethambutol, which has potential ocular side effects, but it is not the most crucial initial test.
D. Chest X-ray: Though useful for diagnosing and monitoring TB, this has already been established via sputum smear in this case.
E. Liver function tests (LFTs): Most appropriate because first-line anti-TB medications (like isoniazid and rifampicin) are hepatotoxic. Additionally, the patient's occasional alcohol consumption could already be a strain on the liver.
Why Liver Function Tests?
The British Thoracic Society recommends LFTs to be checked in all cases and monitored throughout treatment, given the hepatotoxicity of anti-TB medications. In the context of this patient, who also consumes alcohol occasionally, LFTs are even more crucial. Monitoring liver function is essential to promptly identify and manage drug-induced liver injury, which could be life-threatening if left undetected.
Summary:
Before initiating treatment for TB, several factors should be considered, including the potential for medication side effects and interactions with existing comorbidities. In this specific case, given the hepatotoxic nature of anti-TB medications and the patient’s lifestyle, LFTs are the most critical initial investigation. This will help in tailoring the safest and most effective treatment regimen for this patient.
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Reference:
NICE guideline on tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control: This is a comprehensive guideline from the National Institute for Health and Care Excellence (NICE) that covers the prevention, identification and management of latent and active TB in children, young people and adults. It includes recommendations on diagnosis, treatment, infection control, case finding, adherence, service organisation and more.
BNF treatment summary on tuberculosis: This is a concise summary from the British National Formulary (BNF) that provides information on the recommended regimens for the treatment of TB. It also includes information on the dosage, duration, monitoring and adverse effects of anti-TB medications.
Public Health England guidance on tuberculosis screening: This is a guidance from Public Health England (PHE) that sets out the criteria and process for screening people who are at high risk of latent TB infection (LTBI) and offering them treatment. It also provides information on the roles and responsibilities of different health services and organisations involved in TB screening.
NHS website on tuberculosis: This is a website from the National Health Service (NHS) that provides general information on TB for the public. It covers the symptoms, causes, diagnosis, treatment, complications and prevention of TB.
