MCQ Quiz: Tuberculosis

Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, remains a significant global health challenge requiring complex and lengthy pharmacotherapy. For PharmD students, a robust understanding of TB management is essential, from differentiating between latent TB infection (LTBI) and active disease to navigating the intricacies of multi-drug regimens. This quiz covers the cornerstone of TB treatment, RIPE therapy, focusing on the mechanisms, adverse effects, and monitoring parameters for first-line agents. It also delves into the treatment of LTBI, the growing problem of drug-resistant TB (MDR-TB), and the pharmacist’s vital role in patient education and promoting adherence through strategies like Directly Observed Therapy (DOT).

1. The standard first-line, four-drug regimen for treating active tuberculosis is known by the acronym RIPE. This includes Rifampin, Isoniazid, Pyrazinamide, and which other drug?

• a) Erythromycin
• b) Ethambutol
• c) Efavirenz
• d) Etanercept

Answer: b) Ethambutol

2. What is the primary mechanism of action of Isoniazid (INH)?

• a) It inhibits bacterial DNA-dependent RNA polymerase.
• b) It disrupts the plasma membrane of the mycobacteria.
• c) It inhibits the synthesis of mycolic acids, a key component of the mycobacterial cell wall.
• d) It inhibits bacterial protein synthesis by binding to the 30S ribosomal subunit.

Answer: c) It inhibits the synthesis of mycolic acids, a key component of the mycobacterial cell wall.

3. A patient starting on isoniazid should be co-prescribed which vitamin to prevent peripheral neuropathy?

• a) Vitamin C
• b) Vitamin D
• c) Folic Acid
• d) Pyridoxine (Vitamin B6)

Answer: d) Pyridoxine (Vitamin B6)

4. A patient taking rifampin should be counseled about a common, harmless side effect that causes a change in the color of their bodily fluids. What color is expected?

• a) Blue-green
• b) Black
• c) Red-orange
• d) Bright yellow

Answer: c) Red-orange

5. Which of the first-line TB drugs requires baseline and monthly monitoring of visual acuity and color discrimination due to its risk for causing optic neuritis?

• a) Rifampin
• b) Isoniazid
• c) Pyrazinamide
• d) Ethambutol

Answer: d) Ethambutol

6. All four first-line RIPE therapy drugs carry a risk for which serious adverse effect, requiring baseline and routine monitoring of liver function tests (LFTs)?

• a) Nephrotoxicity
• b) Cardiotoxicity
• c) Hepatotoxicity
• d) Ototoxicity

Answer: c) Hepatotoxicity

7. Pyrazinamide is an essential part of the initial phase of TB treatment but can cause which metabolic abnormality?

• a) Hypoglycemia
• b) Hyperkalemia
• c) Hyperuricemia, which can precipitate gout flares.
• d) Hyponatremia

Answer: c) Hyperuricemia, which can precipitate gout flares.

8. What is the standard duration of the initial (intensive) phase of treatment for drug-susceptible active pulmonary TB?

• a) 2 weeks
• b) 1 month
• c) 2 months
• d) 4 months

Answer: c) 2 months

9. After the initial phase, the continuation phase for drug-susceptible active pulmonary TB typically consists of which two drugs for a duration of four months?

• a) Pyrazinamide and Ethambutol
• b) Isoniazid and Rifampin
• c) Rifampin and Ethambutol
• d) Isoniazid and Pyrazinamide

Answer: b) Isoniazid and Rifampin

10. A positive tuberculin skin test (TST) in a healthy person with no known risk factors is generally defined as an induration of what size?

• a) ≥ 5 mm
• b) ≥ 10 mm
• c) ≥ 15 mm
• d) Any visible reaction

Answer: c) ≥ 15 mm

11. Which of the following is an advantage of an Interferon-Gamma Release Assay (IGRA) over a Tuberculin Skin Test (TST) for diagnosing latent TB infection?

• a) IGRA is less expensive.
• b) IGRA results are not affected by prior BCG vaccination.
• c) IGRA does not require a blood draw.
• d) IGRA results are available immediately.

Answer: b) IGRA results are not affected by prior BCG vaccination.

12. Which of the following is a preferred short-course regimen for the treatment of Latent TB Infection (LTBI)?

• a) 6 months of pyrazinamide.
• b) 3 months of once-weekly isoniazid plus rifapentine.
• c) 1 month of ethambutol.
• d) 9 months of RIPE therapy.

Answer: b) 3 months of once-weekly isoniazid plus rifapentine.

13. A patient is diagnosed with multidrug-resistant TB (MDR-TB). By definition, the M. tuberculosis isolate is resistant to at least which two drugs?

• a) Pyrazinamide and Ethambutol
• b) Rifampin and Ethambutol
• c) Isoniazid and Rifampin
• d) Isoniazid and Pyrazinamide

Answer: c) Isoniazid and Rifampin

14. Rifampin is a potent inducer of many cytochrome P450 enzymes. This leads to a clinically significant drug interaction with which of the following medications?

• a) Warfarin
• b) Oral contraceptives
• c) Many protease inhibitors used for HIV
• d) All of the above

Answer: d) All of the above

15. What is Directly Observed Therapy (DOT)?

• a) A diagnostic imaging technique for TB.
• b) A strategy where a healthcare worker watches the patient swallow every dose of medication.
• c) A type of surgical intervention for TB.
• d) Self-administration of TB medications at home.

Answer: b) A strategy where a healthcare worker watches the patient swallow every dose of medication.

16. Which of the following is a symptom of active pulmonary TB?

• a) Productive cough lasting more than 3 weeks.
• b) Unexplained weight loss.
• c) Night sweats.
• d) All of the above.

Answer: d) All of the above

17. The mechanism of action of rifampin involves:

• a) Inhibition of mycolic acid synthesis.
• b) Inhibition of bacterial DNA-dependent RNA polymerase.
• c) Disruption of the bacterial cell membrane.
• d) Inhibition of arabinosyl transferase.

Answer: b) Inhibition of bacterial DNA-dependent RNA polymerase.

18. A patient is diagnosed with active TB and is also HIV-positive, taking an efavirenz-based antiretroviral regimen. What is the concern with co-administering rifampin?

• a) Rifampin will increase efavirenz levels, causing toxicity.
• b) Rifampin will decrease efavirenz levels, potentially leading to HIV treatment failure.
• c) Efavirenz will inactivate rifampin.
• d) There is no interaction between these two medications.

Answer: b) Rifampin will decrease efavirenz levels, potentially leading to HIV treatment failure.

19. What is a common alternative to rifampin in HIV-positive patients on protease inhibitors to avoid significant drug interactions?

• a) Rifabutin
• b) Rifapentine
• c) Isoniazid
• d) Ethambutol

Answer: a) Rifabutin

20. A patient on RIPE therapy calls the pharmacy complaining of numbness and tingling in their hands and feet. This symptom is most likely caused by which medication?

• a) Rifampin
• b) Isoniazid
• c) Pyrazinamide
• d) Ethambutol

Answer: b) Isoniazid

21. Before initiating ethambutol, it is crucial to obtain a baseline:

• a) Electrocardiogram (ECG)
• b) Serum creatinine
• c) Vision exam
• d) Chest X-ray

Answer: c) Vision exam

22. Which of the first-line TB drugs is most associated with causing drug-induced lupus erythematosus?

• a) Rifampin
• b) Isoniazid
• c) Pyrazinamide
• d) Ethambutol

Answer: b) Isoniazid

23. The continuation phase of TB treatment is designed to:

• a) Rapidly decrease the bacterial load.
• b) Prevent the emergence of drug resistance.
• c) Eradicate the remaining, persistent mycobacteria.
• d) Treat latent TB infection.

Answer: c) Eradicate the remaining, persistent mycobacteria.

24. For a patient with a TST induration of 7 mm, which of the following conditions would make this a “positive” test for LTBI?

• a) The patient is a healthcare worker.
• b) The patient is a recent contact of a person with infectious TB.
• c) The patient has no known risk factors.
• d) The patient is a foreign-born person from a low-prevalence country.

Answer: b) The patient is a recent contact of a person with infectious TB.

25. A 4-month course of daily rifampin is an accepted treatment regimen for:

• a) Active TB
• b) Latent TB Infection (LTBI)
• c) MDR-TB
• d) Atypical mycobacterial infections

Answer: b) Latent TB Infection (LTBI)

26. The primary mode of transmission for Mycobacterium tuberculosis is:

• a) Contaminated food or water.
• b) Bloodborne contact.
• c) Inhalation of airborne respiratory droplets.
• d) Sexual contact.

Answer: c) Inhalation of airborne respiratory droplets.

27. Pyrazinamide is most active against mycobacteria in what type of environment?

• a) A neutral pH environment.
• b) An alkaline environment.
• c) An acidic intracellular environment (e.g., within lysosomes).
• d) An oxygen-rich environment.

Answer: c) An acidic intracellular environment (e.g., within lysosomes).

28. A patient on RIPE therapy presents with elevated LFTs (3-5 times the upper limit of normal) but is asymptomatic. What is the most appropriate next step?

• a) Discontinue all four drugs immediately.
• b) Continue all drugs and recheck LFTs in one week.
• c) Add a hepatoprotective agent like milk thistle.
• d) Increase the dose of isoniazid.

Answer: b) Continue all drugs and recheck LFTs in one week.

29. Extensively drug-resistant TB (XDR-TB) is defined as MDR-TB with additional resistance to:

• a) Any two second-line drugs.
• b) Any fluoroquinolone and at least one of the three second-line injectable drugs.
• c) Ethambutol and Pyrazinamide.
• d) All oral TB medications.

Answer: b) Any fluoroquinolone and at least one of the three second-line injectable drugs.

30. Which of the following is considered a second-line agent for the treatment of drug-resistant TB?

• a) Amoxicillin
• b) Bedaquiline
• c) Doxycycline
• d) Metronidazole

Answer: b) Bedaquiline

31. The “gold standard” for diagnosing active pulmonary TB is:

• a) Tuberculin skin test (TST)
• b) Chest X-ray showing cavitary lesions.
• c) Sputum culture positive for M. tuberculosis.
• d) Interferon-Gamma Release Assay (IGRA).

Answer: c) Sputum culture positive for M.tuberculosis.

32. What is the primary reason for using combination therapy to treat active TB?

• a) To shorten the duration of treatment to one month.
• b) To reduce the cost of medication.
• c) To prevent the development of drug-resistant strains of M. tuberculosis.
• d) To minimize all side effects.

Answer: c) To prevent the development of drug-resistant strains of M. tuberculosis.

33. What is the mechanism of action of ethambutol?

• a) It inhibits protein synthesis.
• b) It inhibits mycolic acid synthesis.
• c) It inhibits arabinosyl transferase, an enzyme involved in cell wall synthesis.
• d) It inhibits DNA gyrase.

Answer: c) It inhibits arabinosyl transferase, an enzyme involved in cell wall synthesis.

34. A patient should be counseled to take isoniazid on an empty stomach because:

• a) It causes severe nausea with food.
• b) Food, particularly high-fat meals, can decrease its absorption.
• c) It interacts with dairy products.
• d) It must be taken with a full glass of water.

Answer: b) Food, particularly high-fat meals, can decrease its absorption.

35. A patient on pyrazinamide should be advised to avoid which of the following?

• a) Dairy products
• b) Excessive alcohol consumption due to increased risk of hepatotoxicity.
• c) Grapefruit juice
• d) Leafy green vegetables

Answer: b) Excessive alcohol consumption due to increased risk of hepatotoxicity.

36. Treatment of TB in pregnant women should generally:

• a) Be delayed until after delivery.
• b) Consist of a standard regimen, but with the exclusion of pyrazinamide in some cases due to lack of teratogenicity data.
• c) Involve only two drugs to minimize fetal exposure.
• d) Be managed with second-line agents exclusively.

Answer: b) Consist of a standard regimen, but with the exclusion of pyrazinamide in some cases due to lack of teratogenicity data.

37. Extrapulmonary TB refers to:

• a) A TB infection that is resistant to all drugs.
• b) A TB infection that occurs outside of the lungs.
• c) Latent TB infection.
• d) A TB infection that has resolved.

Answer: b) A TB infection that occurs outside of the lungs.

38. Which of the following is a key role for a pharmacist in TB care?

• a) Performing sputum induction.
• b) Reading chest X-rays.
• c) Counseling patients on medication adherence and managing side effects.
• d) Administering the TST.

Answer: c) Counseling patients on medication adherence and managing side effects.

39. A patient on RIPE therapy develops jaundice (yellowing of the skin and eyes) and dark urine. This is a sign of what serious adverse effect?

• a) Optic neuritis
• b) Peripheral neuropathy
• c) Severe hepatotoxicity
• d) Renal failure

Answer: c) Severe hepatotoxicity

40. A sputum sample is tested using an acid-fast bacillus (AFB) smear. What does a positive result indicate?

• a) Definitive diagnosis of active TB.
• b) Presence of mycobacteria, which could be M. tuberculosis or other species.
• c) The patient has latent TB.
• d) The patient is not contagious.

Answer: b) Presence of mycobacteria, which could be M. tuberculosis or other species.

41. The BCG vaccine is a live attenuated strain used in many countries to prevent severe forms of TB in children. A person who has received the BCG vaccine will likely have:

• a) Lifelong immunity to TB.
• b) A negative TST result.
• c) A positive TST result, which may complicate interpretation.
• d) A negative IGRA result.

Answer: c) A positive TST result, which may complicate interpretation.

42. Which second-line drug class for MDR-TB is associated with a risk of QT prolongation?

• a) Aminoglycosides
• b) Fluoroquinolones
• c) Ethionamide
• d) Cycloserine

Answer: b) Fluoroquinolones

43. A patient with latent TB infection:

• a) Is actively sick and can spread TB to others.
• b) Has a normal chest X-ray and a negative sputum smear.
• c) Does not have M. tuberculosis in their body.
• d) Has a positive TST or IGRA but is not infectious and has no symptoms.

Answer: d) Has a positive TST or IGRA but is not infectious and has no symptoms.

44. What is the purpose of the continuation phase of TB therapy?

• a) To kill rapidly dividing bacilli.
• b) To sterilize the sputum.
• c) To eliminate the remaining persistent bacilli and prevent relapse.
• d) To diagnose drug resistance.

Answer: c) To eliminate the remaining persistent bacilli and prevent relapse.

45. Which of the following is NOT a first-line drug for treating tuberculosis?

• a) Isoniazid
• b) Rifampin
• c) Moxifloxacin
• d) Pyrazinamide

Answer: c) Moxifloxacin

46. If a patient on RIPE therapy experiences significant nausea, a pharmacist might recommend:

• a) Discontinuing all medications immediately.
• b) Taking the medications with a small snack or at bedtime.
• c) Doubling the dose of the medications.
• d) Adding an antacid to their regimen.

Answer: b) Taking the medications with a small snack or at bedtime.

47. A patient with a history of a gout flare should be monitored carefully if started on which TB medication?

• a) Isoniazid
• b) Rifampin
• c) Ethambutol
• d) Pyrazinamide

Answer: d) Pyrazinamide

48. How long must a patient with active, drug-susceptible pulmonary TB be isolated to prevent transmission?

• a) For the entire 6-month treatment course.
• b) Until they have completed the initial 2-month phase of treatment.
• c) Until they have had three consecutive negative sputum smears and are on effective therapy.
• d) Isolation is not necessary for TB.

Answer: c) Until they have had three consecutive negative sputum smears and are on effective therapy.

49. An asymptomatic patient with a positive TST and a normal chest X-ray is diagnosed with LTBI. The main reason to treat this condition is to:

• a) Prevent the patient from spreading TB to others.
• b) Prevent the latent infection from progressing to active TB disease in the future.
• c) Improve the patient’s current symptoms.
• d) Cure the infection within one month.

Answer: b) Prevent the latent infection from progressing to active TB disease in the future.

50. What is a critical factor in the success of any tuberculosis treatment regimen?

• a) The brand name of the medications used.
• b) The patient’s adherence to the full course of therapy.
• c) The time of day the medications are taken.
• d) The patient’s insurance coverage.

Answer: b) The patient’s adherence to the full course of therapy.