Infection · Moderate
This case is fictional and exists for study. It describes no real patient.
32 years · male
A 32-year-old male presents to the emergency department with a 6-week history of productive cough, night sweats, a 5 kg weight loss, and intermittent low-grade fevers. He reports occasional mild haemoptysis over the past three days. He moved to the UK from South Asia two years ago and has no other past medical history. Physical examination reveals a thin man with bronchial breathing and coarse crackles over the right upper pulmonary zone. Chest radiography shows consolidation with a distinct thick-walled cavity in the right upper lobe.
Vital signs
- HR
- 96 bpm
- BP
- 118/74 mmHg
- RR
- 18/min
- Temp
- 37.8 °C
- SpO₂
- 96%
Examination findings
- Bronchial breathing in the right upper zone
- Coarse crackles in the right upper zone
- Temporal wasting and low BMI
Investigations
| Haemoglobin | 11.2 g/dL | reference: 13.0-17.0 |
| White Blood Cell Count | 11.5 10^9/L | reference: 4.0-11.0 |
| C-reactive Protein (CRP) | 68 mg/L | reference: 0-5 |
Question 1 of 3
Which of the following is the most appropriate diagnostic investigation to confirm active pulmonary tuberculosis in this patient?
Microscopic examination for acid-fast bacilli (AFB) with Ziehl-Neelsen or auramine staining and mycobacterial culture of three sputum samples (at least one early morning sample) is the definitive diagnostic standard for active pulmonary tuberculosis. IGRA and Mantoux tests cannot distinguish between latent and active tuberculosis and should not be used to diagnose active disease. HRCT provides anatomical detail but cannot yield a microbiological diagnosis.
Teaching point: Active pulmonary tuberculosis must be confirmed with three sputum samples for AFB stain and mycobacterial culture, including nucleic acid amplification testing (NAAT).
Question 2 of 3
In addition to arranging diagnostic samples, which immediate action is required to prevent transmission while managing this patient in hospital?
Apply to questions[1]. Move the key to the single-room option, rebuild the distractors so none duplicates another, and rewrite the explanation and teaching point to NG33. prompt: "In addition to arranging diagnostic samples, which is the single most appropriate immediate infection control action while he is in hospital?" options: 0. "Admit him to a single room and ask him to wear a surgical mask whenever he leaves it" 1. "Delay isolation until a negative-pressure room becomes available or he can be transferred to a hospital that has one" 2. "Nurse him in an open bay with the curtains drawn until the sputum smear results are available" 3. "Start empirical oral amoxicillin and discharge him with outpatient clinic follow-up" answer_index: 0 explanation: "NICE NG33 requires anyone with suspected infectious or confirmed pulmonary or laryngeal TB who remains in a hospital setting to be placed in a single room (1.5.1.2). Each patient is then risk assessed for multidrug-resistant TB: previous TB drug treatment, contact with a known multidrug-resistant case, or birth or residence in a country where the WHO reports that 5% or more of new cases are multidrug-resistant (1.4.1.1). This man has none of these, so he is at low risk and is cared for in a single room as a minimum (1.5.1.4), continuing for the first 2 weeks of standard treatment (1.5.1.8). He should wear a surgical mask whenever he leaves the room, until he has had at least 2 weeks of treatment (1.5.1.12). A negative-pressure room is reserved for those at high risk of, or with confirmed, multidrug-resistant TB (1.5.1.4, 1.5.3.1), for aerosol-generating procedures such as bronchoscopy, sputum induction or nebulised treatment (1.5.1.10), and for admissions to wards containing immunocompromised patients such as transplant recipients or people with HIV (1.5.1.6). FFP3 masks for staff and visitors are specified for suspected or known multidrug-resistant TB (1.5.3.5). Isolation must not be postponed while a higher level of accommodation is sought, and an open bay exposes other patients and staff. TB is a notifiable disease: notify the local health protection team without waiting for culture confirmation." teaching_point: "Suspected infectious pulmonary TB is isolated in a single room; a negative-pressure room is reserved for high multidrug-resistant TB risk, aerosol-generating procedures, or wards housing immunocompromised patients." Also amend acuity.reasoning: replace "requires urgent airborne isolation" with "requires urgent isolation in a single room". Alternative, if the item must keep negative pressure as the key: leave the options alone but add an MDR risk factor to the stem, e.g. after "no other past medical history" insert "He was treated for tuberculosis in his home country three years ago and stopped the tablets after two months." That makes him high risk under 1.4.1.1, which mandates a negative-pressure room and rapid rifampicin-resistance testing (1.5.1.4, 1.5.3.1) and FFP3 for staff (1.5.3.5), so option C becomes uniquely correct. Question 3 still works, since it explicitly stipulates confirmed fully drug-sensitive disease. Do not adopt the reviewer's rewording of option D in either case, as it collides with option A." Healthcare staff must wear fitted FFP3 masks to reduce nosocomial airborne transmission. Standard single rooms without negative pressure or open bays expose other patients and staff to airborne droplets.
Teaching point: Suspected infectious pulmonary tuberculosis requires immediate airborne isolation in a negative-pressure facility and FFP3 mask usage.
Question 3 of 3
Assuming diagnostic confirmation of fully drug-sensitive active pulmonary tuberculosis, which standard drug regimen should be initiated according to guidelines?
Standard treatment for active, fully sensitive pulmonary tuberculosis consists of a 2-month intensive phase with four drugs (Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol - RIPE), followed by a 4-month continuation phase with two drugs (Rifampicin and Isoniazid - RI). Ethambutol can be stopped early if full drug sensitivity is demonstrated, but the initial quadruple therapy is standard. The total standard duration is 6 months.
Teaching point: Standard first-line therapy for active drug-sensitive pulmonary tuberculosis is 2 months of RIPE followed by 4 months of RI.
Key learning points
- Pulmonary tuberculosis typically presents with chronic cough, night sweats, fever, weight loss, and apical cavitary lesions on chest X-ray.
- Definitive microbiological diagnosis requires three sputum samples for acid-fast bacilli microscopy, culture, and molecular testing (NAAT).
- Standard pharmacological treatment for active drug-susceptible TB is 2 months of RIPE followed by 4 months of RI (6 months total).
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