193.3 🩺 內科專科考前版

193.3.0.1 1⃣ Taiwan TB Epidemiology

  • 5000-6000 cases/yr (declining but persistent)
  • 老化 + reactivation (老幎 + 慢病)
  • 移民 + 倖籍勞工 contributing
  • 公費 TB clinic + DOT (Taiwan CDC strict adherence)
  • LTBI screening in 慢病 / immuno candidates
  • 盧醫垫 hint: 糖尿病 + 慢性 cough / 老幎 + 體重枛茕 + CXR ç•°åžž → suspect TB ALWAYS, IGRA + 痰 AFB

193.3.0.2 2⃣ DM + TB

  • DM increases TB risk 2-3× and worsens outcome
  • 同時 HbA1c management improves TB outcome
  • TB treatment may worsen glycemia (PZA, INH)
  • Rifampin reduces sulfonylurea + DPP-4 inhibitor levels → adjust DM treatment

193.3.0.3 3⃣ Steroid + TB Meningitis

  • Dexamethasone 0.4 mg/kg/d IV tapering × 4 wk → 0.1 mg/kg/d × 4 wk → PO taper × 4 wk
  • Reduces mortality (Cochrane meta-analysis)
  • Reduces neurologic morbidity
  • Start with TB Tx initiation

193.3.0.4 4⃣ Pott Disease Management

  • MRI spine
  • Biopsy + culture
  • 12 months TB Tx
  • Surgical: spinal instability, neurologic deficit, cold abscess drainage
  • Bracing during healing
  • Long follow-up

193.3.0.5 5⃣ IRIS (Immune Reconstitution)

  • HIV + TB + ART → IRIS in 10-30%
  • Worsening fever, LAP, pulmonary infiltrates, neurologic
  • Treatment: continue TB + ART, add steroid for severe (especially CNS)
  • Severe IRIS rare but life-threatening

193.3.0.6 6⃣ DOT vs Self-Administered

  • DOT preferred for high-risk: high transmission, prior Tx failure, HIV+, MDR-TB, homeless, mental illness, substance abuse
  • vDOT (video) — equivalent to in-person for compliant patients
  • Self-administered acceptable for low-risk + standard regimens

193.3.0.7 7⃣ Active Case Finding + Contact Tracing

  • All confirmed cases — Public Health investigation
  • 家人 + 同䜏 contacts screened (CXR + symptom + IGRA)
  • Treat active + LTBI as indicated
  • Workplace + school contacts as appropriate

193.3.0.8 8⃣ 健保 / Taiwan TB Program

  • 公費 TB treatment + DOT
  • LTBI screening + Tx for high-risk
  • BCG at birth (公費)
  • Drug supply guaranteed
  • 通報 mandatory

193.3.0.9 9⃣ Future Directions

  • M72/AS01E Phase 3 — 50% efficacy in preventing reactivation
  • AI-guided CXR interpretation
  • Point-of-care diagnostics
  • Universal BPaL/BPaLM availability
  • Shorter regimens for drug-sensitive (4-month standard)