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The tuberculin skin test identifies individuals who have been infected with M tuberculosis but does not distinguish between active and latent infection The test is used to evaluate a person who has symptoms of tuberculosis, an asymptomatic person who may be infected with M tuberculosis (eg, after contact exposure), or to establish the prevalence of tuberculous infection in a population Routine testing of individuals at low risk for tuberculosis is not recommended The Mantoux test is the preferred method: 01 mL of purified protein derivative (PPD) containing 5 tuberculin units is injected intradermally on the volar surface of the forearm using a 27-gauge needle on a tuberculin syringe The transverse width in millimeters of induration at the skin test site should be measured after 48 72 hours Table 9 11 summarizes the criteria established by the Centers for Disease Control and Prevention (CDC) for interpretation of the Mantoux tuberculin skin
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Table 9 11 Classification of positive tuberculin skin test reactions1
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Reaction Size 5 mm 1 2 3 4 1 2 3 4 Group HIV-positive persons Recent contacts of individuals with active tuberculosis Persons with fibrotic changes on chest x-rays suggestive of prior tuberculosis Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 mg/d of prednisone for 1 month or more)
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Recent immigrants (< 5 years) from countries with a high prevalence of tuberculosis (eg, Asia, Africa, Latin America) HIV-negative injection drug users Mycobacteriology laboratory personnel Residents of and employees2 in the following high-risk congregate settings: correctional institutions; nursing homes and other long-term facilities for the elderly; hospitals and other health care facilities; residential facilities for AIDS patients; and homeless shelters 5 Persons with the following medical conditions that increase the risk of tuberculosis: gastrectomy, 10% below ideal body weight, jejunoileal bypass, diabetes mellitus, silicosis, chronic renal failure, some hematologic disorders, (eg, leukemias, lymphomas), and other specific malignancies (eg, carcinoma of the head or neck and lung) 6 Children < 4 years of age or infants, children, and adolescents exposed to adults at high risk 1 Persons with no risk factors for tuberculosis
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A tuberculin skin test reaction is considered positive if the transverse diameter of the indurated area reaches the size required for the specific group All other reactions are considered negative 2 For persons who are otherwise at low risk and are tested at entry into employment, a reaction of > 15 mm induration is considered positive Source: Screening for tuberculosis and tuberculosis infection in high-risk populations: recommendations of the Advisory Council for the Elimination of Tuberculosis MMWR Morb Mortal Wkly Rep 1995;44(RR-11):19
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test Different criteria for determination of a positive reaction are used, based on the prior likelihood of infection, to maximize the performance of the test In patients who have serial testing, a tuberculin skin test conversion is defined as an increase of 10 mm of induration within a 2-year period regardless of patient age In general, it takes 2 10 weeks after tuberculosis infection for an immune response to PPD to develop Both false-positive and false-negative results occur False-positive tuberculin skin test reactions occur in persons previously vaccinated against M tuberculosis with bacillus Calmette-Gu rin (BCG) (extract of Mycobacterium bovis) and in those infected with nontuberculous mycobacteria False-negative tuberculin skin test reactions may result from improper testing technique, concurrent infections, malnutrition, advanced age, immunologic disorders, lymphoreticular malignancies, corticosteroid therapy, chronic renal failure, HIV infection, and fulminant tuberculosis Some individuals with latent tuberculosis infection may have a negative skin test reaction when tested many years after exposure Serial testing may create a false impression of skin test conversion Dormant mycobacterial sensitivity is sometimes restored by the antigenic challenge of the initial skin test This phenomenon is called boosting A two-step testing procedure is used to reduce the likelihood that a boosted tuberculin reaction will be misinterpreted as a recent infection Following a negative tuberculin skin test, the person is retested in 1 3 weeks If the second test is negative, the person is uninfected or anergic; if positive, a boosted reaction is likely Two-step testing should be used for the initial tuberculin skin testing of individuals who will be tested repeatedly, such as health care workers Anergy testing is not
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recommended for routine use to distinguish a true-negative result from anergy Poor anergy test standardization and lack of outcome data limit the evaluation of its effectiveness Interpretation of the tuberculin skin test in persons who have previously received BCG vaccination is the same as in those who have not had BCG Novel in vitro T-cell based assays promise significant change in the identification of persons with latent M tuberculosis infection Potential advantages of in vitro testing include reduced variability and subjectivity associated with placing and reading the PPD, fewer false-positive results from prior BCG vaccination, and better discrimination of positive responses due to nontuberculous mycobacteria Persons with concomitant HIV and tuberculosis infection usually respond best when the HIV infection is treated concurrently In some cases, prolonged antituberculous therapy may be warranted Therefore, all patients with tuberculosis infection should be tested for HIV within 2 months after diagnosis
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