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Tuberculin skin Testing Mantoux tuberculin skin test. Dr.T.V.Rao MD. Tuberculosis: PRIMARY Infection. 95% of cases begin with pulmonary focus usually a SINGLE focus hypersensitivity develops 2 to 6 weeks until then, focus may grow larger hypersensitivity brings caseation.

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Tuberculin skin testing mantoux tuberculin skin test

Tuberculin skin TestingMantoux tuberculin skin test

Dr.T.V.Rao MD

Dr.T.V.Rao MD


Tuberculosis primary infection
Tuberculosis: PRIMARY Infection

  • 95% of cases begin with pulmonary focus

  • usually a SINGLE focus

  • hypersensitivity develops 2 to 6 weeks

    • until then, focus may grow larger

    • hypersensitivity brings caseation


Primary infection lympho hematogenous spread
PRIMARY Infection: Lympho-hematogenous spread

  • 8-14 weeks after onset of TB

  • usually occult

  • Mantoux positive during this phase

  • body wide seeding occurs during this phase

    • bone, kidney, meninges etc.

    • 3% of children with nl CXR’s develop calcifications in lung apices (SIMON FOCI)


infection

Lympho-hematogenous

spread

healed PRIMARY

infection

USUAL PROGRESSION

OF PRIMARY INFECTION

Dr.T.V.Rao MD


PROGRESSIVE PRIMARY DISEASE

lymph node involvement

cavitation

pleural effusion

Dr.T.V.Rao MD


Tuberculin skin testing
Tuberculin Skin Testing

  • The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice.

Dr.T.V.Rao MD


Diagnosis of latent tb with the tuberculin skin test
Diagnosis of latent TB with the Tuberculin skin test

The issues:

  • Applying the tuberculin skin test

  • Reading the test

  • Interpreting the test – including in children

  • Management of positive TST

Dr.T.V.Rao MD


Indications for skin test screening

Persons with signs and/or symptoms suggestive of tuberculosis disease

Recent contacts of persons known or suspected to have tuberculosis

Persons with undiagnosed upper lobe fibrotic lesions

Persons infected with HIV

Alcoholics and intravenous drug abusers

Persons with medical conditions known to increase the risk of disesase if infection has occurred:

silicosis, gastrectomy, jejunoileal bypasss, significant weight loss below IBW, chronic renal failure, diabetes mellitus, high dose corticosteroid treatment or other immunosuppressive therapy, leukemia, lymphoma, malignancy

Groups at high risk of infection:

Latin America, Oceana, medically underserved populations, residents of long term care facilities

Groups that would pose a significant risk to others if diseased: employees of health care facilities, schools, child care facilities

ATS/CDC

Indications for skin test screening

Dr.T.V.Rao MD


The tb skin test materials

OLD TUBERCULIN tuberculosis disease

culture of TB bacillus in glycol peptone broth

TB “tine” test

PURIFIED PROTEIN DERIVATIVE (PPD)

TB bacillus grown in Long’s media, filtered after heating

adopted by WHO as standard in 1950

PPD-S 1952

dose = 5 IU

The TB Skin Test: MATERIALS

Dr.T.V.Rao MD


The tb mantoux skin test
The TB (Mantoux) Skin Test tuberculosis disease

  • Intra-dermal

    • quality control important

    • trained practioner necessary

  • Delayed hypersensitivity

    • cell mediated

    • 48-72 hours

  • False negative

    • immuno-compromized conditions

    • measles/measles immunizations

  • Nonspecific reactions

    • increase >10 IU

    • cross reactions, atypical MB

Dr.T.V.Rao MD


Applying the tuberculin skin test
Applying the tuberculin skin test tuberculosis disease

Courtesy of Dr. Marc Steben

Dr.T.V.Rao MD


Applying the tuberculin skin test1
Applying the tuberculin skin test tuberculosis disease

Dr.T.V.Rao MD


Reaction to the tuberculin skin test
Reaction to the tuberculin skin test tuberculosis disease

Courtesy of Dr. Marc Steben

Dr.T.V.Rao MD


Reading the tuberculin skin test
Reading the tuberculin skin test tuberculosis disease

Courtesy of Dr. Marc Steben

Dr.T.V.Rao MD


Reading the tuberculin skin test1
Reading the tuberculin skin test tuberculosis disease

  • Read 2-3 days after placing the test

  • Feel for induration

  • Color change without induration is not included in the measurement

  • Use a ruler or calipers

  • Have someone else check if unsure

  • Always document the exact size (mm) – not just “positive” or “negative”

Dr.T.V.Rao MD


A positive skin test only indicates
a Positive skin test only indicates tuberculosis disease

  • A positive TB skin test only tells that a person has been infected with TB bacteria.  It does not tell whether the person has latent TB infection (LTBI)or has progressed to TB disease.

Dr.T.V.Rao MD


Reading the skin testing in tuberculosis
Reading the skin testing in tuberculosis tuberculosis disease

  • The reaction should be measured in millimetres of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis).

Dr.T.V.Rao MD


Primary infection lympho hematogenous spread1
PRIMARY Infection: tuberculosis diseaseLympho-hematogenous spread

  • 8-14 weeks after onset of TB

  • usually occult

  • Mantoux positive during this phase

  • body wide seeding occurs during this phase

    • bone, kidney, meninges etc.

    • 3% of children with nl CXR’s develop calcifications in lung apices (SIMON FOCI)


Reading the tuberculin skin test2
Reading the tuberculin skin test tuberculosis disease

  • Read 2-3 days after placing the test

  • Feel for induration

  • Color change without induration is not included in the measurement

  • Use a ruler or calipers

  • Have someone else check if unsure

  • Always document the exact size (mm) – not just “positive” or “negative”

Dr.T.V.Rao MD


Factors causing decreased ability to respond to tuberculin

Factors related to the person being tested tuberculosis disease

Infections

Viral (measles, mumps, chickenpox)

Bacterial (typhoid fever, brucelosis, typhus, pertussis, overwhelming TB,

Fungal (South American blastomycosis)

Live virus vaccinations (MMR)

Metabolic derangements (chronic renal failure)

Nutritional factors (severe protein depletion)

Diseases affecting lymphid organs (Hodgkin’s lymphoma, chronic lymphocytic leukemia, sarcoidosis)

Factors causing decreased ability to respond to tuberculin

Dr.T.V.Rao MD


Factors causing decreased ability to respond to tuberculin contd
Factors causing decreased ability to respond to tuberculosis diseasetuberculin (CONTD)

  • Drugs (corticosteroids, other immunosuppressive agents)

  • Age (newborn, elderly)

  • Recent overwhelming infection with M. tuberculosis

  • Stress (surgery, burns, mental illness, graft versus host reactions)

  • Factors related to the tuberculin used

  • Factors related to the method of administration

  • Factors related to reading the test and recording results

  • Dr.T.V.Rao MD


    Miliary disease generalized hematogenous tuberculosis

    generalized dissemination through bloodstream tuberculosis disease

    caseous focus ruptures into blood vessel

    growth of tubercle within the blood vessel

    may be acute, occult or chronic

    uniformly fatal if not treated

    rare

    usually occurs in the first 4 months after primary infection

    MILIARY DiseaseGeneralized Hematogenous Tuberculosis

    Dr.T.V.Rao MD


    MILIARY tuberculosis diseaseDisease

    • millet seed appearance on X-ray

    • Mantoux positive?

    • Most children still have active primary complex when miliary disease strikes

    • most develop meningitis


    Evaluation of a patient with positive tst
    Evaluation of a patient with positive TST tuberculosis disease

    Evaluate for active TB

    • Re-check symptoms and exam – cough, fever, weight loss, enlarged lymph nodes, dyspnea

    • Chest X-ray, if possible

    Dr.T.V.Rao MD


    Dr.T.V.Rao MD


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