TUBERCULIN SKIN TESTING

MANTOUX TUBERCULIN SKIN TEST

Dr.T.V.Rao MD

DR.T.V.RAO MD 1
 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
• 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)
 USUAL PROGRESSION
OF PRIMARY INFECTION

infection

Lympho-hematogenous
spread

healed PRIMARY
DR.T.V.RAO MD
infection
4
 PROGRESSIVE PRIMARY DISEASE
lymph node involvement

cavitation

pleural effusion

DR.T.V.RAO MD 5
 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 6
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 7
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
DR.T.V.RAO MD 8
 THE TB SKIN TEST: MATERIALS
• OLD TUBERCULIN
• 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

DR.T.V.RAO MD 9
 THE TB (MANTOUX) SKIN TEST
• 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 10
 APPLYING THE TUBERCULIN SKIN TEST

Courtesy of Dr. Marc Steben

DR.T.V.RAO MD 11
 APPLYING THE TUBERCULIN SKIN TEST

DR.T.V.RAO MD 12
REACTION TO THE TUBERCULIN SKIN TEST

Courtesy of Dr. Marc Steben

DR.T.V.RAO MD 13
 READING THE TUBERCULIN SKIN TEST

Courtesy of Dr. Marc Steben

DR.T.V.RAO MD 14
 READING THE TUBERCULIN SKIN TEST
• 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 15
 A POSITIVE SKIN TEST ONLY INDICATES
• 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 16
 READING THE SKIN TESTING IN
TUBERCULOSIS
• 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 17
 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)
 READING THE TUBERCULIN SKIN TEST
• 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 19
 FACTORS CAUSING DECREASED ABILITY TO
RESPOND TO TUBERCULIN
• Factors related to the person being tested
• 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)

DR.T.V.RAO MD 20
 FACTORS CAUSING DECREASED ABILITY TO
RESPOND TO TUBERCULIN (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 21
 MILIARY DISEASE
GENERALIZED HEMATOGENOUS TUBERCULOSIS
• generalized dissemination through bloodstream
• 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

DR.T.V.RAO MD 22
 MILIARY Disease
• 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
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 24
 • Programme Created by Dr.T.V.Rao MD for
Medical and Health Care Workers in the
Developing World
• Email
• doctortvrao@gmail.com

DR.T.V.RAO MD 25