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Tuberculin skin Testing Mantoux tuberculin skin test

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

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  1. Tuberculin skin TestingMantoux tuberculin skin test Dr.T.V.Rao MD Dr.T.V.Rao MD

  2. 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

  3. 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)

  4. infection Lympho-hematogenous spread healed PRIMARY infection USUAL PROGRESSION OF PRIMARY INFECTION Dr.T.V.Rao MD

  5. PROGRESSIVE PRIMARY DISEASE lymph node involvement cavitation pleural effusion Dr.T.V.Rao MD

  6. 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

  7. 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

  8. 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

  9. 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 The TB Skin Test: MATERIALS Dr.T.V.Rao MD

  10. 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

  11. Applying the tuberculin skin test Courtesy of Dr. Marc Steben Dr.T.V.Rao MD

  12. Applying the tuberculin skin test Dr.T.V.Rao MD

  13. Reaction to the tuberculin skin test Courtesy of Dr. Marc Steben Dr.T.V.Rao MD

  14. Reading the tuberculin skin test Courtesy of Dr. Marc Steben Dr.T.V.Rao MD

  15. 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

  16. 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

  17. 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

  18. 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)

  19. 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

  20. 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) Factors causing decreased ability to respond to tuberculin Dr.T.V.Rao MD

  21. 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

  22. 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 MILIARY DiseaseGeneralized Hematogenous Tuberculosis Dr.T.V.Rao MD

  23. MILIARYDisease • millet seed appearance on X-ray • Mantoux positive? • Most children still have active primary complex when miliary disease strikes • most develop meningitis

  24. 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

  25. 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

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