Tb Guideforspecialistes Part2
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59 Chapter 6. Diagnos is o f tub erc ulo us infectio n: the tuberculin test Chapter summary The tuberculin test demonstrates the existence of a state of host hypersensitivity to the proteins of the tuberculous bacillus, most often acquired as a result of infection with M. tub erc ulo sis , although hypersensitivity can also be induced by bacille Calmette-Guérin (BCG) vaccination or infection with environmental mycobacteria. The tuberculin skin test gives rise to an inflammatory reaction with an important dermal cellular infiltrate at the location of the tuberculin inoculation. This reaction is identified as a visible and palpable induration at the site of inoculation, and can be accompanied by swelling, erythema, and, sometimes, vesiculation, necrosis, and regional lymphadenitis. The performance of the tuberculin skin test requires the use of 2 units of tuberculin purified protein derivative (PPD)-RT23 or 5 units of PPD- CD68, both doses being bioequivalent to 5 units of PPD-S, which is considered the international standard. The result is expressed in terms of millimetres of induration, taking into account that its interpretation is very complex and dependent on many variables that can influence not only reaction size but also the appearance of false-negative and false-positive readings, particularly in the case of BCG vaccination. The tuberculin test does not affect non-infected individuals, regardless of how often it is performed. In low- and middle-income countries, because of the difficulty of pres ervin g tube rcul in at the most peri pher al leve ls of the healt h care system, and because of large-scale BCG vaccination, this test is rendered practically unusable. Its use should therefore be restricted to centres where a paediatrician is available and to referral hospitals. In these settings, the indication for the tuberculin test is limited to children with suspected tuberculosis (TB) (disease, not infection), health care personnel (in an attempt to identify recent converters), and to very select cases of severe immune deficiency. The tuberculin test cannot be used as a discriminatory test for indicating preventive treatment or chemoprophylaxis. The test should not be repeated if there is evidence that the test had already been performed in the past and shown to be positive, regardless of the diameter
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