Mantoux test

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The Mantoux skin test consists of an intradermal injection of one-tenth of a milliliter (ml) of
PPD tuerculin!
The si"e of induration is measured #$%&' hours later! (rythema (redness) should not e
measured!
Mantoux test injection site in a suject )ithout chronic conditions or in a hi*h-risk *roup
clinically dia*nosed as ne*ati+e at ,- hours
The Mantoux test or Mendel-Mantoux test (also kno)n as the Mantoux screening test,
tuberculin sensitivity test, Pirquet test, or PPD test for purified protein deri+ati+e) is a
screenin* tool for tuerculosis (T.)! /t is one of the major tuerculin skin tests used around
the )orld, lar*ely replacin* multiple-puncture tests such as the Tine test! The 0eaf test )as
used until '--, in the 12, )hen it )as replaced y the Mantoux test! /t is endorsed y the
3merican Thoracic 4ociety and 5enters for Disease 5ontrol and Pre+ention! /t )as also used
in the 1446 and is no) pre+alent in most of the former 4o+iet states!
Contents
7 0istory
' Procedure
8 5lassification of tuerculin reaction
# False positi+e result
, False ne*ati+e result
9 .5: +accine and the Mantoux test
& 3ner*y testin*
$ T)o-step testin*
; 6ecent de+elopments
7- 0eaf test
77 4ee also
7' 6eferences
History
Tuerculin is a *lycerol extract of the tuercle acillus! Purified protein deri+ati+e (PPD)
tuerculin is a precipitate of species-nonspecific molecules otained from filtrates of
sterili"ed, concentrated cultures! The tuerculin reaction )as first descried y 6oert 2och
in 7$;-! The test )as first de+eloped and descried y the :erman physician Felix Mendel in
7;-$
<7=
/t is named after 5harles Mantoux, a French physician )ho uilt on the )ork of 2och
and 5lemens +on Pir>uet to create his test in 7;-&!
/n 7;8;, M! 3! ?inniko+a in the 1446 created a modified +ersion of PPD! /n 7;,#, the
4o+iet 1nion started mass production of PPD-?, named after ?inniko+a!
<citation needed=
Procedure
3 standard dose is , tuerculin units (T1 - -!7 ml)
<'=
(The standard Mantoux test in the 12
consists of an intradermal injection of ' T1 of 4tatens 4erum /nstitute (44/) tuerculin 6T'8
in -!7 ml solution for injection!)
<8=
is injected intradermally (et)een the layers of dermis) and
read #$ to &' hours later! This intradermal injection is termed the Mantoux technique! 3
person )ho has een exposed to the acteria is expected to mount an immune response in the
skin containin* the acterial proteins!
The reaction is read y measurin* the diameter of induration (palpale raised, hardened area)
across the forearm (perpendicular to the lon* axis) in millimeters! /f there is no induration,
the result should e recorded as @- mm@! (rythema (redness) should not e measured!
<citation
needed=
/f a person has had a history of a positi+e tuerculin skin test, or had a recent tuerculin skin
test ()ithin one year), another skin test should e used!
<citation needed=
Classification of tuberculin reaction
The results of this test must e interpreted carefully! The personAs medical risk factors
determine at )hich increment (, mm, 7- mm, or 7, mm) of induration the result is
considered positi+e!
<#=
3 positi+e result indicates T. exposure!
, mm or more is positi+e in
o 3n 0/B-positi+e person
o Persons )ith recent contacts )ith a T. patient
o Persons )ith nodular or firotic chan*es on chest C-ray consistent )ith old
healed T.
o Patients )ith or*an transplants, and other immunosuppressed patients
7- mm or more is positi+e in
o 6ecent arri+als (less than fi+e years) from hi*h-pre+alence countries
o /njection dru* users
o 6esidents and employees of hi*h-risk con*re*ate settin*s (e!*!, prisons,
nursin* homes, hospitals, homeless shelters, etc!)
o Mycoacteriolo*y la personnel
o Persons )ith clinical conditions that place them at hi*h risk (e!*!, diaetes,
prolon*ed corticosteroid therapy, leukemia, end-sta*e renal disease, chronic
malasorption syndromes, lo) ody )ei*ht, etc!)
o 5hildren less than four years of a*e, or children and adolescents exposed to
adults in hi*h-risk cate*ories
7, mm or more is positi+e in
o Persons )ith no kno)n risk factors for T.
<,=
(DoteE Tar*eted skin testin* pro*rams should only e conducted amon* hi*h-risk *roups)
3 tuerculin test con+ersion is defined as an increase of 7- mm or more )ithin a t)o-day
period, re*ardless of a*e! 3lternate criteria include increases of 9, 7', 7, or 7$ mm!
<9=
False positive result
T4T (Tuerculin skin test) positi+e is measured y si"e of induration! The measurement of
the induration is determined to e positi+e dependin* on risk factors! For example, a lo)-risk
patient must ha+e a lar*er induration for a positi+e than a hi*h-risk patient! 0i*h-risk *roups
include recent contact, 0/B, chest radio*raph )ith firotic chan*es, or*an transplant
recipient, and immunosuppression!
3ccordin* to the Fhio Department of 0ealth and 14 Department of 0ealth, the .acillus
5almette%:uGrin (.5:) +accine does not protect a*ainst T. infection! /t does, thou*h, *i+e
$-H of children protection a*ainst tuerculous menin*itis and miliary tuerculosis!
Therefore, a positi+e T4TIPPD in a person )ho recei+ed .5: +accine is interpreted as latent
T. infection (?T./)!
<&=
Due to the testAs lo) specificity, most positi+e reactions in lo)-risk
indi+iduals are false positi+es!
<$=
3 false positi+e result may e caused y nontuerculous
mycoacteria or pre+ious administration of .5: +accine! Prior +accination )ith .5: may
result in a false-positi+e result for many years after)ards!
<;=
False positi+es can also occur )hen the injected area is touched, causin* s)ellin* and itchin*!
3nother source of false positi+e results can e from aller*ic reaction or hypersensiti+ity!
3lthou*h rare, aout -!-$ reported reactions per million doses of tuerculin, these reactions
can e dan*erous and precautions should e taken y ha+in* epinephrin a+ailale!
<7-=
False negative result
The result of PPD or tuerculin test is suppressed y the follo)in* conditionsE
/nfectious mononucleosis
?i+e +irus +accine - The test should not e carried out )ithin 8 )eeks of li+e +irus
+accination and should e rearran*ed!
4arcoidosis
0od*kinAs disease
5orticosteroid therapyI4teroid use
Malnutrition
/mmunolo*ically compromised - Those on immuno-suppressi+e treatment or those
)ith 0/B and lo) 5D# T cell counts, fre>uently sho) ne*ati+e results from the PPD
test!
<citation needed=
This is ecause the immune system needs to e functional to mount a response to the protein
deri+ati+e injected under the skin! 3 false ne*ati+e result may occur in a person )ho has een
recently infected )ith T., ut )hose immune system hasnAt yet reacted to the acteria!
1pper respiratory +irus infection
/n case a second tuerculin test is necessary it should e carried out in the other arm to a+oid
hypersensitisin* the skin!
BCG vaccine and the Mantoux test
The role of Mantoux testin* in people )ho ha+e een +accinated is disputed! The 14
recommends tuerculin skin testin* is not contraindicated for .5:-+accinated persons, and
prior .5: +accination should not influence the interpretation of the test! The 12
recommends interferon-J testin* should e used to help interpret positi+e Mantoux tests, and
serial tuerculin skin testin* must not e done in people )ho ha+e had prior .5:
+accinations! /n *eneral, the 14 recommendation results in a much lar*er numer of people
ein* falsely dia*nosed )ith latent tuerculosis, )hile the 12 approach proaly misses
patients )ith latent tuerculosis )ho should e treated!
<citation needed=
3ccordin* to the 14 *uidelines, latent tuerculosis infection dia*nosis and treatment is
considered for any .5:-+accinated person )hose skin test is 7- mm or *reater, if any of
these circumstances are presentE
Was in contact )ith another person )ith infectious T.
Was orn or has li+ed in a hi*h T. pre+alence country
/s continually exposed to populations )here T. pre+alence is hi*h
nergy testing
/n cases of aner*y, a lack of reaction y the odyAs defence mechanisms )hen it comes into
contact )ith forei*n sustances, the tuerculin reaction )ill occur )eakly, thus
compromisin* the +alue of Mantoux testin*! For example, aner*y is present in 3/D4, a
disease )hich stron*ly depresses the immune system! Therefore, aner*y testin* is ad+ised in
cases )here suspicion is )arranted that it is present! 0o)e+er, routine aner*y skin testin* is
not recommended!
<77=
!"o-step testing
4ome people )ho )ere pre+iously infected )ith T. may ha+e a ne*ati+e reaction )hen
tested years after infection, as the immune system response may *radually )ane! This initial
skin test, thou*h ne*ati+e, may stimulate (oost) the odyAs aility to react to tuerculin in
future tests! Thus, a positi+e reaction to a suse>uent test may e misinterpreted as a ne)
infection, )hen in fact it is the result of the oosted reaction to an old infection!
1se of t)o-step testin* is recommended for initial skin testin* of adults )ho )ill e retested
periodically (e!*!, health care )orkers)! This ensures any future positi+e tests can e
interpreted as ein* caused y a ne) infection, rather than simply a reaction to an old
infection!
The first test is read #$%&' hours after injection!
o /f the first test is positi+e, consider the person infected!
o /f the first test is ne*ati+e, *i+e a second test one to three )eeks after the first
injection!
The second test is read #$%&' hours after injection!
o /f the second test is positi+e, consider the person pre+iously infected!
o /f the second test is ne*ati+e, consider the person uninfected!
<7'=
3 person )ho is dia*nosed as @infected@ on t)o-step testin* is called a @tuerculin reactor@!
The 14 recommendation that prior .5: +accination e i*nored results in almost uni+ersal
false dia*nosis of tuerculosis infection in people )ho ha+e had .5: (mostly forei*n
nationals)!
#ecent develop$ents
3s a replacement for the Mantoux test, se+eral other tests are ein* de+eloped! The
KuantiF(6FD-T. :old lood test measures the patientLs immune reacti+ity to the T.
acterium, and is useful for initial and serial testin* of persons )ith an increased risk of latent
or acti+e tuerculosis infection! :uidelines for its use )ere released y the 5D5 in Decemer
'--,!
<78=
KuantiF(6FD-T. :old is FD3-appro+ed in the 1nited 4tates, has 5( Mark
appro+al in (urope and has een appro+ed y the M0?W in Mapan!
Heaf test
Main articleE 0eaf test
The 0eaf tuerculin skin test )as used in the 1nited 2in*dom, ut discontinued in '--,!
The e>ui+alent Mantoux test positi+e le+els done )ith 7- T1 (-!7 ml at 7-- T1Iml, 7E7---)
are
N, mm induration (0eaf --7)
,%7, mm induration (0eaf ')
O7, mm induration (0eaf 8-#)
%ee also
Tuerculosis
?atent tuerculosis
KuantiF(6FD
Tine test
#eferences
Wikimedia 5ommons has media related to Mantoux test!
7! F! Mendel! Therapeutische Monatshefte, .erlin, 7;-8, 79E 7&&! Die +on
Pir>uetAsche 0autreaktion und die intra+enPse Tuerkulinehandlun*!Medi"inische
2linik, MQnchen, 7;-$, #E #-'-#-#!
'! DT.( - Mantoux T. 4kin Test Faciliator :uide - Part 7E 3dministerin*
8! @/mmunisation@, 12 *o+ernment, Department of 0ealth
#! From the 5D5 team of the 5D5 team at the 4askatche)an ?un* 3ssociation,
photos of a PPD ump!
,! Mantoux Test in eac!int!
9! Men"ies, Dick (7 Manuary 7;;;)! @/nterpretation of 6epeated Tuerculin
Tests@! American Journal of Respiratory and Critical Care Medicine &'( (7)E 7,%'7!
doiE7-!779#Iajrccm!7,;!7!;$-77'-! PM/D ;$&'$7'!
&! /nformation also from FD0 lecture at the Fhio 4tate 1ni+ersity ,I'#I'-7'!
$! 4tarke M6 (Mul 7;;9)! @Tuerculosis 4kin Testin*E De) 4chools of Thou*ht@!
Journal of the American Academy of Pediatrics () (7)E 7'8%7',! /44D --87-#--,!
PM/D $99$8$8!
;! 5hatur+edi D, 5ockcroft 3 (7;;')! @Tuerculosis screenin* amon* health
ser+ice employeesE )ho needs chest C-raysR@! J Soc Occup Med *+ (#)E 7&;%$'!
doiE7-!7-;8IoccmedI#'!#!7&;!
7-! Mames (! Froeschle, Frederick ?! 6uen, and 3! Michael .loh ('--')!
@/mmediate 0ypersensiti+ity 6eactions after 1se of Tuerculin 4kin Testin*@!
Clinical Infectious Diseases ,* (7)E e7'%e78! doiE7-!7-$9I8'#,$&!
77! Tuerculin and 3ner*y Testin* in 0/B-4eropositi+e and 0/B-4erone*ati+e
Persons - Marko)it" et al! 77; (8)E 7$, - 3nnals of /nternal Medicine
7'! Fffice of 0ealth and 0uman 4er+ices! @.ooster Phenomenon@! 6etrie+ed
'--$--&--'!
78! :uidelines for 1sin* the KuantiF(6FD-T. :old Test for Detectin*
Mycobacterium tuberculosis /nfection, 1nited 4tates
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