Positive Tuberculin Reaction Research Articles

Outbreak of Tuberculosis in a Church

A 48-year-old white man (index case) with an abnormal chest radiograph remained undiagnosed for tuberculosis for 4 years. Investigation by purified protein derivative (PPD) tuberculin test revealed positive tuberculin reactions (> or = 10 mm induration) in seven of eight (88%) initial close contacts, and in 12 of 46 (26%) coworkers. On the suspicion that transmission had also occurred among members of the index case's church congregation, a PPD tuberculin test survey of 184 of 200 of the members revealed 77 (42%) positive reactors. Thirty percent of the members under the age of 35 years were infected, suggesting transmission of infection. Eight cases of active tuberculosis (including the index case) were detected, yielding a high case rate (4.3%) among the parishioners. Three of the cases were confirmed recent PPD converters. Although bacteriologic findings were available in only three of the eight cases, two cases had phage typing of organism identical to the index case; the third had recrudescent tuberculous disease. Of the remaining five cases without bacteriologic confirmation, two had pleural tuberculosis, one child had progressive primary tuberculosis, and two persons had localized pulmonary nodules suggestive of primary infection progressing to disease. Because transmission of tuberculous infection may occur in any closed environment, including a church, physicians must be conversant with tuberculosis control measures and preventive therapy guidelines to preclude unforeseen transmission of disease.

Chemotactic heterogeneity of eosinophils in idiopathic pulmonary eosinophilia.

Heterogeneity in the chemotactic response of eosinophils to 5 T cell line eosinophilic chemotactic factors (ECFs) was assessed in 5 patients with idiopathic pulmonary eosinophilia. Eosinophils from 2 patients responded to all 5 ECFs (group 1), whereas eosinophils from the other 3 patients responded to ECF-PI 5, PI 6, PI 7 and PI 8 but failed to respond to ECF-PI 9 (group 2). It was further found that group 1 showed an elevated level of lactate dehydrogenase and a positive tuberculin reaction, whereas group 2 showed neither. The effects of steroid therapy on the chemotactic responses of eosinophils were also examined. In group 1, the chemotactic response of eosinophils to ECF-PI 9 was significantly diminished after therapy; in contrast it was elevated in group 2. This change was accompanied by resolution of both clinical symptoms and pulmonary infiltration of eosinophils. These findings suggest that pulmonary eosinophilia can be divided into two types on the basis of eosinophil chemotactic response and laboratory findings. The heterogeneous responses of eosinophils to ECFs may provide a useful marker for classification of pulmonary eosinophilia and evaluation of therapy.

International controversies in interpreting the mantoux test with special reference to Saudi Arabia

There is a general decline in the incidence of pulmonary tuberculosis (PTB) in developed countries, but infection by HIV has increased the incidence of PTB in affected countries. There are no signs of a similar decline in the incidence of PTB in some developing countries. The Mantoux technique for tuberculin testing continues to be among the effective diagnostic tools. The medical literature and textbooks of medicine show disagreement as to what constitutes a positive (specific) tuberculin reaction. This short review was intended to cite some examples of these differences and suggest a cutting point for use in the Kingdom of Saudi Arabia (KSA) based on the prevalence of environmental mycobacteria (Mycobacteria other than M. tuberculosis, MOTT). From this review different researchers within the KSA used different cut-off points at a time that the prevalence of MOTT was unknown, until 1993 when it was reported to be as low as 3.8/1000 population (based on sputum culture) and that the Kingdom is categorised among the middle PTB prevalent countries. Consequently, it seems appropriate to have 5 mm as a cutting point (positive) in all unvaccinated patients, particularly for those who were in contact with an infectious case, or having symptoms compatible with PTB, and also patients who were immuno-compromised as in HIV infection. This cut-off point can be revised and raised to 8 mm provided that the prevalence of PTB becomes lower than the current reported rate and MOTT prevalence remains low, but the 5 mm cutting point should remain for the aforementioned categories of patients.

Circulating gamma delta-T-cell-receptor-positive lymphocytes in sarcoidosis.

We investigated phenotypic surface markers of peripheral blood lymphocytes including expression of gamma delta T cell receptor (TCR gamma delta) in 185 patients with sarcoidosis and 42 normal subjects. The proportion of TCR gamma delta+ lymphocytes in peripheral blood of patients with sarcoidosis (5.5 +/- 5.4%) was significantly higher than in normal subjects (3.6 +/- 2.2%; p < 0.05). A number of patients with sarcoidosis had prominently increased levels of circulating TCR gamma delta+ lymphocytes. Successive measurements of circulating TCR gamma delta+ lymphocytes demonstrated the persistence of increased levels of circulating TCR gamma delta+ lymphocytes. We divided the patients with sarcoidosis into two groups, one with high, the other with low TCR gamma delta+ expression. Compared with the low-value group, the high-value group had significantly decreased levels of circulating CD4+ lymphocytes, decreased incidence of a positive tuberculin reaction, and higher levels of serum angiotensin-converting enzyme and lysozyme, suggesting that these two groups may differ in their immunological response and disease activity of sarcoidosis. Measurement of TCR gamma delta+ expression in the circulation seems to be useful for estimating the disease activity of sarcoidosis.

Tuberculin Booster Reactions and Conversions

Letters1 September 1994Tuberculin Booster Reactions and ConversionsRichard Menzies, MDRichard Menzies, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-121-5-199409010-00043 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:In response to the letters of Drs. Harrington and Dr. Sobel, our data suggest that, compared with those with positive initial tuberculin reactions, the participants with positive booster reactions (defined as a PPd-T2 reaction of ≥ 10mm and a PPd-T2 minus PPd-T1 reaction of ≥ 6 mm) were more likely to have had bacille Calmette–Guérin vaccination or sensitization to atypical mycobacterial antigens, both considered causes of false-positive tuberculin reactions. Dr. Sobel's data from Israeli school children support our conclusion that positive booster reactions are much less likely to represent previous tuberculous infection (that is, true-positive) than initial tuberculin ...

Two-step tuberculin testing in staff and residents of a nursing home.

This study examined the prevalence and determinants of tuberculin reactors and the booster response in 272 (97%) residents and 218 (69%) staff of an urban nursing home where a case of miliary TB was being investigated. Many subjects were foreign born (56%), and 15% had a history of BCG vaccination (34% of staff). Testing was done with 5 TU PPD-S (Connaught). Those with < 10 mm induration at 48 h were retested at 1 wk. Test sizes > 9 mm were classified positive (reactors). A questionnaire was given to collect information on risk factors for a positive test. Results showed that 28% (36% staff and 22% of residents) of subjects were reactors at the initial test, 6% at the booster test (staff and residents), and 32% at either test (40% staff and 26% residents). BCG (OR 4.8) and foreign birth (OR 1.7) were significantly associated with total reactors. The association with foreign birth was inversely related to the time since immigration. Only BCG was associated with a positive booster test (OR 6.7). Of positive tuberculin reactions in individuals with a history of BCG, 72% were attributed to the vaccine. We concluded that (1) staff as well as residents should be two-step tested when retesting is anticipated; (2) the prevalence of tuberculin reactors is highly related to the prevalence of BCG vaccinees and foreign birth; and (3) chemoprophylaxis is probably not indicated for isolated tuberculin reactors with a history of BCG.

Takayasu arteritis in Korean children: clinical report of seventy cases.

Seventy cases of Takayasu arteritis in Korean children are reported. There were 57 females and 13 males (male-to-female ratio; 1:4.4). The youngest patient was a 3-year-old female. Family history was positive in one patient. The most common chief complaints on admission were dyspnea, headache, palpitation, and edema which were due to hypertension and congestive heart failure. Hypertension was seen in 65 out of 70 patients (92.8%). The abdominal aorta, thoracic aorta, and renal arteries were the most commonly involved sites in these children. Two patients had nephrotic syndrome. The frequency of positive tuberculin reaction was much higher in children with Takayasu arteritis compared with the general population, and the intensity of the reaction was also stronger. The majority of the patients required immediate medical treatment to control congestive heart failure due to hypertension at initial presentation. When ESR was elevated, corticosteroid was administered. Surgical treatment showed good results in six out of ten cases. Percutaneous intraluminal angioplasty was effective for lowering the blood pressure in six out of nine cases. In three cases, restenosis occurred and angioplasty was repeated in two cases.

The Isoniazid Debate

To the Editor. — We read with interest Colice's article 1 in which he repeats our analysis of isoniazid preventive therapy 2 using somewhat different data. We were gratified to find that our model and assumptions were explicated in sufficient detail to allow its independent recreation. We disagree, however, with his analysis because of the rather selective biases in his data. Although Colice correctly used data from young adults 3-5 in estimating the isoniazid-induced hepatitis case-fatality rate for a 30-year-old man, he then inappropriately used data primarily relevant to elderly persons in estimating the tuberculosis case-fatality rate. In the two studies that he cited, 6-7 that rate was much lower (either zero or nearly zero) among young adults. This inconsistency is particularly troubling because reactivation of tuberculosis is most likely to occur in the years proximate to the discovery of the positive tuberculin reaction; the rate of reactivation declines over

Mantoux Reaction Survey Conducted in the Northern Region of Saudi Arabia

A nationwide epidemiological survey is under way to assess the prevalence of tuberculosis infection in the inhabitants of Saudi Arabia. The assessment tools include the Mantoux test and culturing of sputum samples obtained from inhabitants of the five regions of the Kingdom. The study population has been selected using a proportional-to-population-size method with cluster sampling and urban/rural stratification. We report the results of the Mantoux test for the Northern Region, where 1340 subjects were screened. Only 4% of the non BCG-vaccinated children had a positive reaction (tuberculosis index = TI) which identifies the region as a middle prevalence country (2-14%), and indicates the need for better detection and treatment of open cases of tuberculosis in the community. The TI rose steeply with age to 58% in the 65+-year age group, which denotes the existence of a large pool of infected but healthy subjects who are liable to suffer active disease. The TI was higher males and in those doing manual work, but was not statistically influenced by nationality (Saudis versun non-Saudis), place of residence, or level of education. Our findings support the view that a positive tuberculin reaction in a child aged 5 to 14 years who has been vaccinated with bacillus Calmette-Guerin (BCG) should be attributed to infection with Mycobacterium tuberculosis and not BCG. This conclusion is based on our finding that only 5% of the children int he group of vaccinated subjects has a positive Mantoux reaction, 5% had an intermediate reaction (5 to 9 mm induration), and 90% had a negative reaction (0 to 4 mm induration).

非定型抗酸菌が分離されたッベルクリン反応陽性牛の皮膚結核

In August 1989, a dairy cow showed positive tuberculin reaction in Niigata Prefecture.Necropsy revealed skin lesions on the posterior region of the udder, approximately 50 cm under the vulva. The lesions consisted of multiple, cutaneous and subcutaneous nodules between 0.5 to 1 cm in diameter. Lesions were encapsulated by a thick connective tissue and the cut surface exuded a yellow brown pus. The supramammary lymph node was swollen with hemorrhage. Histologically, the skin lesions were composed of tuberculous granuloma. The center of the lesions showed necrosis, caseation and calcification, and epitheloid cells, Langhans-type giant cells, many lymphocytes and a small number of neutrophils were seen in the surrounding area. A few acid-fast bacilli were found in necrotic areas. The epitheloid cells and giant cells also infiltrated into the supramammary lymph node. No acid-fast bacilli were isolated from the lymph node.Acid-fast bacilli belonging to RUNYON'S group IV were isolated from the skin lesions. Guinea pigs sensitized with isolated acid-fast bacilli showed a positive reaction against mammalian tuberculin.

An Epidemic of Primary Tuberculosis in a Canadian Aboriginal Community

In 1987, an outbreak of primary tuberculosis occurred in a Canadian aboriginal community of 350 people. The source case was a young woman who had been symptomatic for four months with smear positive cavitary pulmonary tuberculosis. Her 17 siblings and their families were frequent close contacts. Among the 626 persons surveyed in the community and environs, 35 additional active cases of tuberculosis were identified. The mean age of cases was 13 years and the median age 10 years. The method of diagnosis was bacteriological in 20 and radiological in 16. There were 257 positive tuberculin reactors of whom 120 had no previous record of a positive skin test. Isoniazid prophylaxis was recommended to all new reactors, close household contacts, reactors under the age of 35 years and reactors with lung scars. One late case was identified at one year of follow-up in a contact who had refused prophylaxis. The rates of infection and disease were higher in the family (65% and 46%, respectively) than in the community and environs (19% and 5.6%, respectively). This report illustrates the nature of a point source epidemic of primary tuberculosis in a susceptible community with a predictable reservoir of infection. The delay in diagnosis of the source case allowed numerous new infections to occur. However, prompt aggressive contact follow-up was successful in containing the epidemic. To prevent future outbreaks, the reservoir of infected persons must be identified and administered chemoprophylaxis.

New approaches to the diagnosis of tuberculosis in childhood with special reference to neurotuberculosis

Bacteriological diagnosis of tuberculosis in childhood is often unsuccessful owing to the difficulty in obtaining suitable specimens. Many attempts have been made to diagnose tuberculosis immunologically but with very limited success. Positive tuberculin reactions may be the result of nonspecific sensitization while negative reactions occur in undernourished children. Serodiagnostic tests suffer from problems of specificity, even when very specific antigens are used, and are often least helpful in diagnostically difficult cases. Detection of antigen has proved to be of more value, especially with clean specimens such as cerebrospinal and pleural fluids. Detection of specific components of Mycobacterium tuberculosis by linked gas chromatography and mass spectroscopy is very sensitive and specific but the equipment is very costly. Detection of specific DNA sequences of M. tuberculosis in specimens by use of labelled 'DNA probes' is rather insensitive although the sensitivity may be increased greatly by use of the polymerase chain reaction to amplify small amounts of the specific DNA. Non specific indicators of tuberculosis are generally unhelpful although the bromide partition test and assay of the enzyme adenosine deaminase in cerebrospinal fluid appear to be of value in the diagnosis of tuberculous meningitis. More research is required to develop a simple, specific and automated test for tuberculosis in childhood.

Smear- and culture-negative pulmonary tuberculosis: four-month short-course chemotherapy.

Patients with positive tuberculin reaction, abnormal chest radiograph, and negative bacteriology are often treated empirically for tuberculosis (TB) after exclusion of other causes. Therapy generally consists of two bactericidal drugs (rifampin [RIF] and isoniazid [INH]) for 9 months or INH for 9 to 12 months. With such a small bacillary population, even less therapy might suffice. Thus we began in January 1980 to discontinue therapy at 4 months when there was sufficient evidence of a paucity of bacilli demonstrated by at least three negative smears and cultures for TB at the start of therapy. To date, 452 such patients have been so treated. Radiographic abnormalities included pulmonary infiltration of varying extent, pleural residuals, and hilar adenopathy. The full course of therapy could not be completed in 38 (8.4%) patients due to death, relocation, or drug toxicity. Side effects of the drugs occurred in 21 (4.7%) patients, but toxic hepatitis occurred in only four (0.9%) patients. Thus, 414 patients completed the full 4-month course of therapy. Of these, 126 (30.4%) patients showed radiographic and/or clinical response suggesting active infection. The remainder showed no such improvement, suggesting either a mistake in diagnosis or dormant TB. During follow-up of the 414 patients from 6 to 78 months (median, 44 months), five (1.2%) patients relapsed: three among responders and two among nonresponders. Thus, among persons suspected of having TB but with negative bacteriology, 4 months of chemotherapy with INH and RIF gave results comparable to those achieved with 9 months of therapy in smear- and culture-positive cases.

Tuberculosis in children and adolescents in the 1980s

Tuberculosis (TBC) continues to be a major health problem. Between January 1, 1980, and April 30, 1986, 211 children and adolescents presented with a positive tuberculin reaction or symptoms suggestive of tuberculosis. Active disease occurred in 35 (17%); 29 of these had primary infection, whereas 4 adolescents presented with cavitary pulmonary disease and 1 infant each had Pott's disease and cervical adenitis. The proportion of patients with active disease was greater in infants and toddlers; 2 of whom also had meningitis. Two children with active disease were infected with human immunodeficiency virus, 1 of whom died with cavitary tuberculosis. Only 43% of 211 patients were born in the United States. The ethnic distribution was Hispanic 45%, Oriental 30%, Black 18% and other 7%. Bacillus Calmette-Guérin vaccination was documented in 53 (25%) patients; 5 (9%) of these developed active disease. Despite vaccination and the availability of effective drugs, tuberculosis persists and appears to be increasing. Meeting the challenge of tuberculosis in the future will require more rapid diagnostic methods and recognition of the burden of infection in human immunodeficiency disease-infected children, together with revitalization of screening and follow-up programs, especially for toddlers and adolescents.

Lymphadenopathy in an inner-city population consisting principally of intravenous drug abusers with suspected acquired immunodeficiency syndrome.

Generalized lymphadenopathy in intravenous drug abusers (IVDAs) at risk for AIDS has not been well studied. We have retrospectively analyzed the results of lymph node biopsies obtained from 27 patients referred to the Infectious Diseases Service for evaluation of generalized lymphadenopathy and suspected AIDS during a recent 18-month period. Fourteen of the patients were heterosexual IVDAs, 7 were male homosexual IVDAs, and 6 were male homosexual non-IVDAs. All of the patients were residents of the Bronx, New York. Mycobacterium tuberculosis (TB) was the most frequent diagnosis established on lymph node biopsies from IVDAs, in 12 out of 21 (57%). Tuberculous adenitis was not diagnosed in the 6 non-IVDAs. All TB patients were febrile, 11 (91%) had lost weight, and 10 (84%) had an abnormal chest roentgenogram. The 5TU PPD skin test, however, was reactive in only 2 (16%) of 12 patients. Tuberculosis is important to consider in patient populations with exposure histories to both AIDS and TB. The alarmingly high prevalence of TB in this drug addict population emphasizes the importance of lymph node biopsies with acid-fast smears and mycobacterial cultures in symptomatic IVDAs. Preventive antituberculosis therapy for HIV-positive persons, especially IVDAs, with a history of positive tuberculin reactions or of recent household contact should be seriously considered.

Epidermis and lymphocyte interactions during a tuberculin skin reaction. I. Increased ETAF/IL-1 like activity, expression of tissue antigens and mixed skin lymphocyte reactivity.

Forty-one persons were tested for tuberculin skin reactivity. Epidermal cells (ECs) were isolated from the tuberculin reaction and from a contra lateral, non injected skin area. We found a significant increase of epidermal thymocyte activating factor (ETAF) in epidermis overlying a positive tuberculin reaction together with an increase of OKT6 and class II (HLA-DR) positive cells. Allogeneic lymphocytes proliferated significantly more when mixed with ECs from a positive tuberculin skin test. Injection of tuberculin per se or a negative reaction did not induce similar changes. The described model seems useful for functional studies of ECs and lymphocytes in patients with contact dermatitis.

The Age Threshold for Isoniazid Chemotherapy

To the Editor.— Although the decision analysis by Rose et al 1 applies a useful model to explore how risks and benefits must be weighed in deciding whether the individual with a positive tuberculin reaction should take isoniazid, we believe that the analysis is flawed by two major problems. First, the authors misapplied cross-sectional data to their longitudinal model and thereby greatly overestimated the number of cases of tuberculosis that would be expected over the lifetime of individuals whose only risk factor for the development of tuberculosis is a positive tuberculin reaction. The longitudinal studies cited by Rose et al demonstrate that the longer a tuberculin reactor goes without developing tuberculosis, the lower the likelihood that tuberculosis will develop. Rather than incorporating this fact into their model (or at least performing a sensitivity analysis to demonstrate its implications), the authors merely mention in their discussion that this issue was not

Tuberculosis in a children's hospital.

We reviewed 26 cases of tuberculosis seen in The Children’s Hospital, Temple Street over the past 10 years by means of a retrospective study of hospital records. In all cases we specifically looked for clinical and bacteriological findings which helped lead to an early diagnosis. There were 15 cases of pulmonary tuberculosis and 11 cases of extrapulmonary disease including 7 cases of tuberculous meningitis. 36% had received BCG vaccination. 16% had positive cultures of mycobacterium tuberculosis. 86% had a positive tuberculin reaction and 73% had definite contact with open tuberculosis. 84% of patients with contacts had a positive tuberculin reaction. There was no mortality, but long-term sequelae occurred in 5 of the 7 cases of tuberculous meningitis.

耳下腺結核の１症例

A 46-year-old woman wasfound to have tuberculosis of the parotid gland with tuberculous cervical lymphadenitis. The most provable route of infection was lymphogenous from the oral cavity.A review of the literature indicates that the parotid gland is more frequently involved by tuberculosis than any of the other salivary glands, and that tuberculosis of the sublingual gland is rare. Two distinct types are found:a subacute type, which often runs its course with pain and/or fistula formation etc., and a chronic type which sometimes produces no symptoms.We must consider tuberculosis in cases of parotid gland tumor with acceluated E. S. R. value, positive tuberculin reaction or a family and/or past history of tuberculosis.

The Age Threshold for Isoniazid Chemoprophylaxis

Isoniazid chemoprophylaxis recommendations include its use in persons who have positive tuberculin reactions, but neither recent conversion nor other activation risk factors, only if they are under age 35 years. Above this threshold, the isoniazid hepatitis risk is said to outweigh the benefit of preventing activation. Because this policy is controversial, we performed a decision analysis contrasting those who take with those who decline isoniazid therapy according to three outcome measures: life expectancy, likelihood of illness (isoniazid hepatitis and active tuberculosis), and likelihood of fatal illness. We found no threshold between ages 10 and 80 years by the measures of life expectancy and likelihood of fatal illness; isoniazid benefits outweigh risks for all, though the margin is small for the elderly. A threshold exists only in the likelihood of illness: isoniazid risks outweigh benefits for those aged 50 to 65 years. Only extreme variations of assumptions affect these findings. Chemoprophylaxis recommendations should include low-risk tuberculin reactors over age 35 years.