Tuberculosis skin testing

Persons with acquired immunodefidency syndrome or those who are positive for the human immunodefidency virus and have a positive tuberculosis skin test or a negative tuberculosis skin test but a history of a prior significant reaction to purified protein derivative (a skin test for tuberculosis)... 

The nurse would question why the HCP is ordering a PPD, which is a tuberculosis skin test. TB is not a risk factor for developing SBE. 

Strive to identify persons with active tuberculosis. Provide medical surveillance at no cost to the employee, including pre-placement evaluation, tuberculosis skin tests, annual evaluations, and twice yearly exams for those exposed. Evaluate and manage individuals with a positive skin test. Use acid-fast bacilli isolation rooms for those with active or suspected TB infection. Maintain such rooms under negative pressure and use outside exhaust or high efficiency particulate air (HEPA)-filtered ventilation. Develop an employee information and training plan. 

Infectious patients present a difficult challenge when trying to protect health care workers. These patients must be isolated from the health care workers as well as from the other patients in the hospital. Special isolation rooms are used for this purpose. These rooms are generally used for isolation of infectious tuberculosis (TB) patients, but could be used for patients with other airborne-transmitted diseases. In the United States, there were 22 812 new cases of tuberculosis in 1993, equal to 8.7 per 100 000 population. This represents a 2.8% increase since 1985, following a 6-7% annual decline from 1981-1984.Several studies have documented higher than expected tuberculin skin test (TST) conversion rates in hospital personnel.The National Institute for Occupational Safety and Health " reports that multiple-drug-resistant (MDR) strains of TB have been reported in 40 states and have caused outbreaks in at least 21 hospitals, with 18-35% of exposed workers having documented TST conversions. 

Because of the risks of adverse reaction to the vaccine by persons who had already been exposed to the disease a sensitivity test must be carried out prior to immunization with BCG. A Mantoux skin test assesses an individual s sensitivity to a purified protein derivative (PPD) prepared fi om heat-treated antigens (tuberculin) extracted fiom M tuberculosis. A positive test imphes past infection or past, successful immunization Those with strongly positive tests may have active disease and should be referred to a chest clinic. Many people with active TB, especially disseminated TB, however, sero-convert fiom skin test positive to skin test negative. Results of the skin test must therefore be interpreted with care. 

Prior to initiating infliximab, obtain a tuberculin skin test to rule out latent tuberculosis. Assure that patients do not have a clinically significant systemic infection or New York Heart Association Class III or IV heart failure. 

Purified protein derivative (PPD) Material used in the tuberculin skin test, the most common test for exposure to Mycobacterium tuberculosis. 

Evaluate patients for latent tuberculosis infection with a tuberculin skin test. Initiate treatment of latent tuberculosis infection prior to therapy with infliximab. 

Tuberculosis Persons with positive tuberculin skin tests and one or more of the following (a) HIV infection, (b) close contacts with newly diagnosed disease, (c) recent skin test conversion, (d) medical conditions that increase the risk of developing tuberculosis, (e) age < 35 Isoniazid, rifampin, or pyrazinamide Excellent... 

Therapy depends on etiology. In individuals who are suspected of having tuberculosis, diagnosis should make use of a purified protein derivative skin test, chest radiograph, and sputum cultures if necessary. These individuals should be referred for comanagement to their primary physician or to an infectious disease specialist. Though antituberculin agents are systemically administered, the ocular lesions are appropriately treated with topical steroids. In most instances, patients respond to 1% prednisolone acetate every 3 to 4 hours for the first day, subsequently tapered rapidly on the basis of the clinical response. 

A thorough history and examination is important to determine the cause of phlyctenulosis. Inspect the lid margins for signs of staphylococcal blepharitis and question the patient regarding recent infections or tuberculosis exposure. If there is reason to suspect tuberculosis or if no other cause can be found, a tuberculin skin test may be indicated. If diarrhea or gastrointestinal distress is present, consider a stool examination for nematodes. 

Tuberculosis QuantiFERON-TB Gold Chest Internist Purified protein derivative skin test... 

Burgoyne CF, Verstraeten TC, Friberg TR. Tuberculin skin-test-induced uveitis in the absence of tuberculosis. Graefes Arch Clin Exp Ophthalmol 1991 229(3) 232-6. 

Adult immunizations are important to document as well and include vaccines such as pneumococcusl (for elderly and those at risk for pneumonia), influenza, hepatitis B, and tetanus. Although not an immunization, skin testing for tuberculosis might also be included under this section in high-risk patients (elderly, health care worker, or immunocompromised patient). 

The accepted indications for delayed hypersensitivity skin testing include evaluation of immune disorders or chronic diseases that cause cellular immune dysfunction (e.g., uremia, cancer, AIDS, etc), exposure to infectious pathogens (e.g., Mycobacterium tuberculosis), evaluation of nutritional status (because malnutrition can result in cell-mediated immune deficiency), and in some cases, assessment of immune senescence. 

Aside from consideration of drug toxicity, some antimicrobial use requires more in tensive risk-benefit analysis. An example of this is the decision to use isoniazid prophylactically to prevent tuberculosis. Because the hepatotoxicity of isoniazid increases in frequency with age, older persons (>45 years) who are candidates for isoniazid prophylaxis (positive skin test) must have additional risk factors for tuberculosis to balance the potential toxic effects. These include evidence of recent skin-test conversion, immunosuppression, or previous gastrectomy. Older patients without additional risk factors are more likely to suffer toxicity from isoniazid than derive benefit from its use. ... 

The booster effect occurs in patients who do not respond to an initial skin test but show a positive reaction if retested about a week later. Patients with past M. tuberculosis infection and some patients with past immunization with bacillus Calmette-Guerin (BCG) vaccine or past infection with other mycobacteria may boost with a second skin test. Individuals who require periodic skin testing, such as health care workers, should receive a two-stage test initially. Once they are shown to be skin-test-negative, any positive skin test later shows recent infection, and this requires treatment. 

Bacille Calmette-Guerin Vaccine (BCG). The BCG vaccine is an attenuated, hybridized strain of M. bovis. It was developed in 1921 and is used as a prophylactic vaccine against TB. Administration of BCG vaccine is compulsory in many developing countries and is officially recommended in many others. Vaccination with BCG produces a subclinical infection resulting in sensitization of T-lymphocytes and cross-immunity to M. tuberculosis, as well as cutaneous hypersensitivity and, in many cases, a positive tuberculin skin test. 

The use of prophylactic isoniazid therapy for transplant patients with evidence of exposure to M. tuberculosis (those with a positive purified protein derivative skin test) remains controversial. Risk of reactivation and development of clinical tuberculosis is enhanced with posttransplant immunosuppression. Some clinicians believe, however, that the risk of isoniazid-induced hepatotoxicity, especially in liver transplant recipients, in whom the rate of hepatotoxicity has been reported as high as 40%, outweighs the benefits of treatment. High-risk patients who may be considered for isoniazid prophylaxis include those with a positive skin test, those with previously diagnosed tuberculosis who may not have been treated adequately, patients in close contact with individuals with active pulmonary disease, and patients with abnormal chest radiographs consistent with old tuberculosis who have not received prior prophylaxis. " ... 

Infliximab therapy is associated with increased incidence of respiratory infections of particular concern is potential reactivation of tuberculosis or other granulomatous infections with subsequent dissemination. The FDA recommends that candidates for infliximab therapy should be tested for latent tuberculosis with purified protein derivative, and patients who test positive should be treated prophylactically with isoniazid. However, anergy with a false-negative skin test has been noted in some patients with Crohn s disease, and some experts routinely perform chest radiographs to look for active or latent pulmonary disease. Infliximab also is contraindicated in patients with severe congestive heart failure. The significant cost of infliximab is an important consideration in some patients. 

Infants and children with negative tuberculin skin test who are at high risk of intimate and prolonged exposure to pulmonary tuberculosis... 

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