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No estimate 0-24 25-49 50-99 100-299 300 or more Estimated new TB cases (all forms) per 100 000 population
Active Disease
Low-High
None
None-florid Often infectious if pulmonary Often positive May be abnormal, Infiltrates, cavities 4 drugs pending sensitivities
Mantoux CXR
Therapy
TB screening
Screening guidance
#nl$ screen if $ou plan on doing something %ith the results f looking for infection or disease, onl$ screen those that ha&e a reason to be infected
Screening lo% pre&alence populations %ill result in a high proportion of false positi&e results
Screening modalities
Chest radiograph screening detects'
(cti&e pulmonar$ disease Those at high risk of de&eloping acti&e disease Will miss most people with latent infection
Tuberculin skins testing and Interferon Gamma Release Assays (IGRAs detect'
)atent infection
Contraindications
Se&ere reactions in the past Pre&ious documented positi&e -*tensi&e skin disease Recent significant &iral illness
"ot Contraindications
Pregnanc$ Recent &accination %ith a killed &accine BCG &accination histor$ Pre&iousl$ positi&e but not documented Children
Sensiti&it$ closer to ;,< for acti&e disease Specificit$ influenced b$ BCG &accination, other m$cobacterial e*posure
Boosting
#ccurs %ith remote BCG, at$pical m$cobacteria, M. tuberculosis e*posure Common 4178,<6
#lder indi&iduals Ma*imal if inter&al bet%een 3 and 1 %eeks
Partiall$ corrected for b$ +7step testing but can ha&e continued boosting
BCG:3 $ear of age
18mm
Iseman, 2000
Con&ersion
!ifferent definitions'
A mm' more sensiti&e, less specific
Ma$ be difficult to interpret gi&en &ariabilit$
Re&ersion
/p to >< of positi&e adults %ill become negati&e on repeat testing
More common in adults More common in those %ith moderate siCed induration More common in those %ith boosting
-speciall$ if boosted after 8 or more serial tests
Summar$
Reading and interpreting skin tests is not so simple5 This %as supposed to be fi*ed b$ nterferon Gamma Release (ssa$s
DE7based tests
T7Spot5TB
-) SP#T
(d&antages of GR(s
More specific than the TST 4donGt react to BCG and most other non7TB m$cobacteria6 #nl$ 3 &isit re.uired Do boosting phenomenon T7Spot5TB is more sensiti&e than the TST in immunocompromised
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Hemodial$sis patients
!isad&antages
Same general issues as the TST in immunocompromised i5e5 the$ donGt %ork as %ell -*pensi&e, often patients must pa$ for them )imited a&ailabilit$ Ha&e same issues %ith re&ersion as the TST The risk of de&eloping acti&e TB in the setting of a positi&e GR( is unclear
!iscordant results
TST H, GR( I
Secondar$ to BCG or false negati&e GR(?
TST 7, GR( H
Poor sensiti&it$ of the TST or false positi&e GR(?
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GR( Summar$
(t present, the role for GR(s is relati&el$ limited
testing lo% risk populations %ho ha&e recei&ed BCG mmunocompromised populations 4T7Spot5TB6
Conclusions
Chest radiograph screening is best as an initial assessment for pulmonar$ TB TSTs and GR(s are best for detecting latent infections
nterpreting TSTs is complicated GR(s ha&e some ad&antages but are not panaceas
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michael5gardamJuhn5ca
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