Mantoux test

The Mantoux skin test consists of an intradermal injection of exactly one tenth of a milliliter
(mL) of PPD tuberculin.
The size of induration is measured 4872 hours later. Erythema (redness) should not be
measured.
Mantoux test injection site in a subject without chronic conditions or in a high risk group
clinically diagnosed as negative at 50 hours.
The Mantoux test (also known as the Mantoux screening test, Tuberculin Sensitivity Test,
Pirquet test, or PPD test for Purified Protein Derivative) is a diagnostic tool for tuberculosis. It
is one of the two major tuberculin skin tests used in the world, largely replacing multiplepuncture tests such as the Tine test

Tuberculin is a glycerol extract of the tubercle bacillus. Purified protein derivative (PPD)
tuberculin is a precipitate of non-species-specific molecules obtained from filtrates of sterilized,
concentrated cultures. It was first described by Robert Koch in 1890. The test is named after
Charles Mantoux, a French physician who developed on the work of Koch and Clemens von
Pirquet to create his test in 1907.
In 1939, M. A. Linnikova in the USSR created a modified version of PPD. In 1954, the Soviet
Union started mass production of PPD-L, named after Linnikova.
Procedure
A standard dose of 5 Tuberculin units (0.1 mL)[1] (The standard Mantoux test in the UK consists
of an intradermal injection of 2TU of Statens Serum Institute (SSI) tuberculin RT23 in 0.1ml
solution for injection.)[2] is injected intradermally (between the layers of dermis) and read 48 to
72 hours later. This intradermal injection is termed the mantoux technique. A person who has
been exposed to the bacteria is expected to mount an immune response in the skin containing the
bacterial proteins.
The reaction is read by measuring the diameter of induration (palpable raised hardened area)
across the forearm (perpendicular to the long axis) in millimeters. If there is no induration, the
result should be recorded as "0 mm". Erythema (redness) should not be measured.
If a person has had a history of a positive tuberculin skin test, or has not had a recent tuberculin
skin test (within one year), another skin test may be needed; if negative.
Classification of tuberculin reaction

The results of this test must be interpreted carefully. The person's medical risk factors determine
at which increment (5 mm, 10 mm, or 15 mm) of induration the result is considered positive.[3] A
positive result indicates TB exposure.

5 mm or more is positive in
o HIV-positive person
o

Recent contacts of TB case

Persons with nodular or fibrotic changes on chest x-ray consistent with old healed
TB

Patients with organ transplants and other immunosuppressed patients

10 mm or more is positive in
o

Recent arrivals (less than 5 years) from high-prevalence countries

Injection drug users

Residents and employees of high-risk congregate settings (e.g., prisons, nursing

homes, hospitals, homeless shelters, etc.)

Mycobacteriology lab personnel

Persons with clinical conditions that place them at high risk (e.g., diabetes,
prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic
malabsorption syndromes, low body weight, etc.)

Children less than 4 years of age, or children and adolescents exposed to adults in
high-risk categories

15 mm or more is positive in
o

Persons with no known risk factors for TB

(Note: Targeted skin testing programs should only be conducted among high-risk
groups)

A tuberculin test conversion is defined as an increase of 10 mm or more within a 2-year period,

regardless of age.
False positive result
Due to the test's low specificity, most positive reactions in low-risk individuals are falsepositives.[4] A false positive result may be caused by nontuberculous mycobacteria or previous
administration of BCG vaccine. Prior vaccination with BCG may result in a false-positive result
for many years afterwards.[5]

False positives can also occur when person touches the injected area, causing swelling and
itching.
False negative result
Those that are immunologically compromised, especially those with HIV and low CD4 T cell
counts, frequently show negative results from the PPD test.[citation needed] This is because the immune
system needs to be functional to mount a response to the protein derivative injected under the
skin.
BCG vaccine and the Mantoux test
There is disagreement about the role of Mantoux testing in people who have been vaccinated.
The US recommendation is that tuberculin skin testing is not contraindicated for BCGvaccinated persons and that prior BCG vaccination should not influence the interpretation of the
test. The UK recommendation is that interferon- testing should be used to help interpret positive
Mantoux tests, and that serial tuberculin skin testing must not be done in people who have had
prior BCG vaccination. In general, the US recommendation results in a much larger number of
people being falsely diagnosed with latent tuberculosis, while the UK approach probably misses
patients with latent tuberculosis who should be treated.
According to the U. S. guidelines, latent tuberculosis infection (LTBI) diagnosis and treatment
for LTBI is considered for any BCG-vaccinated person whose skin test is 10 mm or greater, if
any of these circumstances are present:

Was in contact with another person with infectious TB

Was born or has lived in a high TB prevalence country

Is continually exposed to populations where TB prevalence is high.

Anergy testing
In cases of anergy, a lack of reaction by the body's defence mechanisms when it comes into
contact with foreign substances, the tuberculin reaction will occur weakly, thus compromising
the value of Mantoux testing. For example, anergy is present in AIDS, a disease which strongly
depresses the immune system. Therefore, anergy testing is advised in cases where suspicion is
warranted that it is present. However, routine anergy skin testing is not recommended.[6]
Two-step testing
Some people who were previously infected with TB may have a negative reaction when tested
years after infection, as the immune system response may gradually wane. This initial skin test,
though negative, may stimulate (boost) the body's ability to react to tuberculin in future tests.
Thus, a positive reaction to a subsequent test may be misinterpreted as a new infection, when in
fact it is the result of the boosted reaction to an old infection.

Use two-step testing for initial skin testing of adults who will be retested periodically (e.g.,
health care workers). This ensures that any future positive tests can be interpreted as being
caused by a new infection, rather than simply a reaction to an old infection.

Return to have first test read 4872 hours after injection

If first test is positive, consider the person infected.

If first test is negative, give second test 13 weeks after first injection

Return to have second test read 4872 hours after injection

If second test is positive, consider person previously infected

If second test is negative, consider person uninfected [7]

A person who is diagnosed as "infected" on two-step testing is called a "tuberculin converter".

The US recommendation that prior BCG-vaccination be ignored results in almost universal false
diagnosis of tuberculosis infection in people who have had BCG (mostly foreign nationals).
Recent developments
As a replacement for the Mantoux test, several other tests are being developed. QuantiFERONTB Gold is a blood test that measures the patients immune reactivity to the TB bacterium and is
useful for initial and serial testing of persons with an increased risk of latent or active
tuberculosis infection. Guidelines for the use of the QuantiFERON test were released by the
CDC in December 2005.[8] QuantiFERON-TB Gold is FDA approved in the United States, has
CE Mark approval in Europe and has been approved by the MHLW in Japan.
Heaf Test
The Heaf test is a tuberculin skin test formerly used in the United Kingdom, but discontinued in
2005.
The equivalent Mantoux test positive levels done with 10 TU (0.1 mL 100 TU/mL, 1:1000) are

<5 mm induration (Heaf 0-1)

515 mm induration (Heaf 2)

>15 mm induration (Heaf 3-4)

National Immunization Schedule

Vaccine

Age

Birth
Primary vaccination
BCG
Oral polio
DPT
Hepatitis B*
Measles
Booster Doses
DPT + Oral polio
DT
Tetanus toxoid (TT)
Vitamin A
Pregnant women
Tetanus toxoid (PW): 1st dose

* Only in project area

X
X

6 weeks

X
X
X

14

9-12

weeks

months

10 weeks

X
X
X

X
X
X
X

16 to 24 months
5 years
At 10 years and again at 16 years
9, 18, 24, 30 and 36 months
As early as possible during pregnancy (first contact)

2nd dose

1 month after 1st dose

Booster

If previously vaccinated, within 3 years