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Editorial
Diagnosis of latent tuberculosis infection:
The tuberculin skin test and interferon gamma
release assays
Mukhtar A. Adeiza
Department of Medicine, Ahmadu Bello University Teaching Hospital, PMB 06, Shika-Zaria, Kaduna State, Nigeria.
E-mail: editor@anmjournal.com
INTRODUCTION
T he clinical manifestations of tuberculosis (TB)
represent a complex interaction between the
causative organism, Mycobacterium tuberculosis, and
the human host immune response.[1] TB is the most
common cause of infectious disease-related mortality
worldwide after the human immunodeficiency
virus (HIV). The World Health Organization (WHO)
estimates that 2 billion people are infected worldwide,
and according to the 2010 global TB report, there
were an estimated 9.4 million incident cases of
TB with 12% of these occurring in HIV-positive
patients.[2] The bulk of this disease burden resides in
sub-Saharan Africa and the majorities of these infections
are asymptomatic and may reactivate later in life. This
huge global reservoir is termed latent tuberculosis
infection (LTBI) and constitutes an important source
of infection and a continuous source of transmission.
The goal of testing for LTBI is to identify individuals
who are at increased risk for the development of TB
and therefore would benefit from treatment. Currently,
there is no available gold standard or confirmatory test
for the diagnosis of LTBI and available surrogates are
not without limitations with respect to technical issues
with test performance, cost, specificity, sensitivity,
effect of Bacille Calmette-Guérin (BCG) vaccine, and
environmental mycobacteria.
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DOI: 10.4103/0331-3131.92946
Annals of Nigerian Medicine / Jul-Dec 2011 / Vol 5 | Issue 2
LATENT TUBERCULOSIS INFECTION
LTBI is a subclinical or asymptomatic infection with
M. tuberculosis without clinical, bacteriological,
or radiological evidence of active disease. Primary
infection with M. tuberculosis leads to clinical disease
in only~10% of individuals. In the remaining cases,
the ensuing immune response arrests further growth of
M. tuberculosis. The pathogen is completely eradicated
in only~10% of people, while the immune response
in the remaining~90% of individuals only succeeds
in containment of infection[3] as some bacilli escape
killing by blunting the microbicidal mechanisms of
immune cells (such as phagosome-lysosome fusion,
antigen presentation by MHC class I, class II, and CD1
molecules, production of nitric oxide, and other reactive
nitrogen intermediates) and remain in nonreplicating
(dormant or latent) state in old lesions.[3,4] Of these
latently infected individuals, 5%–10% will develop
active disease during their life time. However, the
risk of developing active disease is greatly increased
(5%–15% every year and ~50% over lifetime) by HIV
coinfection.[4] Other factors that increase the risk of
reactivation of latent TB include old TB with lung
scarring, immunosuppression, organ transplantation,
malignant disease, end-stage renal failure, and diabetes
mellitus.[5]
Even though there is no gold standard for the diagnosis
of LTBI,[6] attempt at measuring LTBI using surrogates is
important for the overall control of the disease. Offering
antituberculous treatment to individuals with LTBI by
currently available tests significantly decreases their
risk of developing active TB. For years, the diagnosis
of LTBI infection relied on the tuberculin skin test
(TST) which is known to have several limitations
compromising its sensitivity and specificity. Recently,
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Adeiza: Diagnosis of latent tuberculosis infection
immune-based blood tests were developed with the
hope of improving the diagnosis of LTBI.[7]
TUBERCULIN SKIN TEST
For more than 100 years, the usual method used to
diagnose LTBI was the TST, which clearly shows, after
injecting a purified protein derivative (PPD), a state of
prior hypersensitivity in the body when confronted with
this substance.[8] The TST measures an immunological
response: cell-mediated immunity (CMI) to a previously
acquired infection with a mycobacterium that shares
antigens with those contained in the tuberculin.[9] It is a
form of a delayed type hypersensitivity (DTH) response
to a complex cocktail of >200 M. tuberculosis antigens
and the test result is usually read as induration (in mm)
recorded 48–72 hours after intradermal injection of
PPD.[4,6] A positive TST indicates that the reacting person
has, at some preceding point in time, became infected
with a Mycobacterium that has left an immunological
imprint.[9]
The criteria for a positive TST vary considerably and
depend on the innoculum and type of PPD preparation
used in the test. In the United States, 5 tuberculin
units (TUs) are generally used and the induration of
≥5 mm in very high-risk groups like HIV-seropositive
or organ transplant recipient or in a person in contact
with a known case of active TB is considered as
positive.[5] However, in foreign-born persons originating
from high TB incidence countries or persons at higher
risk of exposure to M. tuberculosis (such as health care
professionals, residents of long-term care facilities or
patients with chronic diseases), induration of ≥10 mm
is regarded as positive TST. For those with no risks, an
induration of ≥15 mm is considered positive. These
guidelines ignored the effect of BCG vaccination when
interpreting the TST.[4]
Skin testing is most suitable for detecting M. tuberculosis
infection in developing countries where >80% of
the global TB cases occur,[4] as it does not require
extensive laboratory facilities and health care workers
are already familiar with administering and reading
skin tests. However, TST has several inherent problems
as the antigens present in PPD are also present in the
vaccine strain Mycobacterium bovis BCG and several
environmental mycobacteria. Hence, TST has lower
specificity as the test cannot differentiate between
infection with M. tuberculosis, prior vaccination with
M. bovis BCG, or sensitization with environmental
36
mycobacteria. Furthermore, sensitivity of TST is
limited in immunocompromised individuals due to
anergy. [4,10] These factors have compromised the
sensitivity and specificity of TST for the diagnosis of
LTBI. It is important to keep in mind that a negative
TST does not exclude infection or active disease. Testing
with tuberculin PPD is dependent on the presence
of an intact cell-mediated immune response. In the
setting of HIV infection, reduced CMI and decreasing
CD4+ T-lymphocyte counts can lead to decreased DTH
responsiveness, resulting in false-negative skin tests.
INTERFERON GAMMA RELEASE ASSAYS
In recent years, several immunodiagnostic assays
have been developed for diagnosing M. tuberculosis
infection. These assays, referred to as interferon (IFN)-
release assays (IGRAs), have been specifically designed
to overcome the problem of low specificity of the
TST. In fact, they detect cellular immune response
to antigens which are absent in BCG and most
environmental mycobacteria, and specifically present in
M. tuberculosis.[11] Two such antigens, early-secreted
antigenic target (ESAT)-6 and culture filtrate protein
(CFP)-10, encoded in the mycobacterial genomic region
of difference (RD)-1[12,13] were first evaluated in a 6-day
lymphocyte stimulation test and found to be sensitive
and specific for diagnosing TB. Subsequently, other
IGRAs were developed that differed from the classical
LST with respect to the in vitro incubation period, the
type of cells cultured; whole blood, frozen or fresh
peripheral blood mononuclear cells (PBMCs), and the
way that the IFN- response is detected by enzyme-linked
immunosorbent assay (ELISA; Cellestis Ltd, Australia)
or enzyme-linked immunospot assay (ELISPOT/T-
SPOT.TB; Oxford Immunotec, UK). At present, the
third generation of this test, called QuantiFERON-TB
Gold In Tube (QFT-GIT), is already on the market and
includes a third mycobacterial antigen: the TB 7.7 and
tubes specifically designed to collect blood samples
for this test.[13]
The new IGRAs are unaffected by prior BCG vaccination,
show considerable promise, and have excellent
specificity.[6] They are ex vivo tests, thus reducing
the potential risk of adverse events and boosting.[14]
They also have the important operational advantage
of requiring only a single patient visit. In the last few
years, there has been an explosion of studies evaluating
IGRAs in different settings and study populations.[15]
Adetifa et al., comparing the T-SPOT.TB (ELISPOT) and
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Adeiza: Diagnosis of latent tuberculosis infection
QFT-GIT in the Gambia, showed that the ELISPOT test
was more sensitive than the QFT-GIT (78.7% vs 64.0%)
for diagnosing TB disease. The two tests performed
similarly in the diagnosis of LTBI in TB contacts, but
there was significant discordance between the IGRAs
and the TST.[16] Current evidence suggests that the
IGRAs perform similarly to the TST in identifying
HIV-infected individuals with LTBI and the decision to
use either test should be based on country guidelines,
resource, and logistical considerations.[17]
In resource-rich countries, IGRAs are increasingly being
utilized and some guidelines have suggested replacing
TST by IGRAs or using them as confirmatory tests in
those with positive TST results. In some evaluation,
this two-step approach is the most cost-effective.
These guidelines also recommended using IGRAs in
situations where TST may not be reliable (e.g., in
immunocompromised patients).[18-21] The question is
whether IGRA tests should complement or replace
TST. The latter test is cheap and sensitive for diagnosis
of LTBI. However, in BCG-vaccinated individuals,
its specificity is clearly inferior to that of the IGRAs.
These expensive tests may not be affordable to many
developing countries and therefore, it is likely that TST
will remain in use in many parts of the world.[7]
CONCLUSION
In comparison, the TST lacks specificity, requires
multiple visits, and is affected by BCG, environmental
mycobacteria, and boosting but is cheap and can be
easily performed by well-trained personnel. In contrast,
the IGRAs require single visit, can be performed ex
vivo, have higher specificity, but are expensive and
sometimes discordant with the TST. The IGRAs are an
important step in the search for better diagnostic tests
for LTBI, but the bulk of the literature are from cross-
sectional studies carried out in high resource, low TB
prevalence settings, and there is a need to test their
performance in longitudinal studies conducted in low
resource, high TB prevalence settings like sub-Saharan
Africa where the burden of immunosuppresion due the
HIV pandemic is high.
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