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CASE SERIES
Year : 2015  |  Volume : 59  |  Issue : 3  |  Page : 213-216  

Tuberculin skin testing: Spectrum of adverse reactions


1 Graded Specialist, Department of Pediatrics, 92 Base Hospital, Srinagar, Jammu and Kashmir, India
2 Graded Specialist, Department of Dermatology and Venerology, 92 Base Hospital, Srinagar, Jammu and Kashmir, India
3 Classified Specialist, Department of Preventive and Social Medicine, 135 Station Health Organisation, C/O 56 APO, Srinagar, Jammu and Kashmir, India

Date of Web Publication7-Sep-2015

Correspondence Address:
Ramar Praveen
Department of Pediatrics, 92 Base Hospital, C/o 56 APO. Armed forces cant
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.164663

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   Abstract 

Tuberculin skin testing (TST) is one of the primary diagnostic modalities recommended by the World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE) study conducted in the United Kingdom (UK) for diagnosing tuberculosis (TB). Even after acceptance as a diagnostic modality and stern standardization, TST has its own flaws that include a spectrum of adverse reactions. We report a series of cases with a spectrum of adverse reactions occurring with a higher frequency than present in the available evidence. The study has some demerits such as being a retrospective one with interobserver variation and lack of histopathological confirmation. The observation is presented to accentuate the fact that adverse reactions are not a rarity and that further studies are required to establish the cause and exact incidence of the same.

Keywords: Adverse reactions, blistering and necrosis, tuberculin skin testing (TST)


How to cite this article:
Praveen R, Bahuguna A, Dhadwal BS. Tuberculin skin testing: Spectrum of adverse reactions. Indian J Public Health 2015;59:213-6

How to cite this URL:
Praveen R, Bahuguna A, Dhadwal BS. Tuberculin skin testing: Spectrum of adverse reactions. Indian J Public Health [serial online] 2015 [cited 2019 Nov 13];59:213-6. Available from: http://www.ijph.in/text.asp?2015/59/3/213/164663

Tuberculosis (TB) is a major health problem globally. It is a single major infectious disease causing significant morbidity and mortality among all human beings. [1] The diagnostic algorithms recommended by the World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE) study conducted in the United Kingdom (UK) incorporate a careful and thorough assessment of all the evidence derived from a careful history, clinical examination, and relevant investigations, e.g., the tuberculin skin testing (TST), chest x-ray (CXR), and sputum smear microscopy. [2]

We report a series of 13 cases with a spectrum of adverse reactions to one of the diagnostic modalities, namely, TST.

The study was conducted by a retrospective analysis of the registry maintained of the patients who underwent the test in a zonal hospital in Srinagar, Kashmir, India over a period of 6 months from June 2012 to December 2012. A total of 113 patients with suspected TB were subjected to TST during the study period. Purified protein derivative with Tween 80 and 10 tuberculin unit (TU) strength, PPD RT 23 and 10TU stored between 2°C and 8°C was used for testing. The test was carried out by trained personnel with standard dose and the recommended method (Mantoux method) of administration. All the patients were instructed to keep the place uncovered and not rub and scratch. The test was read after 72 h of administration. Reading was carried out in good lighting. The basis of reading was taken as the presence or absence of induration, which may have been determined by inspection and palpation. The diameter of induration was measured transversely to the long axis of the forearm and recorded in millimeters. [3] The procedures followed in the research were in accordance with the ethical standards of the institutional ethics committee on human experimentation and with the Helsinki Declaration of 1975 as revised in 2000.

In our observation of over 6 months, out of 113 patients 13 developed adverse reactions (11.5%). We identified four patients (3.5%) with blistering and necrosis of the skin at the administered site [Figure 1] and [Figure 2], three with angioedema (2.6%), dermograhism in one (0.8%) [Figure 3], urticarial rash in four, and all the generalized urticarias (3.5%) [Figure 4] and granulomatous reactions in one (0.8%). We had five out of 13 patients with adverse reactions that lasted more than 24 h (38%). Eight (61%) patients had systemic/generalized (more than one anatomical surface apart from test site) manifestations of adverse reaction.
Figure 1: Skin blister following TST

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Figure 2: Ulceration and skin necrosis in the forearm following TST

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Figure 3: Granulomatous reaction following TST

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Figure 4: Urticarial reaction following TST

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Dr. Robert Koch had demonstrated an altered reaction to the tubercle bacilli (heat-killed extract known as Koch's lymph) injected into the skin of a normal guinea pig versus a guinea pig with TB in 1890, known as the Koch phenomenon. In 1912, Mantoux introduced the intradermal injection technique for TST. [4],[5] TST has evolved over 100 years; despite all the stern scrutiny and standardizing measures, this test is still not devoid of side effects. Although adverse reactions to TST are uncommon, local allergic reactions to tuberculin or its components can occur in 2-3% of those tested. [6] We observed a higher incidence (11.5%) of adverse reactions to TST compared to the available evidence. The allergic gamut encompasses immediate wheal and flare reactions with erythema and induration that subsides at 24 h [probably an immunoglobin E (IgE)-mediated response to 7% polysaccharide in purified protein derivative (PPD)], fever, vesiculation, ulceration, proximal lymphangitis, regional lymphadenopathy, phlycten, and rarely shock and foreign body reaction at the injection site. [7] In our study, four patients (3.5%) developed blistering and necrosis of the skin at the administered site in contradiction to the available literature that states that approximately 1-2% of patients with a positive tuberculin reaction experience blistering or necrosis. We identified three patients with angioedema (2.6%); however, there was no airway compromise or circulatory collapse. This is a contrast to the available literature that quotes anaphylactic reactions as one per million administered doses. [8] The investigators could not find reported data for the incidence of dermographism and urticarial and granulomatous reactions after TST.

Out of the 13 patients 12, except the one with dermographism, required pharmacological treatment. The observed adverse reactions of the treatment offered are as tabulated in [Table 1]. We administered 10TU strength of PPD RT 23 (due to the nonavailability of 1TU, 2TU, and 5TU in our setting) against the standard WHO recommendation of 1TU for community screening. [9] Studies have authenticated the fact that there is no linear relation between tuberculin dose and the skin reaction observed [10] and hence, our results cannot be ascribed to using higher strengths of TU.
Table 1: Spectrum of adverse reactions for TST

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We admit that there were a few pitfalls in this study that we feel are the inherent demerits of a retrospective analysis; these limitations included the fact that the human error or interadministrator variation in the technique of the test given was not taken into consideration and the lack of histopathological confirmation of the adverse reactions.

We report this observation to accentuate the verity that adverse drug reaction (ADR) of TST is not a rarity and it is noted at a higher rate than that quoted in the available literature to the best of the authors' knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Mustapha MG, Garba AM, Rabasa AI, Gimba MS. Prevalence of Mantoux test positivity among apparently healthy children in Maiduguri, Nigeria. S Afr J CH 2009;3:80-2.  Back to cited text no. 1
    
2.
Stop TB Partnership Childhood TB Subgroup World Health Organization. Guidance for National tuberculosis programs on the management of tuberculosis in children. Chapter 1: Introduction and diagnosis of tuberculosis in children. Int J Tuberc Lung Dis 2006;10:1091-7.  Back to cited text no. 2
[PUBMED]    
3.
Nayak S, Acharjya B. Mantoux test and its interpretation. Indian Dermatol Online J 2012;3:2-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Menzies D. Tuberculin skin testing. In: Reichman LB, Hershfield ES, editors. Tuberculosis: A Comprehensive International Approach. New York: Marcel Dekker; 2000. p. 279-322.  Back to cited text no. 4
    
5.
Bleiker JH. The past, the present and the future of tuberculin test in tuberculosis control. Bull Int Union Tuberc Lung Dis 1989;64:33-4.  Back to cited text no. 5
    
6.
Al Jahdali HH, Bahroon S, Abba AA, Memish ZA, Alrajhi AA, AlBarrak A, et al.; Saudi Thoracic Society; Saudi Society of Medical Microbiology and Infectious Disease; Saudi Association of Public Health; Society of Family and Community Medicine. Saudi guidelines for testing and treatment of latent tuberculosis infection. Ann Saudi Med. 2010;30:38-49.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Kim Y, Dawes-Higgs E, Zagarella S. Foreign body reaction involving a Mantoux test site. Australas J Dermatol 2005;46:169-71.  Back to cited text no. 7
    
8.
Youssef E, Wooltorton E. Serious allergic reactions following tuberculin skin tests. CMAJ 2005;173:34.  Back to cited text no. 8
    
9.
Chadha VK. Tuberculin test. Indian J Pediatr 2001;68:53-8.  Back to cited text no. 9
    
10.
Dimoliatis ID, Liaskos CA. Six Mantoux tuberculin skin tests with 1, 2, 5, 10, 20, and 50 units in a healthy male without side-effects - Is skin reaction a linear function of tuberculin dose? Cases J 2008;1:115.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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