Indian Journal of Public Health

: 2015  |  Volume : 59  |  Issue : 3  |  Page : 213--216

Tuberculin skin testing: Spectrum of adverse reactions

Ramar Praveen1, Amit Bahuguna2, Bhumesh Singh Dhadwal3,  
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

Correspondence Address:
Ramar Praveen
Department of Pediatrics, 92 Base Hospital, C/o 56 APO. Armed forces cant


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.

How to cite this article:
Praveen R, Bahuguna A, Dhadwal BS. Tuberculin skin testing: Spectrum of adverse reactions.Indian J Public Health 2015;59:213-216

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Praveen R, Bahuguna A, Dhadwal BS. Tuberculin skin testing: Spectrum of adverse reactions. Indian J Public Health [serial online] 2015 [cited 2023 Mar 27 ];59:213-216
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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}{Figure 2}{Figure 3}{Figure 4}

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}

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.

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Conflicts of interest

There are no conflicts of interest.


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