Mantoux test

For the Mantoux test, special disposable tuberculin syringes with thin short needles and a short oblique cut are used.

[1], [2]

Indications for the Mantoux sample

For mass tuberculin diagnostics, the Mantoux test with 2 TE is administered to all children and adolescents vaccinated with BCG regardless of the previous result 1 time per year. The first Mantoux test is given to a child at the age of 12 months. For children who are not vaccinated with BCG, the Mantoux test is performed 6 months once every six months before the child receives BCG vaccination, then by the standard method once a year.

The Mantoux test can also be used for individual tuberculin diagnostics. It is carried out in the conditions of a children's polyclinic, somatic and infectious hospitals for the differential diagnosis of tuberculosis and other diseases, in the presence of chronic diseases with a torpid, undulating course, with the ineffectiveness of traditional methods of treatment and the presence of additional risk factors for infection or tuberculosis (contact with a tuberculosis patient, absence vaccinations against tuberculosis, social risk factors, etc.).

In addition, there are groups of children and adolescents who need to be given Mantoux test 2 times a year under the conditions of a common treatment network:

• patients with diabetes mellitus, peptic ulcer of the stomach and duodenum, blood diseases, systemic diseases. HIV-infected, receiving long-term hormone therapy (more than 1 month);
• with chronic nonspecific diseases (pneumonia, bronchitis, tonsillitis), subfebrile condition of unclear etiology;
• Not vaccinated against tuberculosis, regardless of the child's age;
• children and adolescents from social risk groups who are in institutions (shelters, centers, reception centers) that do not have medical records (upon admission to the institution, then 2 times a year for 2 years).

When carrying out individual tuberculin diagnostics, the threshold of sensitivity to tuberculin is used - the lowest concentration of tuberculin, to which the body responds positively. To determine the sensitivity threshold for tuberculin, use an intradermal Mantoux test with various dilutions of dry purified tuberculin.

In children with suspected specific eye damage in order to avoid a focal reaction, it is advisable to start tuberculin diagnostics from the setting of cutaneous or intradermal samples with 0.01 and 0.1 TE.

Tuberculin tuberculin samples (plaster, ointment) are now of more historical significance, they are rarely used, more often for the diagnosis of skin tuberculosis, or in cases when, for some reason, the use of more common cutaneous and intradermal tuberculin samples is impossible. The Pirke test is also rarely used.

Graduated skin test (GKP) of Grinchar and Karpilovsky is carried out, if necessary, for differential diagnosis, to clarify the nature of tuberculin allergy, and the evaluation of the treatment.

A sample with subcutaneous injection of tuberculin is indicated when it is necessary to determine the activity of tuberculosis of respiratory organs, as well as for etiologic diagnosis and determination of tuberculosis activity of extrapulmonary localizations.

Mantoux test

The ampoule with tuberculin is carefully wiped with gauze moistened with 70% ethanol, then the neck of the ampoule is filed with a knife to open the ampoules and break off. Tuberculin is removed from the ampoule by a syringe and a needle, which is then used to place the Mantoux sample. In the syringe, take 0.2 ml of the drug (ie 2 doses), then release the solution to a label of 0.1 ml in a sterile cotton swab. It is inadmissible to release the solution into the protective cap of the needle or into the air, as this can lead to allergic reactions of the health personnel. The ampoule with tuberculin after opening is suitable for use for no more than 2 hours while maintaining it under aseptic conditions.

The intradermal test is performed only in a procedural room. The patient is sitting. On the inner surface of the middle third of the forearm, the skin area is treated with 70% ethyl alcohol solution, dried with sterile cotton wool, tuberculin is injected strictly intradermally, for which the needle is directed upwards into the upper layers of the stretched skin parallel to its surface. After introducing the needle hole into the skin, 0.1 ml of Tuberculin solution (i.e., one dose) is injected from the syringe. The injection site is not re-treated with alcohol, since the risk of infection with the injection site is small (PPD-L contains quinizol). With the right technique, a papule is formed in the skin in the form of a "lemon crust" with a diameter of at least 7-9 mm whitish, which soon disappears.

The Mantoux test is performed by a specially trained nurse. Response after 72 h evaluates the doctor or trained nurse. The results are entered in the registration forms: No. 063 / y (vaccination map). № 026 / у (medical card of the child). № 112 / у (history of development of the child). In this case, the manufacturing company, the serial number, the expiration date of tuberculin, the date of the sample, the drug in the right or left forearm, as well as the result of the sample (the size of the infiltrate or papules in millimeters, in the absence of infiltration - the size of hyperemia).

With the proper organization of tuberculin diagnostics, 90-95% of the child and adolescent population of the administrative territory should be covered annually. In organized collectives, mass tuberculin diagnostics is carried out in institutions either by specially trained medical personnel or by brigade method, which is preferable. In the brigade method, children's polyclinics are formed by brigades - two nurses and a doctor. For unorganized children, the Mantoux test is performed in a children's polyclinic. In rural areas, tuberculosis diagnostics is carried out by district rural district hospitals and feldsher-midwife stations. Methodical guidance tuberculin diagnostics is carried out by a pediatrician of an anti - tuberculosis dispensary (a cabinet). In the absence of an anti-tuberculosis dispensary (cabinet), the work is performed by the head of the outpatient department for childhood (district pediatrician) in conjunction with the district TB doctor.

In response to the introduction of tuberculin in the body of a pre-sensitized person, a local, general and / or focal reaction develops.

• Local reaction is formed at the site of the introduction of tuberculin, can manifest itself as hyperemia, papula, infiltrate, vesicles, bulla, lymphangitis, necrosis. The local reaction is of diagnostic importance for the dermal and intradermal administration of tuberculin.
• The general reaction is characterized by general changes in the human body and can manifest itself in the form of deterioration of health, increased body temperature, headaches, arthralgias, changes in blood tests (monocytopenia, dysproteinemia, minor acceleration of ESR, etc.). The general reaction often develops with subcutaneous injection of tuberculin.
• Focal reaction develops in patients in the focus of a specific lesion - in tuberculosis foci of different localization. With pulmonary tuberculosis, the focal reaction may appear hemoptysis, increased cough and catarrhal symptoms, increased sputum discharge, pain in the chest; with extrapulmonary tuberculosis - an increase in inflammatory changes in the zone of tuberculosis lesion. Along with the clinical manifestations of radiographic examination, it is possible to increase the perifocal inflammation around the tuberculosis foci. Focal reaction is more pronounced with subcutaneous injection of tuberculin.

The result of the Mantoux test is evaluated after 72 hours. The diameter of the papule or hyperemia in millimeters is measured with a transparent ruler. The ruler is positioned perpendicular to the axis of the forearm. To correctly interpret the results, not only a visual evaluation of the reaction is necessary, but also palpation of the place of introduction of tuberculin, since with a weakly expressed papule slightly rising above the skin level and in the absence of hyperemia the reaction can be regarded as negative. With hyperemia that goes beyond the papule, light pressure on the reaction area with your thumb allows you to short-circuit the hyperemia and measure only the papule.

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The Pirke test

The sample is the cutaneous use of dry purified tuberculin, diluted to a content of 100 thousand TE in 1 ml. A drop of this solution of tuberculin, applied to the skin, produces skin scarification. The result is estimated after 48-72 hours.

Evaluation of Mantoux test results

The results of the sample can be evaluated as follows:

• negative reaction - complete absence of infiltration (papules) and hyperemia, the presence of a stabile reaction of 0-1 mm is permissible;
• doubtful reaction - infiltrate (papule) of 2-4 mm size or hyperemia of any size without infiltration;
• positive reaction - infiltrate (papule) of 5 mm or more, as well as vesicles, lymphangitis, screenings (several papules of any size around the place of introduction of tuberculin):
  • weakly positive - papule size 5-9 mm:
  • medium intensity - the size of the papule is 10-14 mm;
  • expressed - the size of the papule is 15-16 mm;
  • hyperergic - the size of the papule is 17 mm and higher in children and adolescents. 21 mm and above in adults, as well as vesicle-necrotic reactions, lymphangitis, screenings, regardless of the size of the papule.

In our country, the entire children's population is subject to vaccination against tuberculosis at certain times, according to the vaccination calendar. After the introduction of the BCG vaccine, HRT also develops in the body, as a result of which reactions with 2 TE purified tuberculin in standard dilution become positive - a so-called post-vaccination allergy (PVA) develops. The appearance of a positive reaction as a result of spontaneous infection of the body is regarded as an infectious allergy (IA). Study of Mantoux test results in dynamics in combination with data on the timing and frequency of BCG vaccinations. As a rule, in the overwhelming majority of cases, allows differential diagnosis between PVA and IA.

Positive results of the Mantoux test are regarded as PVA in the following cases:

• the occurrence of positive and questionable reactions to 2 TE in the first 2 years after previous vaccination or revaccination of BCG;
• correlation of papule size after tuberculin administration and size of postvaccinal) sign of BCG (scar); the papule up to 7 mm corresponds to the ribs up to 9 mm. And the papule to 11 mm - to the scars more than 9 mm.

The result of the Mantoux test is assessed as IA (HRT) in the following cases:

• transition of a negative reaction to a positive one, not associated with vaccination or revaccination of BCG. - "turn" of tuberculin samples;
• an increase in the size of the papule by 6 mm or more for one year in tuberculin-positive children and adolescents;
• Gradual, over several years, increased sensitivity to tuberculin with the formation of moderate reactions or pronounced reactions;
• 5-7 years after vaccination or revaccination, BCG is stable (for 3 years or more) the remaining sensitivity to tuberculin at the same level without the tendency to fade-monotonous sensitivity to tuberculin;
• exacerbation of sensitivity to tuberculin after a previous IA (usually in children and adolescents, previously observed in a phthisiopaediatrica and received a full course of preventive treatment).

According to the results of the mass tuberculin diagnostics in the dynamics among children and adolescents, the following contingents allocate:

• uninfected - these are children and adolescents who have an annual negative Mantoux test result, as well as adolescents with PVA;
• Children and adolescents infected with mycobacteria tuberculosis.

For early detection of tuberculosis and for its timely prevention it is important to record the moment of primary infection of the body. This does not cause difficulties in the transition of negative reactions to positive, not related to vaccination or revaccination of BCG. Such children and adolescents should be sent to the TB specialist for timely examination and preventive treatment. Preventive specific treatment for 3 months in the early period of primary infection prevents the development of local forms of tuberculosis. To date, the proportion of tuberculosis in children and adolescents, identified in the period of "bend", ranges from 15 to 43.2%.

The development of tuberculosis in children and adolescents with increasing sensitivity to tuberculin for the year by 6 mm and more has been proved. It was suggested that such children and adolescents also be preventively treated within 3 months

The increase in sensitivity to tuberculin in an infected child before hyperaemia indicates a high risk of developing local tuberculosis. These patients are also subject to phthisiatric consultation with an in-depth examination of tuberculosis and the decision to prescribe preventive treatment.

Children and adolescents with monotonous reactions to tuberculin in combination with two or more risk factors for tuberculosis are also subject to phthisiatric consultation with an in-depth examination of tuberculosis.

If there is a difficulty in interpreting the nature of sensitivity to tuberculin, children are subject to preliminary monitoring in the group 0 of dispensary registration with obligatory medical and prophylactic measures at the pediatric site (hyposensitization, sanation of foci of infection, dehelminthization, achievement of a remission period in chronic diseases) under the supervision of a pediatric phthisiatrician. Repeated examination in the dispensary is carried out after 1-3 months.

The study of sensitivity to tuberculin in children and adolescents with active forms of tuberculosis, as well as those infected (according to the data of mass and individual tuberculin diagnostics combined with clinical radiology data) made it possible to propose an algorithm for monitoring patients depending on the nature of susceptibility to tuberculin and the presence of risk factors tuberculosis.

[4], [5], [6],