Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting

doi:10.1016/j.jaad.2011.09.007

Journal of the American Academy of Dermatology

Volume 66, Issue 1, January 2012, Pages 148-152

https://doi.org/10.1016/j.jaad.2011.09.007 Get rights and content

Treatment with tumor necrosis factor-alfa inhibitors and other systemic medications increases the risk of reactivating a latent tuberculosis (TB) infection. Therefore, screening for latent TB infection is important in dermatology patients eligible for treatment with these medications. Although the tuberculin skin test (TST) has its limitations, it has been the standard choice for diagnosis of latent TB infection. Since the development of interferon gamma release assays (IGRAs), the role of the TST has been re-evaluated and IGRAs have increasingly been incorporated into national guidelines. Although there are situations when either test may be performed, in individuals who have received a BCG vaccination and in those who are unlikely to return for a TST reading, IGRAs may be particularly helpful in distinguishing patients at risk for TB. This article discusses the advantages and disadvantages of both the TST and the IGRA and presents a summary of the Centers for Disease Control and Prevention 2010 guidelines for using IGRAs.

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Cited by (14)

Comparative study of concordance and costs between tuberculin skin test and QuantiFERON®-TB Gold In-Tube in the diagnosis of latent tuberculosis infection among contacts of patients with pulmonary tuberculosis
2015, Medicina Clinica
El diagnóstico de la infección latente tuberculosa (ILT) es posible realizarlo mediante la prueba de la tuberculina (PT) o bien a través de las denominadas técnicas de interferon-γ release assays (IGRAS, «análisis de liberación del interferón-γ»), siendo QuantiFERON^®-TB Gold In-Tube (QF-G-IT) la más usada. Los IGRAS permiten evitar algunos inconvenientes de la PT, especialmente la reacción cruzada con la vacuna con bacilo de Calmette-Guérin (BCG). No obstante, también presentan algunos problemas, como son los derivados del coste de la técnica, así como el ser un método de laboratorio que precisa una infraestructura y experiencia adecuadas. No existe un claro consenso sobre cuál de las técnicas debería utilizarse de forma prioritaria para el diagnóstico de la ILT.
Se trata de un estudio comparativo entre la PT y la QF-G-IT en nuestra cohorte de contactos de pacientes con tuberculosis pulmonar durante el período de estudio (n = 101). Se realizó un análisis de la concordancia global y por grupos según los contactos estuvieran vacunados con BCG o no. Se realizó, además, un estudio de costes de ambas técnicas y de las estrategias diagnósticas basadas en ellas.
La concordancia entre la PT y la QF-G-IT fue aceptable en el global de la muestra, pero muy buena en el grupo de no vacunados. Se registraron muy pocos casos de valores indeterminados. El estudio de costes mostró que la PT era más económica que la QF-G-IT; sin embargo, al analizar el coste de las estrategias según cada técnica, la PT mostró un mayor coste-beneficio.
Aconsejamos considerar QF-G-IT como la única y preferente técnica para el diagnóstico de la ILT en contactos convivientes, basados en una buena concordancia general entre ambas técnicas (más aún si eliminamos el efecto de la vacuna) y un estudio de costes favorable a QF-G-IT.
Recently diagnosis of latent tuberculosis infection (LTBI) can be made using the tuberculin skin test (TST) or by techniques known as interferon-γ release assays (IGRAS), being QuantiFERON^®-TB Gold In-Tube (QF-G-IT) the most used. The IGRAS avoid some drawbacks of the TST, especially cross-reaction with bacillus Calmette-Guérin (BCG) vaccine, but also present some problems such as those arising from cost and the need of having an adequate infrastructure and experience. There is no clear consensus on which technique should be preferentially used for the diagnosis of LTBI.
This is a comparative study between the TST and QT-G-IT in a cohort of contacts of patients with pulmonary tuberculosis during the study period. An analysis of global agreement and groups was performed according to whether the contacts were vaccinated with BCG or not. A study of costs of both techniques and diagnostic strategies based on these techniques was performed.
The agreement between TST and QF-G-IT was acceptable in the whole sample yet it was very good in the unvaccinated group. Few cases of indeterminate values were recorded. The cost study showed that TST was cheaper than QF-G-IT; however when we analyzed the cost of the strategies according to each technique, the QF-G-IT showed a better cost-benefit.
We suggest considering QF-G-IT as the only preferred technique for the diagnosis of LTBI in household contacts, based on good overall agreement between the 2 techniques (even if we eliminate the effect of the vaccine) and a cost analysis favorable to QF-G-IT.
Prospective head-to-head study comparing 2 commercial interferon gamma release assays for the diagnosis of tuberculous uveitis
2014, American Journal of Ophthalmology
Citation Excerpt :
In contrast, the US Centers for Disease Control and Prevention guidance recommends 1-step IGRA testing for screening of latent TB infection. This lack of agreement likely reflects the current areas of uncertainty with regard to IGRAs and will continue to evolve as ongoing research rapidly fills the gaps in our current knowledge.44,45 The limitation of all studies involving extrapulmonary TB, including ocular TB, is the small number of patients who actually have positive TB cultures in ocular samples, which is the gold standard for diagnosis.46
To perform a head-to-head comparison of 2 commercially available interferon-gamma release assays, QuantiFERON-TB Gold In-Tube (Cellestis, Chadstone, Victoria, Australia) and T-SPOT.TB (Oxford Immunotech, Abingdon, Oxfordshire, UK), in the diagnosis of tuberculous uveitis.
Prospective cohort to study diagnostic accuracy.
We recruited consecutive new patients who presented with uveitis to a tertiary institution over a 2-year period. All patients underwent complete ocular examination and systemic evaluation, including T-SPOT.TB, QuantiFERON-TB Gold In-Tube, and tuberculin skin test. Patients were followed-up for a minimum of 1 year after completion of antituberculous therapy where indicated. The main outcome measures were the sensitivity, specificity and accuracy of each test, estimated using Bayesian latent class analysis (presented with 95% Bayesian credible intervals) (Crl). Prior information was obtained from published meta-analyses for diagnostic tests: QuantiFERON Gold In-Tube sensitivity (0.64, 0.59-0.69) and specificity (0.99, 0.99-1.00); T-SPOT. tuberculosis sensitivity (0.50, 0.33-0.67) and specificity (0.91, 0.88-0.93).
From our study in patients with uveitis, QuantiFERON-TB Gold In-Tube was more specific but slightly less sensitive (sensitivity: 0.64, 0.60-0.69; specificity: 0.995, 0.988-0.999) than T-SPOT.TB (sensitivity: 0.67, 0.60-0.74; specificity: 0.91, 0.88-0.93). However, QuantiFERON Gold In-Tube was significantly more accurate in identifying true-positive tuberculous uveitis cases than was T-SPOT.TB among discordant cases (QuantiFERON Gold In-Tube positive 98% vs T-SPOT.TB positive 76%; ratio 1.28, 95% Crl: 1.11-1.72, ie, 95% Crl >1.0, statistically significant).
Based on statistical decision theory, our head-to-head study suggests that QuantiFERON-TB Gold In-Tube is the first-line test that should be performed in preference to T-SPOT.TB (and the tuberculin skin test) for diagnosing tuberculous uveitis.
Presumed Ocular Tuberculosis: A Retrospective Case Series
2022, Research Square
Clinical profile and treatment response of patients with ocular inflammation due to presumed ocular tuberculosis: A retrospective study
2019, Turkish Journal of Ophthalmology
Diagnosis of Ocular Tuberculosis
2018, Ocular Immunology and Inflammation
Controversies in ocular tuberculosis
2017, British Journal of Ophthalmology

View all citing articles on Scopus

: Funding sources: None.

: Disclosure: Dr Kimball is an investigator and/or consultant for and receives grants and honoraria from Abbott, Centocor, and Amgen. Ms Kardos has no conflicts of interest to declare.

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Journal of the American Academy of Dermatology

References (22)

Evidence-based comparison of commercial interferon-gamma release assays for detecting active TB: a meta-analysis

Chest

Guidelines on interferon-γ release assays for tuberculosis infection: concordance, discordance or confusion?

Clin Microbiol Infect

National Psoriasis Foundation consensus statement on screening for latent tuberculosis infection in patients with psoriasis treated with systemic and biologic agents

J Am Acad Dermatol

Antitumor necrosis factor agents and tuberculosis risk: mechanisms of action and clinical management

Lancet Infect Dis

Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection–United States, 2010

MMWR Morb Mortal Wkly Rep

Adverse effects of biologics: a network meta-analysis and Cochrane overview

Cochrane Database Syst Rev

Tuberculosis associated with infliximab, a tumor necrosis factor α-neutralizing agent

N Engl J Med

100 year update on diagnosis of tuberculosis infection

Br Med Bull

Performance of the tuberculin skin test and interferon-gamma release assay in immunocompromised patients in a BCG-vaccinated population

BMC Infect Dis

Tuberculin skin test overestimates tuberculosis hypersensitivity in adult patients with psoriasis

Dermatology

Cited by (14)

Comparative study of concordance and costs between tuberculin skin test and QuantiFERON®-TB Gold In-Tube in the diagnosis of latent tuberculosis infection among contacts of patients with pulmonary tuberculosis

Prospective head-to-head study comparing 2 commercial interferon gamma release assays for the diagnosis of tuberculous uveitis

Presumed Ocular Tuberculosis: A Retrospective Case Series

Clinical profile and treatment response of patients with ocular inflammation due to presumed ocular tuberculosis: A retrospective study

Diagnosis of Ocular Tuberculosis

Controversies in ocular tuberculosis

CommentaryTime for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting

Chest

Clin Microbiol Infect

J Am Acad Dermatol

Lancet Infect Dis

Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection–United States, 2010

MMWR Morb Mortal Wkly Rep

Adverse effects of biologics: a network meta-analysis and Cochrane overview

Cochrane Database Syst Rev

Tuberculosis associated with infliximab, a tumor necrosis factor α-neutralizing agent

N Engl J Med

100 year update on diagnosis of tuberculosis infection

Br Med Bull

Performance of the tuberculin skin test and interferon-gamma release assay in immunocompromised patients in a BCG-vaccinated population

BMC Infect Dis

Tuberculin skin test overestimates tuberculosis hypersensitivity in adult patients with psoriasis

Dermatology

Commentary
Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting