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Lee JH, Sohn HS, Chun JH, Kim HA, Suh CH, Lee YW, Yoon BY. Poor agreement between QuantiFERON-TB Gold test and tuberculin skin test results for the diagnosis of latent tuberculosis infection in rheumatoid arthritis patients and healthy controls. Korean J Intern Med 2014; 29:76-84. [PMID: 24574836 PMCID: PMC3932398 DOI: 10.3904/kjim.2014.29.1.76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/06/2013] [Accepted: 04/15/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We investigated the agreement between the QuantiFERON-TB Gold (QFT-Gold) test and the tuberculin skin test (TST) in the diagnosis of latent tuberculosis infection in patients with rheumatoid arthritis (RA), compared with healthy controls, in Korea. METHODS We recruited 64 patients with RA and 79 healthy controls at two university hospitals in South Korea. The participants underwent both the QFT-Gold test and the TST simultaneously between August 2006 and February 2009. All patients were diagnosed using the classification criteria for RA revised in 1987 by the American College of Rheumatology. Bacillus Calmette-Guérin vaccination status and current medications were evaluated, and disease activities were assessed using the Disease Activity Score in 28 joints. Eleven patients with RA produced indeterminate QFT-Gold test results and were thus excluded from the kappa analysis. RESULTS Based on an induration of 10 mm in diameter as the TST cutoff value, the QFT-Gold test and TST demonstrated 75.0% agreement (κ = 0.23) in patients with RA and 75.9% agreement (κ = 0.19) in healthy controls. Among the 56 patients with RA who had negative TST results, 11 patients (17.2%) also yielded indeterminate QFT-Gold results. CONCLUSIONS Our study showed poor agreement between the results of the QFT-Gold test and the TST in both RA patients and healthy controls. Based on these findings, we emphasize the importance of making clinical decisions in the diagnosis of latent tuberculosis in Koreans with or without RA.
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Affiliation(s)
- Joo-Hyun Lee
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hae Sook Sohn
- Department of Preventive Medicine, Inje University College of Medicine, Busan, Korea
| | - Jin Ho Chun
- Department of Preventive Medicine, Inje University College of Medicine, Busan, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | | | - Bo Young Yoon
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
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Weakly positive tests and chronologic variation of the QuantiFERON assay: A retrospective appraisal of usefulness. Tuberculosis (Edinb) 2013; 93:647-53. [DOI: 10.1016/j.tube.2013.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 06/26/2013] [Accepted: 07/30/2013] [Indexed: 11/15/2022]
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Horne DJ, Narita M, Spitters CL, Parimi S, Dodson S, Limaye AP. Challenging issues in tuberculosis in solid organ transplantation. Clin Infect Dis 2013; 57:1473-82. [PMID: 23899676 PMCID: PMC3805170 DOI: 10.1093/cid/cit488] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 07/19/2013] [Indexed: 12/17/2022] Open
Abstract
Solid organ transplant (SOT) recipients are at risk for opportunistic infections including tuberculosis. Although guidelines on the management of latent tuberculosis and active tuberculosis are available, there remain a number of clinical areas with limited guidance. We discuss challenges in the diagnosis, management, and treatment of latent and active tuberculosis in SOT candidates and recipients who reside in low-tuberculosis-prevalence areas. We discuss the diagnosis of latent tuberculosis in SOT candidates/recipients using tuberculin skin tests and interferon-γ release assays and risk stratification of SOT candidates/recipients that would identify individuals at high risk for latent tuberculosis despite negative test results. Through a careful review of posttransplant tuberculosis cases, we identify a history of treated tuberculosis in SOT recipients as a risk factor for development of posttransplant active tuberculosis. Finally, we include comparisons of recommendations by several large transplant organizations and identify areas for future research.
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Cost-effectiveness of QuantiFERON testing before initiation of biological therapy in inflammatory bowel disease. Inflamm Bowel Dis 2013; 19:2444-9. [PMID: 23945184 PMCID: PMC3889121 DOI: 10.1097/mib.0b013e31829f008f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Anti-tumor necrosis factor α drugs are known to reactivate latent tuberculosis (TB). Current guidelines recommend screening for latent tuberculosis infection, with either tuberculin skin test (TST) or interferon gamma release assays such as QuantiFERON-TB Gold (QFT-G). Given the high rates of anergy to TST among immunosuppressed inflammatory bowel disease (IBD) patients, there is considerable interest in evaluating the superiority of interferon gamma release assays over TST in this patient population to diagnose latent tuberculosis infection. We compared the performance of TST and QFT-G for screening latent TB among immunosuppressed IBD patients based on prevalence, mortality risk from reactivation TB, and costs. METHODS A decision analytical model was constructed to compare 1-year outcomes and costs of using TST or interferon gamma release assay in an immunosuppressed IBD population. RESULTS Under the base case scenario, for every 1000 patients screened, the QFT-G strategy resulted in 0.53 deaths from reactivation TB compared with 1.92 deaths using TST. The QFT-G strategy results in 1.85 reactivation TB versus 6.7 reactivation TB using TST. The model was not sensitive to background prevalence of latent TB. The cost of QFT-G would have to be more than double for the TST strategy to become more cost effective. QFT-G also remains the cost-effective option unless the sensitivity of the TST improves by 400%. CONCLUSIONS Under a broad range of parameter values, the QFT-G strategy dominates the TST strategy in cost-effectiveness. Consideration should be given to QFT-G as the preferred method of identifying latent TB in all immunosuppressed IBD patients.
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Costantino F, de Carvalho Bittencourt M, Rat AC, Loeuille D, Dintinger H, Béné MC, Faure G, Chary-Valckenaere I. Screening for Latent Tuberculosis Infection in Patients with Chronic Inflammatory Arthritis: Discrepancies Between Tuberculin Skin Test and Interferon-γ Release Assay Results. J Rheumatol 2013; 40:1986-93. [DOI: 10.3899/jrheum.130303] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective.Screening for latent tuberculosis infection (LTBI) is mandatory before initiating biologics in patients with chronic inflammatory arthritis (CIA). However, few studies have evaluated the discrepancies between the results of tuberculin skin test (TST) and interferon-γ release assays (IGRA) in these patients. The purpose of our study was to investigate factors associated with TST and IGRA results in a large cohort of patients with CIA before the introduction of biologics.Methods.A total of 563 consecutive patients with CIA (293 rheumatoid arthritis, 270 spondyloarthritis) and eligible for biologics were prospectively enrolled. Demographic, clinical, and biological data were recorded. Risk factors for LTBI were assessed. All patients underwent a TST, a chest radiograph, and an IGRA test (T-SPOT.TB).Results.Agreement between the 2 tests was low (κ = 0.16). The bacillus Calmette-Guerin (BCG) status was significantly associated with discordance between the 2 tests (p = 0.004). The TST positivity rate was 34.8%. Factors associated with a negative TST were female sex (p = 0.02) and immunosuppressive treatment (p = 0.003). The only LTBI risk factor associated with TST positivity was an abnormal chest radiograph (p = 0.02). T-SPOT.TB was positive in 21.7% of patients and indeterminate in 15.6%. Previous active TB and chest radiograph abnormalities were associated with IGRA positivity (p = 0.008 and p = 3.9 × 10−5, respectively). The BCG vaccination was associated with negative IGRA (p = 3 × 10−4). Indeterminate IGRA results were associated with age, C-reactive protein, and immunosuppressive treatment (p = 0.005, 0.007, and 0.004, respectively).Conclusion.Our data support the combined use of T-SPOT.TB and TST in patients with CIA before biologics introduction. However, despite these good diagnostic values, indeterminate results may complicate the use of IGRA.
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Redelman-Sidi G, Sepkowitz KA. IFN-γ Release Assays in the Diagnosis of Latent Tuberculosis Infection among Immunocompromised Adults. Am J Respir Crit Care Med 2013; 188:422-31. [DOI: 10.1164/rccm.201209-1621ci] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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To KW, Reino JJG, Yoo DH, Tam LS. Tumour necrosis factor antagonist and tuberculosis in patients with rheumatoid arthritis: An Asian perspective. Respirology 2013; 18:765-73. [PMID: 23627398 DOI: 10.1111/resp.12106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/01/2013] [Accepted: 04/17/2013] [Indexed: 12/31/2022]
Affiliation(s)
- Kin Wang To
- Division of Respiratory Medicine; Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong, SAR; China
| | - Juan J Gomez Reino
- Department of Medicine and Rheumatology Unit; Hospital Clínico Universitario, USC; Santiago de Compostela; Spain
| | - Dae Hyun Yoo
- Division of Rheumatology, Department of Internal Medicine; Hanyang University Hospital, Hanyang University College of Medicine; Seoul; Korea
| | - Lai Shan Tam
- Division of Rheumatology; Department of Medicine and Therapeutics; Prince of Wales Hospital, The Chinese University of Hong Kong; Hong Kong, SAR; China
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Solovan C, Chiticariu E. Psoriasis, anti-tumor necrosis factor therapy, and tuberculosis: report of three challenging cases and literature review. Infect Dis Ther 2013; 2:59-73. [PMID: 25135824 PMCID: PMC4108098 DOI: 10.1007/s40121-013-0003-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The era of biologic therapies has provided new options for the treatment of chronic plaque psoriasis. However, safety concerns have led to intensive screening and monitoring of patients receiving anti-tumor necrosis factor alpha (anti-TNF-alpha) agents. METHODS The authors describe the cases of three patients with moderate to severe psoriasis treated with anti-TNF agents, with challenging diagnostic and treatment aspects regarding tuberculosis (TB) infection, a serious adverse event associated with this type of treatment. The cases are discussed in the context of a comprehensive literature review describing the risk of TB associated with the use of TNF inhibitors. A critical review of the clinical trials that have tested the safety of these agents is also presented. RESULTS One patient, who tested negatively for latent TB infection (LTBI) during screening, developed active TB under adalimumab therapy. For two other patients the diagnosis and management of LTBI in relation to anti-TNF therapy represented a challenge. Although clinical trials involving the use of anti-TNF therapy for psoriasis haven't demonstrated a high TB incidence, active TB is continuously reported in association with this treatment. CONCLUSIONS Findings from clinical practice and the scientific literature indicate that anti-TNF therapies are associated with an increased risk of TB, and close monitoring of patients is needed.
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Affiliation(s)
- Caius Solovan
- Department of Dermatology, University of Medicine and Pharmacy “Victor Babes” Timisoara, Marasesti 5, 300077 Timisoara, Romania
| | - Elena Chiticariu
- Department of Dermatology, University of Medicine and Pharmacy “Victor Babes” Timisoara, Marasesti 5, 300077 Timisoara, Romania
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Martyn-Simmons C, Mee J, Kirkham B, Groves R, Milburn H. Evaluating the use of the interferon-γ response toMycobacterium tuberculosis-specific antigens in patients with psoriasis prior to antitumour necrosis factor-α therapy: a prospective head-to-head cross-sectional study. Br J Dermatol 2013; 168:1012-8. [DOI: 10.1111/bjd.12176] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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¿Podemos mejorar el estudio de contactos en la tuberculosis? Med Clin (Barc) 2013; 140:305-6. [DOI: 10.1016/j.medcli.2012.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 11/15/2012] [Indexed: 11/18/2022]
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Bartalesi F, Goletti D, Spinicci M, Cavallo A, Attala L, Mencarini J, Fiori G, Li Gobbi F, Mantella A, Benucci M, Prignano F, Pimpinelli N, Matucci Cerinic M, Girardi E, Bartoloni A. Serial QuantiFERON TB-Gold in-tube testing during LTBI therapy in candidates for TNFi treatment. J Infect 2013; 66:346-56. [DOI: 10.1016/j.jinf.2012.10.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 10/16/2012] [Accepted: 10/18/2012] [Indexed: 12/11/2022]
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Trajman A, Steffen RE, Menzies D. Interferon-Gamma Release Assays versus Tuberculin Skin Testing for the Diagnosis of Latent Tuberculosis Infection: An Overview of the Evidence. Pulm Med 2013; 2013:601737. [PMID: 23476763 PMCID: PMC3582085 DOI: 10.1155/2013/601737] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 01/10/2013] [Indexed: 11/18/2022] Open
Abstract
A profusion of articles have been published on the accuracy and uses of interferon-gamma releasing assays. Here we review the clinical applications, advantages, and limitations of the tuberculin skin test and interferon-gamma release assays and provide an overview of the most recent systematic reviews conducted for different indications for the use of these tests. We conclude that both tests are accurate to detect latent tuberculosis, although interferon-gamma release assays have higher specificity than tuberculin skin testing in BCG-vaccinated populations, particularly if BCG is received after infancy. However, both tests perform poorly to predict risk for progression to active tuberculosis. Interferon-gamma release assays have significant limitations in serial testing because of spontaneous variability and lack of a validated definition of conversion and reversion, making it difficult for clinicians to interpret changes in category (conversions and reversions). So far, the most important clinical evidence, that is, that isoniazid preventive therapy reduces the risk for progression to disease, has been produced only in tuberculin skin test-positive individuals.
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Affiliation(s)
- A. Trajman
- Gama Filho University, 20740-900 Rio de Janeiro, RJ, Brazil
- Montreal Chest Institute, McGill University, Montreal, QC, Canada H2X 2P4
| | - R. E. Steffen
- Federal University of Rio de Janeiro, 21941-913 Rio de Janeiro, RJ, Brazil
| | - D. Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada H2X 2P4
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García-Gasalla M, Fernández-Baca V, Juan-Mas A, Payeras-Cifre A, Cifuentes-Luna C, Taberner-Ferrer R, Riera-Oliver J, Ros-Villamajó I, Navarro-Fernández V, Morey Torrandell C, Gallegos-Alvarez C, Mir-Villadrich I. Use of Quantiferon-TB-Gold in Tube® test for detecting latent tuberculosis in patients considered as candidates for anti-TNF therapy in routine clinical practice. Enferm Infecc Microbiol Clin 2013; 31:76-81. [DOI: 10.1016/j.eimc.2012.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 06/10/2012] [Accepted: 06/26/2012] [Indexed: 11/15/2022]
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SCRIVO ROSSANA, SAUZULLO ILARIA, MENGONI FABIO, PRIORI ROBERTA, COPPOLA MARIATERESA, IAIANI GIANCARLO, DI FRANCO MANUELA, VULLO VINCENZO, MASTROIANNI CLAUDIOMARIA, VALESINI GUIDO. Mycobacterial Interferon-γ Release Variations During Longterm Treatment with Tumor Necrosis Factor Blockers: Lack of Correlation with Clinical Outcome. J Rheumatol 2012. [DOI: 10.3899/jrheum.120688] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective.To assess the performance of serial QuantiFeron-TB Gold In-Tube (QFT-GIT) tests in patients with rheumatic diseases during longterm systemic treatment with biologic therapy, evaluating conversions and reversions in relation to the clinical outcome.Methods.We conducted a prospective study on patients awaiting biologic agents. At baseline, they had chest radiographs, QFT-GIT tests, and tuberculin skin tests (TST); QFT-GIT was repeated at 3, 6, 12, and 18 months after onset of biologic therapy. In patients with no evidence of latent tuberculosis infection (LTBI) at baseline, TST was repeated at 12 months of biologic treatment.Results.Among patients (n = 102; women 65.7%; median age 47 yrs, range 20–82), 14 (13.7%) were considered as having LTBI because of a minimum of 1 abnormal screening test. The agreement between QFT-GIT and TST was 88% (κ = 0.14). During biologic treatment, both patients with (n = 14) and those without (n = 88) evidence of LTBI at baseline showed conversions and reversions in QFT-GIT results at different timepoints. These fluctuations were not paralleled by significant clinical changes. The TST repeated at 12 months in patients with no evidence of LTBI at baseline continued to be negative. The median baseline interferon-γ (IFN-γ) concentration was not significantly different from that observed at each subsequent timepoint.Conclusion.Dynamic changes occur with serial IFN-γ release assay testing in patients treated with biologic therapy that do not correlate with clinical outcome. A careful and integrated evaluation of the patient, including clinical information, should guide the treatment decision. This study was underpowered for definite conclusions and further studies are needed to determine the significance of these findings.
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Klinische Präsentationen der Tuberkulose im Alltag. Z Rheumatol 2012; 71:711-6. [DOI: 10.1007/s00393-012-0991-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Tavast E, Tuuminen T, Pakkanen SH, Eriksson M, Kantele A, Järvinen A, Pusa L, Mälkönen T, Seppälä I, Repo H, Lerisalo-Repo M. Immunosuppression Adversely Affects TST but Not IGRAs in Patients with Psoriasis or Inflammatory Musculoskeletal Diseases. Int J Rheumatol 2012; 2012:381929. [PMID: 22666260 PMCID: PMC3362055 DOI: 10.1155/2012/381929] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 03/06/2012] [Accepted: 03/13/2012] [Indexed: 11/18/2022] Open
Abstract
The performance of the interferon gamma release assays (IGRAs) and tuberculin skin test (TST) was reviewed retrospectively in patients with psoriasis, inflammatory musculoskeletal diseases, or miscellaneous inflammatory conditions. The study was carried out over a 22-month period using 109 records of patients with psoriasis (n = 21), musculoskeletal disease (n = 74), or other inflammatory conditions (n = 14). Forty-four (48%) of 109 patients were on immunosuppressive therapy and 38/109 (35%) on systemic glucocorticoid therapy. The agreement between the IGRAs was substantial (κ = 0.71) whilst that between the IGRAs and TST was low (κ = 0.32). Logistic regression models revealed that IGRAs associated with risk factors for latent tuberculosis infection better than TST. TST was influenced by age, BCG vaccination, sex, and glucocorticoid therapy. We found that IGRAs performed equally well with low level of indeterminate results (1-2%). IGRAs were superior to TST because the latter was influenced by BCG-vaccination status and immunosuppressive therapy.
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Affiliation(s)
- Esko Tavast
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland
| | - Tamara Tuuminen
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland
- Eastern Finland Laboratory Centre Joint Authority Enterprise (ISLAB), Mikkeli District Laboratory, Porrassalmenkatu 35-37, FI-50100 Mikkeli, Finland
| | - Sari H. Pakkanen
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, P.O. Box 348, FI-00029 HUS, Helsinki, Finland
| | - Mari Eriksson
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, P.O. Box 348, FI-00029 HUS, Helsinki, Finland
| | - Anu Kantele
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, P.O. Box 348, FI-00029 HUS, Helsinki, Finland
- Institute of Clinical Medicine, University of Helsinki, P.O. Box 20, 00014 Helsingin Yliopisto, Finland
| | - Asko Järvinen
- Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, P.O. Box 348, FI-00029 HUS, Helsinki, Finland
| | - Liana Pusa
- Department of Internal Diseases, Länsi-Uusimaa Hospital, P.O. Box 1020, Itäinen rantakatu 9, 10601 Tammisaari, Finland
| | - Tarja Mälkönen
- Department of Dermatology and Allergology, Helsinki University Central Hospital, P.O. Box 160, HUS 00029, Helsinki, Finland
| | - Ilkka Seppälä
- Division of Clinical Microbiology, Helsinki University Central Hospital, HUSLAB, P.O. Box 400, HUS 00029, Helsinki, Finland
| | - Heikki Repo
- Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland
| | - Marjatta Lerisalo-Repo
- Institute of Clinical Medicine, University of Helsinki, P.O. Box 20, 00014 Helsingin Yliopisto, Finland
- Division of Rheumatology, Department of Medicine, Helsinki University Central Hospital, P.O. Box 440, HUS 00029, Helsinki, Finland
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Balato N, Di Costanzo L, Ayala F, Balato A, Sanduzzi A, Bocchino M. Psoriatic disease and tuberculosis nowadays. Clin Dev Immunol 2012; 2012:747204. [PMID: 22645622 PMCID: PMC3356875 DOI: 10.1155/2012/747204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 02/21/2012] [Indexed: 01/28/2023]
Abstract
Psoriasis is a chronic, relapsing and remitting inflammatory skin and joint disease that has a prevalence of 2-3% in the world's population, whereas of 1-2% in Europe. The traditional concept of psoriasis as the "healthy people's" disease has been recently revised because of ever-increasing reports of associations with various pathological conditions (hypertension, Crohn's disease, type II diabetes mellitus, obesity, dyslipidemia, metabolic syndrome, infectious conditions). Particularly, advances in psoriasis therapies have introduced biologic agents. All the tumor necrosis factor-alpha inhibitors are associated with an increased risk of developing active disease in patients with latent tuberculosis infection, because of TNF-α key role against Mycobacterium tuberculosis. For this reason, exclusion of active tuberculosis and treatment of latent tuberculosis infection are clinical imperatives prior to starting this therapy. Moreover active surveillance for a history of untreated or partially treated tuberculosis or latent form has already been shown to be effective in reducing the number of incident tuberculosis cases.
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Affiliation(s)
- Nicola Balato
- Department of Dermatology, University of Naples Federico II, Italy
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68
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Fraisse P. Diagnostic des infections tuberculeuses latentes (sujets sains, sujets immunodéprimés ou amenés à l’être). Rev Mal Respir 2012; 29:277-318. [DOI: 10.1016/j.rmr.2011.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 05/11/2011] [Indexed: 01/30/2023]
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69
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Amerio P, Amoruso G, Bardazzi F, Campanati A, Cassano N, Conti A, Gisondi P, Guarneri C, Mazzotta A, Piaserico S, Prestinari F, Prignano F, Zane C, de Simone C. Detection and management of latent tuberculosis infections before biologic therapy for psoriasis. J DERMATOL TREAT 2012; 24:305-11. [DOI: 10.3109/09546634.2011.654107] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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70
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Interferon-gamma release assays in the detection of latent tuberculosis infection in patients with inflammatory arthritis scheduled for anti-tumour necrosis factor treatment. Clin Rheumatol 2012; 31:785-94. [DOI: 10.1007/s10067-012-1938-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 12/09/2011] [Accepted: 01/02/2012] [Indexed: 01/09/2023]
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Worjoloh A, –Maeda MK, Osmond D, Freyre R, Aziz N, Cohan D. Interferon gamma release assay compared with the tuberculin skin test for latent tuberculosis detection in pregnancy. Obstet Gynecol 2011; 118:1363-1370. [PMID: 22105266 PMCID: PMC3232049 DOI: 10.1097/aog.0b013e31823834a9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To estimate agreement and correlation between the tuberculin skin test and an interferon gamma release assay for detecting latent tuberculosis (TB) infection in pregnant women. METHODS We conducted a cross-sectional study of pregnant women initiating prenatal care at a university-affiliated public hospital between January 5, 2009, and March 15, 2010. Eligible women received a questionnaire about TB history and risk factors as well as the tuberculin skin test and phlebotomy for the interferon gamma release assay. Agreement and correlation between tests were estimated, and different cutoffs for interferon gamma release assay positivity were used to assess effect on agreement. Furthermore, predictors of test positivity and test discordance were evaluated using multivariable analysis. RESULTS Of the 220 enrolled women, 199 (90.5%) returned for tuberculin skin test evaluation. Over 70% were Hispanic and 65% were born in a country with high TB prevalence. Agreement between the tuberculin skin test and interferon gamma release assay was 77.39 (κ=0.26). This agreement was not significantly changed using different cutoffs for the assay. Birth bacille Calmette-Guérin vaccination was associated with tuberculin skin test positivity (odds ratio [OR] 4.33, 95% confidence interval [CI] 1.4-13.48, P=.01), but not interferon gamma release assay positivity. There were no statistically significant predictors of the tuberculin skin test and interferon gamma release assay result discordance; however, birth in a high-prevalence country was marginally associated with tuberculin skin test-positive and interferon gamma release assay-negative results (OR 2.94, 95% CI 0.86-9.97 P=.08). CONCLUSION Comparing the tuberculin skin test and interferon gamma release assay results in pregnancy, concordance and agreement were poor. Given that much is still unknown about the performance of interferon gamma release assays in pregnancy, further research is necessary before the tuberculin skin test is abandoned for screening of latent TB infection in pregnancy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ayaba Worjoloh
- Duke University, Hubert-Yeargan Center for Global Health and Department of Obstetrics and Gynecology
| | - Midori Kato –Maeda
- Francis J. Curry National Tuberculosis Center, Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital
| | - Dennis Osmond
- Department of Epidemiology and Biostatistics University of California San Francisco, San Francisco, CA
| | - Rachel Freyre
- University of California San Francisco Department of Obstetrics, Gynecology, and Reproductive Sciences
| | - Natali Aziz
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, California
| | - Deborah Cohan
- University of California San Francisco Department of Obstetrics, Gynecology, and Reproductive Sciences
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Vassilopoulos D, Tsikrika S, Hatzara C, Podia V, Kandili A, Stamoulis N, Hadziyannis E. Comparison of two gamma interferon release assays and tuberculin skin testing for tuberculosis screening in a cohort of patients with rheumatic diseases starting anti-tumor necrosis factor therapy. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2011; 18:2102-8. [PMID: 21994356 PMCID: PMC3232699 DOI: 10.1128/cvi.05299-11] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 10/05/2011] [Indexed: 11/20/2022]
Abstract
Gamma interferon release assays (IGRAs) are increasingly used for latent Mycobacterium tuberculosis infection (LTBI) screening in patients with rheumatic diseases starting anti-tumor necrosis factor (anti-TNF) therapies. We compared the performances of two IGRAs, an enzyme-linked immunospot release assay (T-SPOT.TB) and an enzyme-linked immunosorbent assay (QuantiFERON-TB Gold In Tube [QFT-GIT]), to that of tuberculin skin testing (TST) for LTBI screening of 157 consecutive rheumatic patients starting anti-TNF therapies. Among 155 patients with valid results, 58 (37%) were positive by TST, 39 (25%) by T-SPOT.TB assay, and 32 (21%) by QFT-GIT assay. IGRAs were associated more strongly with at least one risk factor for tuberculosis (TB) than TST. Risk factors for a positive assay included chest X-ray findings of old TB (TST), advanced age (both IGRAs), origin from a country with a high TB prevalence, and a positive TST (T-SPOT.TB assay). Steroid use was negatively associated with a positive QFT-GIT assay. The agreement rate between IGRAs was 81% (kappa rate = 0.47), which was much higher than that observed between an IGRA and TST. If positivity by either TST or an IGRA was required for LTBI diagnosis, then the rate of LTBI would have been 46 to 47%, while if an IGRA was performed only for TST-positive patients, the respective rate would have been 11 to 17%. In conclusion, IGRAs appear to correlate better with TB risk than TST and should be included in TB screening of patients starting anti-TNF therapies. In view of the high risk of TB in these patients, a combination of one IGRA and TST is probably more appropriate for LTBI diagnosis.
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Affiliation(s)
- Dimitrios Vassilopoulos
- 2nd Department of Medicine, Hippokration General Hospital, Athens University School of Medicine, Athens, Greece.
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Erckens RJ, Mostard RLM, Wijnen PAHM, Schouten JS, Drent M. Adalimumab successful in sarcoidosis patients with refractory chronic non-infectious uveitis. Graefes Arch Clin Exp Ophthalmol 2011; 250:713-20. [PMID: 22119879 PMCID: PMC3332360 DOI: 10.1007/s00417-011-1844-0] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 09/26/2011] [Accepted: 10/03/2011] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Adalimumab, a humanized monoclonal antibody targeted against TNF-α, has proved to be successful in the treatment of uveitis. Another anti-TNF-α agent, i.e., infliximab, has been reported of benefit in the treatment of refractory sarcoidosis. The aim of this prospective case series was to evaluate the effect of adalimumab on intraocular inflammatory signs and other relevant clinical manifestations (lung function, serological inflammatory parameters, and fatigue) of sarcoidosis. METHODS Sarcoidosis patients with refractory posterior uveitis (n = 26, 17 females, 41 eyes in total) were systematically followed for 12 months after initiation of adalimumab 40 mg sc once a week. Inclusion criteria were non-responsiveness to prednisone and methotrexate (MTX) or intolerance to these drugs. Adjunctive therapy with prednisone and MTX was tapered during treatment with adalimumab. Localization and improvement, stabilization or deterioration of intraocular inflammatory signs was scored. Pulmonary function- and laboratory testing were performed and Fatigue Assessment Scale was completed. Results at baseline, 6 months, and 12 months were compared. RESULTS Choroidal involvement resolved in 10/15 patients, five had partial improvement; vasculitis resolved in 1/1 patient; papillitis resolved in 7/8 patients, one had partial response; macular edema resolved in 5/8 patients, three had partial response; vitreous cleared completely in 5/5 patients. Overall outcome regarding intraocular inflammatory signs showed improvement in 22 patients (85%) and stabilization in four patients (15%). At 12 months, no recurrences were reported in those successfully treated. Laboratory parameters of inflammatory activity (C-reactive protein; serum angiotensin-converting enzyme and soluble interleukin-2 Receptor) improved (p < 0.01). Moreover, fatigue improved in 14/21 (67%) of the patients suffering from fatigue and the diffusion capacity for carbon monoxide (DLCO) improved in 7/8 (88%) of patients with a decreased DLCO (p < 0.01). The dosage of both prednisone and MTX could be tapered down significantly (p < 0.01 and p < 0.05, respectively). CONCLUSIONS Adalimumab appeared successful in sarcoidosis patients with refractory chronic non-infectious uveitis showing improvement in intraocular inflammatory signs as well as in other relevant clinical indicators of disease activity. Future randomized studies are needed to determine the optimal dosage, dose interval and duration of therapy in refractory multisystemic sarcoidosis.
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Affiliation(s)
- R J Erckens
- Department of Ophthalmology, Maastricht University Medical Centre, P. Debyelaan 25, 6229, HX, Maastricht, The Netherlands.
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Bélard E, Semb S, Ruhwald M, Werlinrud AM, Soborg B, Jensen FK, Thomsen H, Brylov A, Hetland ML, Nordgaard-Lassen I, Ravn P. Prednisolone treatment affects the performance of the QuantiFERON gold in-tube test and the tuberculin skin test in patients with autoimmune disorders screened for latent tuberculosis infection. Inflamm Bowel Dis 2011; 17:2340-9. [PMID: 21319275 DOI: 10.1002/ibd.21605] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/08/2010] [Indexed: 12/09/2022]
Abstract
BACKGROUND During screening for latent tuberculosis infection (LTBI), before anti-tumor-necrosis-factor-α treatment, most patients are already receiving immunosuppressive therapy. The objective was to evaluate the performance of the QuantiFERON Gold In-Tube (QFT-IT) and the Tuberculin Skin Test (TST). METHODS A prospective multicenter study included 248 patients with ulcerative colitis (39), Crohn's disease (54), rheumatoid arthritis (111), and spondylo-arthropathy (44). RESULTS QFT-IT was positive in 7/248 (3%), negative in 229 (92%), and indeterminate in 12 (5%). TST was positive in 54/238 (23%) patients. Chest x-ray was suspect for tuberculosis in 5/236 (2%), and 35/167 (21%) had ≥1 risk-factors for infection with Mycobacterium tuberculosis. The main finding was a pronounced negative effect on QFT-IT and TST performance associated with prednisolone treatment. During prednisolone treatment interferon gamma (IFN-γ) response to mitogen stimulation was impaired (median IFN-γ response 4.9 IU/mL; interquartile range [IQR] 0.8 to ≥10.0) compared to patients 1) not receiving corticosteroids (median ≥10.0; IQR 5.0 to ≥10.0; P = 0.0015) or 2) receiving long-acting corticosteroids (median >10.0; IQR 9.7 to >10.0; P = 0.0058). Prednisolone treatment was strongly associated with negative TST, adjusted odds ratio (AOR) 0.22 (0.1-0.8; P = 0.018), and with an increased risk of indeterminate QFT-IT results AOR 16.1 (4.1-63.2; P < 0.001), whereas no negative effect was found for long-acting corticosteroids. Doses of ≥10 mg prednisolone were associated with a 27% risk of indeterminate results. Single use of azathioprine, methotrexate, or 5-aminosalicylate (5-ASA) did not affect the test results. CONCLUSIONS Oral prednisolone severely suppressed QFT-IT and TST performance, whereas the long-acting corticosteroids methotrexate, azathioprine, and 5-ASA did not have a similar detrimental effect. Patients should be screened for LTBI with QFT-IT or TST prior to initiation of prednisolone therapy and negative QFT-IT or TST results interpreted with caution in patients treated with any corticosteroid until further data are available.
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Affiliation(s)
- Erika Bélard
- Department of Gastroenterology, Copenhagen University Hospital, Hvidovre, Denmark
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75
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Sánchez G. C. Tuberculosis: epidemiología y actualización en métodos diagnósticos. Medwave 2011. [DOI: 10.5867/medwave.2011.11.5223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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76
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Arias Guillén M. Avances en el diagnóstico de la infección tuberculosa. Arch Bronconeumol 2011; 47:521-30. [DOI: 10.1016/j.arbres.2011.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 06/03/2011] [Accepted: 06/11/2011] [Indexed: 01/22/2023]
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Diagnosis of tuberculosis infection by tuberculin skin test and a whole-blood interferon-γ release assay in patients considered for anti–tumor necrosis factor-α therapy. Diagn Microbiol Infect Dis 2011; 71:57-65. [PMID: 21851871 DOI: 10.1016/j.diagmicrobio.2010.12.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 12/11/2010] [Accepted: 12/20/2010] [Indexed: 11/22/2022]
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79
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Interferon-gamma release assays for diagnosis of latent tuberculosis infection. Curr Opin Rheumatol 2011. [DOI: 10.1097/bor.0b013e32834a01b9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Santín Cerezales M, Navas Elorza E. Tuberculosis in special populations. Enferm Infecc Microbiol Clin 2011; 29 Suppl 1:20-5. [PMID: 21420563 DOI: 10.1016/s0213-005x(11)70014-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The susceptibility to infection, the pathogenesis and the clinical manifestations of tuberculosis (TB) depend on the immunological status of the host. Immunological status is largely determined by age and comorbidities, but is also affected by other less well known factors. In Spain, most incidental cases of TB arise from the reactivation of remotely acquired latent infections and are favored by the aging of the population and the use of aggressive immunosuppressive therapies. The diagnosis and management of TB in these circumstances is often challenging. On the one hand, the atypical presentation with extrapulmonary involvement may delay diagnosis, and on the other, the toxicity and interactions of the antituberculous drugs frequently make treatment difficult. Immigration from resource-poor, high incidence TB countries, where the social and economic conditions are often suboptimal, adds a new challenge to the control of the disease in Spain. This chapter summarizes our current knowledge of epidemiological, clinical and treatment aspects of TB in particularly susceptible populations.
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Affiliation(s)
- Miguel Santín Cerezales
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, IDIBELL, Departamento de Ciencias Clínicas, Universidad de Barcelona, Red Española de Investigación en Patología Infecciosa, Instituto de Salud Carlos III, Barcelona, Spain.
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81
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Lioté H, Lioté F. Role for interferon-gamma release assays in latent tuberculosis screening before TNF-α antagonist therapy. Joint Bone Spine 2011; 78:352-7. [DOI: 10.1016/j.jbspin.2010.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2010] [Indexed: 01/10/2023]
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82
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Interferon-gamma release assays for diagnosis of latent tuberculosis infection: evidence in immune-mediated inflammatory disorders. Curr Opin Rheumatol 2011; 23:377-84. [DOI: 10.1097/bor.0b013e3283474d62] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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83
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Is tuberculin skin testing reliable during anti–tumor necrosis factor-alfa therapy? A case report and review of the literature. J Am Acad Dermatol 2011; 65:195-7. [DOI: 10.1016/j.jaad.2009.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 11/18/2009] [Accepted: 12/01/2009] [Indexed: 11/22/2022]
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84
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Nacci F, Matucci-Cerinic M. Tuberculosis and other infections in the anti-tumour necrosis factor-alpha (anti-TNF-α) era. Best Pract Res Clin Rheumatol 2011; 25:375-88. [DOI: 10.1016/j.berh.2011.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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85
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Takeda N, Nojima T, Terao C, Yukawa N, Kawabata D, Ohmura K, Usui T, Fujii T, Ito Y, Iinuma Y, Mimori T. Interferon-gamma release assay for diagnosing Mycobacterium tuberculosis infections in patients with systemic lupus erythematosus. Lupus 2011; 20:792-800. [DOI: 10.1177/0961203310397966] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our aim was to analyze the performance of an interferon-gamma release assay, QuantiFERON-TB Gold (QFT-2G), for diagnosing Mycobacterium tuberculosis (MTB) infection in patients with systemic lupus erythematosus (SLE). We performed the QFT-2G and tuberculin skin test (TST) in 71 SLE patients. The QFT-2G results of 279 patients with other connective tissue diseases (CTD) and 35 healthy controls were analyzed. Of the 71 SLE patients, two (2.8%) were positive and 46 (64.8%) were negative by QFT-2G. All SLE patients had no evidence of active MTB infection, apart from one. QFT-2G produced a significantly higher number of indeterminate results in patients with SLE (23/71, 32.4%) compared with those with other CTD (5.7%) or healthy controls (0%) ( p < 0.0001 and p < 0.0001). Decreased lymphocyte counts and high SLEDAI scores in SLE patients were shown to be risk factors for indeterminate results by multivariate analysis ( p = 0.02 and p = 0.04). Among all patients with CTD, SLE itself and lymphocytopenia were found to be independent risks for indeterminate results ( p = 0.00000625 and p = 0.000107). In conclusion, QFT-2G may have more potential to assist in the diagnosis of active and latent MTB infection than TST in SLE patients. However, because of the high frequency of indeterminate results, caution must be used when interpreting the results of QFT-2G among SLE patients, especially those who have parallel or subsequent flares.
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Affiliation(s)
- N Takeda
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - T Nojima
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - C Terao
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - N Yukawa
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - D Kawabata
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - K Ohmura
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - T Usui
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - T Fujii
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Y Ito
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Y Iinuma
- Department of Clinical Infection Disease, Kanazawa Medical University, Ishikawa, Japan
| | - T Mimori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Interferon-γ release assay in the diagnosis of latent tuberculosis infection in arthritis patients treated with tumor necrosis factor antagonists in Korea. Clin Rheumatol 2011; 30:1535-41. [PMID: 21556777 DOI: 10.1007/s10067-011-1771-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Revised: 04/23/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
Abstract
The aim of this study was to evaluate the usefulness of the interferon-γ release assay (IGRA) for the diagnosis of latent tuberculosis infection (LTBI) in arthritis patients who received tumor necrosis factor (TNF) antagonist in Korea. The study involved 107 consecutive patients: 61 (57%) with ankylosing spondylitis and 46 (43%) with rheumatoid arthritis. Screening tests were performed including the tuberculin skin test (TST), the QuantiFERON-TB Gold In-Tube (QFT-IT) test, and chest radiography. A positive QFT-IT test result, regardless of TST results, was considered an indication for LTBI treatment. If the QFT-IT results were indeterminate, a positive TST was regarded as an indication for LTBI treatment. A Bacillus Calmette-Guérin (BCG) scar was found in 63 patients (59%). LTBI treatment was performed in 37 patients (35%), including 36 with positive QFT-IT results and one with indeterminate QFT-IT and positive TST results. No patients developed tuberculosis during a median of 18 months (range, 13-26 months) of TNF antagonist therapy. In 16 patients who had positive TST and negative QFT-IT results, TNF antagonists were given without LTBI treatment. Tuberculosis did not occur, even in these patients, during a median of 24.5 months (range, 15-33.5 months) of TNF antagonist therapy. IGRA may be used instead of TST for the diagnosis of LTBI in patients before starting TNF antagonists in countries where tuberculosis prevalence is intermediate and the BCG vaccination is mandatory at birth, such as in Korea.
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KEYSTONE EDWARDC, PAPP KIMA, WOBESER WENDY. Challenges in Diagnosing Latent Tuberculosis Infection in Patients Treated with Tumor Necrosis Factor Antagonists. J Rheumatol 2011; 38:1234-43. [DOI: 10.3899/jrheum.100623] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Reactivation of latent tuberculosis infection (LTBI) is well recognized as an adverse event associated with anti-tumor necrosis factor-α (anti-TNF-α) therapy. The strengths and weaknesses of current techniques for detecting LTBI in patients with chronic inflammatory diseases such as rheumatoid arthritis (RA) and psoriasis have not been fully examined. T cell hyporesponsiveness due to immunosuppression caused by illness or drugs, referred to as anergy, may produce false-negative tuberculin skin test (TST) and interferon-γ release assay (IGRA) results. The literature suggests that anergy may influence screening performance of TST and IGRA tests in candidates for anti-TNF-α therapy. Conversely, the potential for false-positive TST and IGRA results must be considered, as treatment for LTBI may be associated with significant morbidity. This review examines the reliability issues related to LTBI diagnostic testing and provides practical direction to help prevent LTBI reactivation and facilitate successful anti-TNF-α treatment.
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88
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Lioté H, Lioté F. Place des tests à l’interféron (IGRAs) dans le dépistage de la tuberculose latente (TBL) avant prescription d’agents anti-TNF : le point. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.rhum.2010.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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89
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Santín Cerezales M, Benítez JD. Diagnosis of tuberculosis infection using interferon-γ-based assays. Enferm Infecc Microbiol Clin 2011; 29 Suppl 1:26-33. [DOI: 10.1016/s0213-005x(11)70015-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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90
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A comparison of an interferon-gamma release assay and tuberculin skin test in refractory inflammatory disease patients screened for latent tuberculosis prior to the initiation of a first tumor necrosis factor α inhibitor. Clin Rheumatol 2010; 30:505-10. [PMID: 20737179 PMCID: PMC3062765 DOI: 10.1007/s10067-010-1550-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 07/06/2010] [Accepted: 08/02/2010] [Indexed: 02/02/2023]
Abstract
Treatment with TNFα inhibitors increases risk of reactivating a latent tuberculosis\infection (LTBI). Therefore screening, prior to therapy with TNFα inhibitors, has been recommended, even in low-endemic areas such as well-developed Western Europe countries. We evaluated interferon-gamma release assay (IGRA), as opposed to tuberculin skin test (TST), for detection of LTBI in refractory inflammatory disease patients prior to the initiation of a first TNFα inhibitor. In addition, we evaluated the impact of impaired cellular immunity on IGRA. Patients starting on TNFα inhibition were screened for LTBI by TST and IGRA (Quantiferon-TB Gold). Data on tuberculosis exposure and Bacillus Calmette–Guérin (BCG) vaccination were obtained. Cellular immunity was assessed by CD4+ T lymphocyte cell count. Nine out of 56 patients (16.1%) tested positive for LTBI. A concordant positive result was present in three patients with a medical history of tuberculosis exposure. Six patients with discordant test results had either: (1) a negative TST and positive IGRA in combination with a medical history of tuberculosis exposure (n = 1) or (2) a positive TST and negative IGRA in combination with BCG vaccination (n = 3) or a medical history of tuberculosis exposure (n = 2). CD4+ T lymphocyte cell counts were within normal limits, and no indeterminate results of IGRA were present. IGRA appears reliable for confirming TST and excluding a false positive TST (due to prior BCG vaccination) in this Dutch serie of patients. In addition, IGRA may detect one additional case of LTBI out of 56 patients that would otherwise be missed using solely TST. Immune suppression appears not to result significantly in lower CD4+ T lymphocyte cell counts and indeterminate results of IGRA, despite systemic corticosteroid treatment in half of the patients. Confirmation in larger studies, including assessment of cost-effectiveness, is required.
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91
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Silva DGST, Silva BDDS, Junqueira-Kipnis AP, Rabahi MF. [Tuberculosis in rheumatoid arthritis patients: the difficulty in making the diagnosis of latent infection]. J Bras Pneumol 2010; 36:243-51. [PMID: 20485947 DOI: 10.1590/s1806-37132010000200014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 01/19/2010] [Indexed: 11/21/2022] Open
Abstract
Since the beginning of the use of anti-TNF in the treatment of rheumatoid arthritis and other inflammatory diseases, cases of pulmonary tuberculosis and extrapulmonary tuberculosis have been reported in patients receiving such treatment. In most cases, the disease develops by the time the patient has received the sixth infusion. Every patient should be evaluated for latent tuberculosis infection prior to the use of a TNF inhibitor. However, the diagnosis of latent tuberculosis infection is a challenge. The tuberculin test, which was the only test available to detect latent tuberculosis infection for nearly a century, presents a number of limitations. Tests based on the detection of the in-vitro production of IFN-gamma by mononuclear cells activated by specific antigens appear to be more accurate and have been studied in patients with rheumatoid arthritis.
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Assessment of latent tuberculosis infection in Takayasu arteritis with tuberculin skin test and Quantiferon-TB Gold test. Rheumatol Int 2010; 30:1483-7. [DOI: 10.1007/s00296-010-1444-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 03/12/2010] [Indexed: 11/30/2022]
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Lalvani A, Pareek M. Interferon gamma release assays: principles and practice. Enferm Infecc Microbiol Clin 2010; 28:245-52. [DOI: 10.1016/j.eimc.2009.05.012] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
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Abstract
BACKGROUND Diagnosis and treatment of latent tuberculosis infection (LTBI) is a cornerstone of tuberculosis (TB) control in the developed world. In the last century, the tuberculin skin test (TST) was the only means of diagnosing LTBI. ELISpot and whole-blood ELISA, collectively known as interferon-gamma release assays (IGRAs), are promising new tools. AREAS OF AGREEMENT IGRAs are more specific than TST for diagnosis of LTBI as they are not confounded by previous bacille Calmette-Guerin (BCG) vaccination. Assessing IGRA sensitivity in the absence of a gold standard for LTBI is challenging. Studies have therefore used surrogate markers such as active TB and correlation with degree of TB exposure in contact investigations. These studies suggest that sensitivity of ELISpot is higher than TST while whole-blood ELISA has similar sensitivity to TST. Recent longitudinal studies demonstrating the prognostic power of these tests for development of active TB provide definitive evidence that positive IGRA results reflect infection with dormant yet viable bacilli. AREAS OF CONTROVERSY Is the prognostic power of IGRAs greater than the TST? What are the false-negative rates in immunocompromised individuals with LTBI at high risk of progressing to active TB? GROWING POINTS IGRAs have been incorporated into national guidelines, although their optimal deployment in diagnostic algorithms is evolving. The health economic benefits of utilizing IGRAs are increasingly recognized, partly because their high specificity avoids unnecessary chemoprophylaxis in BCG-vaccinated persons with false-positive TST results. AREAS TIMELY FOR DEVELOPING RESEARCH Current IGRAs are being improved and next-generation tests, with improved sensitivity, could enable the reliable exclusion of LTBI in immunocompromised individuals.
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Affiliation(s)
- Ajit Lalvani
- Tuberculosis Research Unit, Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
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95
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Diel R, Loddenkemper R, Nienhaus A. Evidence-based comparison of commercial interferon-gamma release assays for detecting active TB: a metaanalysis. Chest 2009; 137:952-68. [PMID: 20022968 DOI: 10.1378/chest.09-2350] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Test accuracy of interferon-gamma release assays (IGRAs) for diagnosing TB differs when using older or precommercial tools and inconsistent diagnostic criteria. This metaanalysis critically appraises studies investigating sensitivity and specificity of the commercial T-Spot.TB and the QuantiFERON-TB Gold In-Tube Assay (QFT-IT) among definitely confirmed TB cases. We searched Medline, EMBASE, and Cochrane bibliographies of relevant articles. Sensitivities, specificities, and indeterminate rates were pooled using a fixed effect model. Sensitivity of the tuberculin skin test (TST) was evaluated in the context of IGRA studies. In addition, the rates of indeterminates of both IGRAs were assessed. The pooled sensitivity of TST was 70% (95% CI, 0.67-0.72) compared with 81% (95% CI, 0.78-0.83) for the QFT-IT and 88% (95% CI, 0.85-0.90) for the T-Spot.TB. Sensitivity increased to 84% (95%CI, 0.81-0.87) and 89% (95% CI, 0.86-0.91) for the QFT-IT and T-Spot.TB, respectively, when restricted to performance in developed countries. In contrast, specificity of the QFT-IT was 99% (95% CI, 0.98-1.00) vs 86% for the T-Spot.TB (95% CI, 0.81-0.90). The pooled rate of indeterminate results was low, 2.1% (95% CI, 0.02-0.023) for the QFT-IT and 3.8% (95% CI, 0.035-0.042) for the T-Spot.TB, increasing to 4.4% (95% CI, 0.039-0.05) and 6.1% (95% CI, 0.052-0.071), respectively, among immunosuppressed hosts. The newest commercial IGRAs are superior, in comparison with the TST, for detecting confirmed active TB disease, especially when performed in developed countries.
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Affiliation(s)
- Roland Diel
- Department of Pulmonary Medicine, Hannover Medical School (MHH), Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
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Performance of the tuberculin skin test and interferon-gamma release assay for detection of tuberculosis infection in immunocompromised patients in a BCG-vaccinated population. BMC Infect Dis 2009; 9:207. [PMID: 20003535 PMCID: PMC2801508 DOI: 10.1186/1471-2334-9-207] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Accepted: 12/15/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interferon-gamma release assay (IGRA) may improve diagnostic accuracy for latent tuberculosis infection (LTBI). This study compared the performance of the tuberculin skin test (TST) with that of IGRA for the diagnosis of LTBI in immunocompromised patients in an intermediate TB burden country where BCG vaccination is mandatory. METHODS We conducted a retrospective observational study of patients given the TST and an IGRA, the QuantiFERON-TB Gold In-Tube (QFT-IT), at Severance Hospital, a tertiary hospital in South Korea, from December 2006 to May 2009. RESULTS Of 211 patients who underwent TST and QFT-IT testing, 117 (55%) were classified as immunocompromised. Significantly fewer immunocompromised than immunocompetent patients had positive TST results (10.3% vs. 27.7%, p 0.001), whereas the percentage of positive QFT-IT results was comparable for both groups (21.4% vs. 25.5%). However, indeterminate QFT-IT results were more frequent in immunocompromised than immunocompetent patients (21.4% vs. 9.6%, p 0.021). Agreement between the TST and QFT-IT was fair for the immunocompromised group (kappa = 0.38), but moderate agreement was observed for the immunocompetent group (kappa = 0.57). Indeterminate QFT-IT results were associated with anaemia, lymphocytopenia, hypoproteinemia, and hypoalbuminemia. CONCLUSION In immunocompromised patients, the QFT-IT may be more sensitive than the TST for detection of LTBI, but it resulted in a considerable proportion of indeterminate results. Therefore, both tests may maximise the efficacy of screening for LTBI in immunocompromised patients.
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INANC NEVSUN, AYDIN SIBELZEHRA, KARAKURT SAIT, ATAGUNDUZ PAMIR, YAVUZ SULE, DIRESKENELI HANER. Agreement Between Quantiferon-TB Gold Test and Tuberculin Skin Test in the Identification of Latent Tuberculosis Infection in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis. J Rheumatol 2009; 36:2675-81. [DOI: 10.3899/jrheum.090268] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To compare the Quantiferon-TB Gold test (QTF-G) with the tuberculin skin test (TST) for the detection of latent tuberculosis infection (LTBI) among patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), with reevaluation of the patients treated with tumor necrosis factor-α (TNF-α) antagonists in the followup.Methods.The study involved 140 consecutive patients, 82 with RA and 58 with AS. Thirty patients were evaluated with QTF-G for detection of LTBI before and after 6 months of TNF-α antagonist treatment. QTF-G was also performed on 49 healthy controls. QTF-G results were recorded as positive, negative, or indeterminate. A positive TST was defined as ≥ 5 mm for RA and AS.Results.The percentages of positive QTF-G were comparable in RA and AS (37% vs 32%). The rate of positive QTF-G in healthy controls (29%) was also similar to RA and AS. In contrast to QTF-G results, a high rate of TST positivity was observed in AS compared to RA (82% vs 55%; p = 0.02). The total agreement between QTF-G and TST was observed to be 61% (κ = 0.29) in the whole group, 70% (κ = 0.42) in RA, and 49% (κ = 0.14) in AS. After 6 months of treatment with TNF-α antagonists, a high rate of QTF-G change was observed in patients with indeterminate results (23% vs 3%; p = 0.03).Conclusion.The comparable prevalence of LTBI among the study groups according to QTF-G supports the view that QTF-G is less susceptible to external factors than TST. Sequential testing for QTF-G in patients with indeterminate or negative results may also be helpful in discriminating LTBI better.
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Richeldi L, Losi M, D'Amico R, Luppi M, Ferrari A, Mussini C, Codeluppi M, Cocchi S, Prati F, Paci V, Meacci M, Meccugni B, Rumpianesi F, Roversi P, Cerri S, Luppi F, Ferrara G, Latorre I, Gerunda GE, Torelli G, Esposito R, Fabbri LM. Performance of Tests for Latent Tuberculosis in Different Groups of Immunocompromised Patients. Chest 2009; 136:198-204. [DOI: 10.1378/chest.08-2575] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Diel R, Hauer B, Loddenkemper R, Manger B, Krüger K. Empfehlungen für das Tuberkulose-Screening vor Gabe von TNF-α-Inhibitoren bei rheumatischen Erkrankungen. Z Rheumatol 2009; 68:411-6. [PMID: 19513727 DOI: 10.1007/s00393-009-0475-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Diel
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Berlin
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