Case Presentation

The following scenario emphasizes the necessity of creating a wheal while administering the Mantoux test.

A 46-year-old Asian man who recently immigrated to the United States was seen for routine employment screening for tuberculosis. The nurse initiated a Mantoux test on the right forearm (Figure 1). However, the test had to be repeated on the left forearm because no wheal was noted at the initial site. A small wheal was noted during the second test, and the patient was advised to return to the clinic within 48 to 72 hours to have the results evaluated (Figure 2). The patient returned for a TST reading 2 days later. The right forearm showed no sign of induration (Figure 3), while the left showed >10 mm of induration (Figure 4). The patient was referred for a chest radiograph that was obtained during the same visit, the results of which were normal.

All clinicians should review evidence-based literature especially when it is pertinent to a procedure that is done frequently. Screening individuals at risk for tuberculosis infection identifies groups that should be tested using the Mantoux TST or interferon-gamma release assays, such as QuantiFERON-tuberculosis Gold In-Tube Test and T-SPOT®.41

In most cases, a positive Mantoux test signifies infection with M tuberculosis; however, it does not signify whether the disease is active or where it is located. Pulmonary tuberculosis is usually diagnosed by sputum cultures. To diagnose extrapulmonary tuberculosis, assessment of other specimens, such as cerebrospinal fluid, urine, or pleural fluid, is usually required.

Figure 1. Following improper PPD administration at the right antecubital fossa. The circled area shows the injection site.

Figure 2. Following proper PPD administration demonstrating wheal at the left antecubital fossa.

Figure 3. Day 3 following improper PPD administration.

Figure 4. Day 3 following proper PPD administration.

Implications

When administered correctly, the Mantoux test can be an invaluable tool, leading to early detection, treatment, and containment of tuberculosis. Placement and interpretation of the TST should be performed by qualified health practitioners. An incorrectly placed or interpreted TST can contribute to a delay in identifying an index case, which could lead to an outbreak of tuberculosis either in the local community or on a greater scale.

Educational programs for healthcare providers should include a basic course on TST that includes didactic content on the disease and epidemiology concepts. The content should include disease transmission, pathogenesis, and classification as well as global statistics and both national and local rates in the United States, especially in urban areas. The CDC and local departments of health offer resources that can be included in the course. Practical and clinical experience can be given using simulation with a reactor model arm.

It is the responsibility of the healthcare provider to screen individuals correctly and recognize anyone at high risk, particularly those who work or live in high-risk areas such as prisons, hospitals, schools, and certain neighborhoods. Healthcare providers should stay up to date on how tuberculosis is spread, the mechanism of infection, diagnosis, and treatment.  Tuberculosis education and training programs are available at the CDC website, as well as via other online resources.

Yeow Chye Ng, PhD, CRNP, CPC, AAHIVE, is assistant professor at the College of Nursing at the University of Alabama in Huntsville. Louise C. O’Keefe, PhD, CRNP, is director of the faculty/staff clinic and assistant professor at the College of Nursing at the University of Alabama in Huntsville.

References

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8.  Chin up. “I administered a TB skin test and
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This article originally appeared on Clinical Advisor