<\/p>\n
\u00a0<\/p>\n
PPD in a Nutshell<\/span><\/span><\/p>\n \u00a0<\/p>\n By C. Chong<\/span><\/p>\n Background<\/strong><\/p>\n \u00a0<\/p>\n Tuberculosis caused by \u00a0<\/p>\n Primary infection, usually \u00a0<\/p>\n Primary vaccination with BCG is \u00a0<\/p>\n The rise in TB in the United \u00a0<\/p>\n Screening<\/strong><\/p>\n \u00a0<\/p>\n Standard screening utilizes 5 TU \u00a0<\/p>\n High-risk individuals have a high \u00a0<\/p>\n Interpretation<\/strong><\/p>\n \u00a0<\/p>\n A reactive PPD is a measured area \u00a0<\/p>\n \u00b3<\/span><\/span> \u00a0<\/p>\n \u00a8 \u00a8 \u00a8 \u00a8 \u00a0<\/p>\n \u00b3<\/span><\/span> \u00a0<\/p>\n \u00a8 \u00a8 \u00a8 \u00a8 \u00a8 \u00a8 \u00a8 \u00a0<\/p>\n \u00b3<\/span><\/span> \u00a0<\/p>\n Candidates for Prophylaxis<\/strong><\/p>\n \u00a0<\/p>\n Provide treatment for all \u00a0<\/p>\n \u00a8 \u00a8 \u00a0<\/p>\n \u00a0<\/p>\n Prophylaxis Regardless of the PPD \u00a0<\/p>\n Recent exposure to TB will not \u00a0<\/p>\n \u00a8 \u00a8 \u00a8 \u00a0<\/p>\n Pregnancy<\/p>\n \u00a0<\/p>\n Prophylaxis should be offered to:<\/p>\n \u00a0<\/p>\n \u00a8 \u00a8 \u00a8 \u00a8 \u00a0<\/p>\n Evaluation for active disease can \u00a0<\/p>\n Treatment and Monitoring<\/strong><\/p>\n \u00a0<\/p>\n Treatment generally consists of \u00a0<\/p>\n \u00a0<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":" \u00a0 PPD in a Nutshell \u00a0 By C. Chong Background \u00a0 Tuberculosis caused by Mycobacterium tuberculosis, and rarely by others, had been a public health scourge for centuries.\u00a0 The disease has been linked with overcrowding, poor nutrition, low socioeconomic status, and more recently with immunosuppression. Historically, tuberculosis was very common, presented in many forms,….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1119,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1123","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1123","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1123"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1123\/revisions"}],"predecessor-version":[{"id":1124,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1123\/revisions\/1124"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1119"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1123"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\n<\/span><\/p>\n
\nMycobacterium tuberculosis, and rarely by others, had been a public health
\nscourge for centuries.\u00a0 <\/span>The disease has
\nbeen linked with overcrowding, poor nutrition, low socioeconomic status, and
\nmore recently with immunosuppression.
\n<\/span>Historically, tuberculosis was very common, presented in many forms, and
\nkilled.\u00a0 <\/span>With the advent of
\nchemotherapy, streptomycin and isoniazid, the in the 1950s, treatment of TB
\nentered a new era and there were hopes that TB, like smallpox, would be
\neradicated.\u00a0 <\/span>However, the late 1980s and
\nearly 1990s saw a resurgence of TB with more multidrug resistant cases.\u00a0 <\/span>This makes a case for screening and
\nprophylaxis.\u00a0 <\/span><\/p>\n
\nasymptomatic, by Mycobacterium tuberculosis (Mtb) occurs largely through
\ninhalation of the bacterium (droplet spread) usually over a sustained period of
\ntime.\u00a0 <\/span>Pulmonary TB is the most common
\nform in adults, but other sites, through hematogenous and lymphatic spread,
\ninclude bone, marrow, CNS, GI tract, kidneys, and lymph nodes.\u00a0 <\/span>Disease usually presents after reactivation
\nof an asymptomatic or subclinical primary infection that had been contained by
\nthe host.\u00a0 <\/span>Host factors increasing the
\nsusceptibility to reactivation include poor general health, immunosuppression
\n(disease or medication), and comorbid illnesses.\u00a0 <\/span>Strategies for combating tuberculosis included improved living
\nconditions, vaccination with BCG attenuated M. bovis, and screening for primary
\ninfection and prophylaxis.\u00a0 <\/span><\/p>\n
\noffered outside the United States, Canada and Western Europe where the disease
\nis more prevalent, financial resources more limited and therefore vaccination
\nis felt to be more cost effective.
\n<\/span>However, BCG is not standardized, felt to confer variable protection and
\ncauses a delayed hypersensitivity reaction to PPD.\u00a0 <\/span>Studies of BCG vaccinated populations showed great variability in
\nthe PPD reaction (5 to 25 mm) and whether or not it diminishes over time. In
\naddition, BCG boosters are given in some areas.\u00a0 <\/span>These factors make it difficult to interpret PPD reactions in BCG
\nvaccinated populations.\u00a0 <\/span>Therefore the
\ndecision to offer this population TB prophylaxis is based on standard
\ninterpretations of PPD results, disregarding the BCG history.<\/p>\n
\nStates 1980s and ’90s was felt to be related to 1) increased immigration from
\nareas where TB is endemic, 2) HIV, 3) immunosuppressive medications and
\nconditions, and 4) diminished screening and prophylaxis.\u00a0 <\/span>The rise in multidrug resistant infections
\nwas felt to be related to the availability of common TB medications in areas
\nwhere TB was prevalent and improper and incomplete treatment contributing to
\ncreating resistant strains.<\/p>\n
\nof purified protein derivative (PPD) injected intradermally.\u00a0 <\/span>It is read between 48 and 72 hours for
\ninduration size.\u00a0 <\/span>The Tine and other
\nmultiple puncture tests are not recommended due to lack of standardization and
\nlack of compliance in patient self-reports.
\n<\/span>In persons with a prior positive PPD, chest x-rays can be used to screen
\nfor active disease.\u00a0 <\/span>PPD screening is
\nonly universally recommended for children <<\/span><\/span> 5.\u00a0 <\/span>Periodic screening is recommended for
\nhigh-risk individuals.<\/p>\n
\nrisk of exposure, high morbidity of disease, or high risk of developing
\ndisease.\u00a0 <\/span>High risk of exposure is seen
\nin people who are health care workers, in group homes, dormitory like
\nconditions, shelters, prison, close contacts of people with active disease, or
\nfrom areas where TB is endemic.\u00a0 <\/span>High
\nmorbidity of disease would be present in those with immunosuppression, comorbid
\nillnesses, and are either very young or elderly.\u00a0 <\/span>Those with a higher risk of developing disease include HIV +
\npersons, active IV drug abusers, the homeless, persons taking prednisone or
\nother immunosuppressants, and persons with comorbid conditions.<\/p>\n
\nof induration.\u00a0 <\/span>The reading must be
\nbetween 48 and 72 hours after planting.
\n<\/span>Staff need to be trained to be consistent in the reading.\u00a0 <\/span>Positive readings can be \u00b3<\/span><\/span> 5,
\n10 or 15 mm depending on the following circumstances:<\/p>\n
\n5 mm<\/strong> is positive for the following individuals regardless of BCG status:<\/p>\n
\n<\/span><\/span>HIV seropositive persons<\/p>\n
\n<\/span><\/span>persons with HIV risk factors who had declined testing,
\nincluding history of IVDA and unknown HIV status<\/p>\n
\n<\/span><\/span>close contacts of the person who has pulmonary or
\nlaryngeal TB<\/p>\n
\n<\/span><\/span>persons with radiographic evidence of old, healed TB<\/p>\n
\n10 mm <\/strong>is positive for the following individuals if they do not meet the
\ncriteria for the 5-mm cut off, regardless of BCG status:<\/p>\n
\n<\/span><\/span>persons with medical risk factors for developing active
\nTB other than HIV, such as DM, silicosis, prolonged corticosteroid therapy,
\nother immunosuppressive therapy, cancer of the head and neck, hematologic and
\nreticuloendothelial disease, ESRD, intestinal bypass or gastrectomy, chronic
\nmalabsorption syndromes, or low body weight (10% or more below ideal)<\/p>\n
\n<\/span><\/span>persons with a history of drug injection or substance
\nabuse who are known to be HIV seronegative<\/p>\n
\n<\/span><\/span>persons from an area of the world where the incidence
\nof TB is high<\/p>\n
\n<\/span><\/span>persons from a medically underserved, low income
\ncommunity<\/p>\n
\n<\/span><\/span>employees or residents of congregate settings, such as
\nhospitals, jails, shelters, nursing homes, and drug treatment centers<\/p>\n
\n<\/span><\/span>health care providers<\/p>\n
\n<\/span><\/span>children younger than five years old<\/p>\n
\n15 mm <\/strong>is positive for individuals who meet none of the criteria for the
\n5-mm or 10 mm cutoffs, regardless of BCG status.<\/p>\n
\nhigh-risk individuals with a positive PPD, regardless of age.\u00a0 <\/span>High-risk individuals include:<\/p>\n
\n<\/span><\/span>persons with medical risk factors for developing active
\nTB including but not limited to HIV infection, diabetes, immunosuppression,<\/p>\n
\n<\/span><\/span>persons with high risk of exposure to TB including but
\nnot limited to close contacts, recent converters, persons with occupational or
\nenvironmental exposures.<\/p>\n
\nStatus<\/p>\n
\nresult in a reactive PPD immediately.
\n<\/span>They should be retested 12 weeks after their last exposure.\u00a0 <\/span>During the window period between the two
\nPPD\u2019s, the following individuals should start prophylaxis even if PPD negative:<\/p>\n
\n<\/span><\/span>contacts younger than five years old<\/p>\n
\n<\/span><\/span>contacts between 5 and 15 years old, at the physician’s
\ndiscretion<\/p>\n
\n<\/span><\/span>contacts with HIV infection or other medical risk
\nfactor for TB, and contacts with behavioral risk for HIV who decline HIV
\ntesting<\/p>\n
\n<\/span><\/span>HIV seropositive women or women with HIV risk factors
\nwho are PPD positive – first trimester<\/p>\n
\n<\/span><\/span>PPD+ close contacts with a smear + pulmonary TB patient
\n– first trimester<\/p>\n
\n<\/span><\/span>recent converters – after the first trimester<\/p>\n
\n<\/span><\/span>all others, including positive PPD’s of indeterminate
\nage, radiographic evidence of old TB – 2 to 3 months after delivery<\/p>\n
\ninclude a chest x-ray with appropriate use of a lead shield.<\/p>\n
\nINH 300 mg with or without vitamin B6 25 mg daily for 9 months, depending on
\nindication.\u00a0 <\/span>Monitoring for signs of
\nhepatic toxicity should include physical examination and serial LFTs in
\npatients with a higher risk of hepatotoxicity.
\n<\/span>A sustained, fivefold increase in LFT\u2019s indicate hepatotoxicity and
\nshould lead to discontinuation of the INH.
\n<\/span>Other hepatic toxins including alcohol should be avoided during this
\nperiod.\u00a0 <\/span>Follow-up visits to ensure
\ncompliance and completion of therapy are important.\u00a0 <\/span>If the INH is taken for less than the prescribed period,
\nprophylactic therapy will be incomplete.
\n<\/span>Rifampin can be considered as an alternative.<\/p>\n