Annals of Internal Medicine

LETTERS

Related Article

Delayed Tuberculin Reactivity in Indochinese Persons

To the Editor: The study by Robertson and colleagues (1) evaluated the utility of a variant of
delayed tuberculin reactivity for the evaluation of patients with suspected tuberculous infection in
a high-risk population. The approach is ingenious, but we would like to make some comments.

The appropriate criterion for defining a positive skin-test reaction depends on the population
being tested. In a recent report by the Ad Hoc Committee of the Scientific Assembly on
Microbiology, Tuberculosis, and Pulmonary Infections (2), a reaction of 5mm was considered
positive in close contacts of infectious cases and in patients who had fibriotic lesions on chest
radiography. In a group of patients in which 26% of chest radiographs suggested tuberculosis, it
would be unusual to have only 29% of tuberculin purified protein derivative (PPD) test results
identified as positive. A possible explanation is that the authors considered the positivity of PPD to
be 10 mm.

We would like to know how many patients had induration greater than 5mm in the PPD readings
and whether including the results of these patients as positives would substantially change the
results. If that is the case, the paper would support the concept that in populations with a high
prevalence of tuberculosis, 5 mm of induration after PPD testing should be considered positive.
Second PPD tests would then be limited to patients with induration less than 5 mm.

Miguel A. Muniain, MD
Jesus Rodriguez-Bano, MD
Jose L. Corral, MD
Macarena University Hospital
Seville, Spain 41107

References
1. Robertson JM, Burt DS, Edmonds KL, Molina PL, Kiefe CI, Ellner JJ. Delayed tuberculin
reactivity in persons of Indochinese origin: implications for preventive therapy. Ann Intern Med.
1996;124:779-84.
2. Treatment of tuberculosis and tuberculosis infection in adults and children. Ad Hoc Committee
of the Scientific Assembly on Microbiology, Tuberculosis, and Pulmonary Infections. Clin Infect
Dis. 1995;21:9-27.

In response: We appreciate the letter if Muniain and colleagues. We defined PPD positivity as at
least 10 mm of induration on the basis of the recommendations of the Centers for Disease
Control and Prevention (1). Although many of the chest radiographs suggested tuberculosis, no
active cases were found in the study group. Among the variant reactors, only 8 of 29 (the number
with radiographs available for evaluation) had chest radiographs with evidence of old or active
tuberculosis. The remaining 21 radiographs were clear. Immigration law prohibits the migration of
persons with known tuberculosis unless sputum and culture negativity have been shown. We
excluded all patients who were receiving treatment for known or suspected tuberculosis. Because
the precise incidence and contact with active disease and the time frame of conversion were not
known for our group, we opted to use the more conservative reading of 10 mm as our cutoff point
for defining tuberculin positivity.

Review of our data shows that the mean size of induration for the entire study group ( n = 121)
was 4.92 mm (range, 0 to 19 mm). Results that were defined as PPD negative (<10 mm of
induration; n = 54) had a range of 0 to 9 mm. Of these, 42 (77.8%) were less than 5 mm (41 had
induration of 0 mm on initial evaluation at 72 hours). Of the remaining patients, 2 had 5 mm of
induration, 2 had 6 mm, 1 had 7 mm, 3 had 8 mm, and 4 had 9 mm. Of the 32 variant reactors, 14
(43.8%) had less than 5 mm of induration on the initial reading. When we repeated our analysis
with the new 5-mm cutoff point, variant reactivity still predicted booster positivity (38.5% in
variants compared with 10.3% in negatives; P = 0.02).

The high percentage of patients with delayed tuberculin reactivity even when a cutoff point of 5
mm is used and the continued association between variant reactivity and booster positivity further
validate the importance of being aware of this phenomenon.

John M. Robertson, MD, MPH

University of New Mexico
Albuquerque, NM 87131-5271

Catarina Kiefe, PhD, MD

University of Alabama at Birmingham
Birmingham, AL 35205-4785

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