IGRA

Interferon-gamma release assays

 IGRAs

 Interferon-gamma release assays (IGRAs) are diagnostic tools for

latent tuberculosis infection (LTBI).

 They are surrogate markers of Mycobacterium tuberculosis

infection and indicate a cellular immune response to M.
tuberculosis.
 IGRAs cannot distinguish between latent infection and active
tuberculosis (TB) disease, and should not be used as a sole method
for diagnosis of active TB, which is a microbiological diagnosis.

 A positive IGRA result may not necessarily indicate active TB;

however, a negative IGRA result rules out the possibility of both
active and latent tuberculosis.
 Because IGRAs are not affected by Bacille Calmette-Guérin
(BCG) vaccination status, IGRAs are useful for evaluation of
LTBI in BCG-vaccinated individuals, particularly in settings
where BCG vaccination is administered after infancy or multiple
(booster) BCG vaccinations are given.

 In contrast, the specificity of tuberculin skin test (TST) varies

depending on timing of BCG and whether repeated (booster)
vaccinations are given.
Commercially Available IGRAs Tests

 QuantiFERON-TB Gold Test .

 T-SPOT-TB Test .
 Comparison of tuberculin skin test
and IGRAs

Performance and T.S.T IGRAS

operationl
characteristics

Estimated sensitivity in 75%-90% lower 75%-95% {inadequate

pt with active TB immunocompromised data in
populations immunocompromised
populations}

Estimated specificity in 70%-95%lower in BCG 90%-100% maintained in

healthy individuals with vaccinated BCG vaccinated
no known TBdisease
orexposure
Cross- reactivity with YES Less likely
BCG
Cross-reactivity with YES Less likely
NTM
Association between Moderate to strong Insufficient evidence
test-+ve and positive association
subsequent risk of
active TB during follow-
up
Correlation with YES YES
mycobacterium
tuberculosis exposure
Benefits of treating YES NO evidence
test positive based on
randomized controlled
trials
Boosting phenomenon YES NO
Performance and T.S.T IGRAS
operationl
characteristics
Potential for YES Insufficient evidence
conversions and
reversions
Adverse reactions Rare Rare
Material costs LOW Moderate to high
Patient visits TWO ONE
Laboratory NO YES
infrastructure required
Time to obtain a result 2 to 3 days 1 to 2 days
 ADA
Adenosine Deaminase
Introduction:
Adenosine deaminase (ADA) is one of the
enzymes in the purine metabolism.

It catalyzes the conversion of adenosine

and deoxyadenosine to inosine and
deoxyinosine respectively with the release
of ammonia.
 Importance of ADA:

Indicator of active cellular immunity & T

lymphocyte activation.
Deficiency of ADA in human manifest
primarily as a severe lymphopenia.
Level of ADA increase in tuberculosis because
of stimulation of T cells by mycobacterial
antigen.
ADA activity was elevated in the sera from
patients with hepatic diseases, hematological
malignancies and infectious diseases.
 Isoenzyme & Source:

ADA has two principal isoenzymes-

i) ADA-1

ii)ADA-2
 ADA-1 :
Can be found in all cell types.
A high ADA1 level indicates cell injury.
Serum concentrations of ADA1 were high
in patients with acute leukemias, chronic
myeloid leukemia and acute liver injury.
The isoenzyme ADA-1 is elevated in the
presence of empyema and parapneumonic
effusions.
 ADA 2:
Found only in macrophage & monocyte.
ADA2 comes from stimulated T-cells.
Serum ADA2 levels were raised in patients with
tuberculosis
adult T-cell leukemia,
multiple myeloma
infectious mononucleosis ,
acquired immunodeficiency syndrome,
chronic hepatic diseases
 ADA-2 is a more efficient diagnostic
marker of TB pleurisy than total ADA
activity.
 With diagnostic threshold of 40 U/L,
ADA-2 has 100% sensitivity and 96%
specificity for early diagnosis of TB
pleurisy.
 False positive ADA:
 False positive results
lymphoma,
rheumatoid arthritis,
SLE
adenocarcinoma
empyema
In cases of suspected false negative or positive
ADA levels,level of ADA-1/ ADA(total) ratio is
a good parameter.
 A proportion of ADA-1/ADA (total) <
0.42 is a good indicator of TB, with an
accuracy of 99%, a sensitivity of 100%
and a specificity of 98.6% , but high ADA
activity with ADA-1/ ADA (total) ratio
>0.45 is indicative of malignancy or
empyema.
 Pleural fluid:
 Several studies have suggested that an
elevated pleural fluid ADA level predicts
tuberculous pleuritis with a sensitivity of 90-
100% and a specificity of 89-100% is .The
reported cutoff value for ADA (total) varies
from 40 to 50 U/L.
 One study showed that ADA level, especially
when combined with differential cell counts
and lymphocyte/neutrophil ratios, remains a
useful test in the diagnosis of tuberculous
pleuritis.
 When the lymphocytes to neutrophils ratio (L/N) >
0.75 was considered together with the ADA
activity > 40 U/L, the result improved considerably
for the diagnosis of tuberculous pleuritis. The
pleural fluid ADA values can be used in conjunciton
with cell counts, in the following way:
 1- A lymphocyte exudate (L/N ratio >0.75) with a
high ADA value (> 40 U/L) is highly suggestive of
TB pleurisy.
 2- A lymphocyte exudate with low ADA value (<40
U/L) is suggestive of nonhematologic malignancies.
 3- A neutrophilic exudate (L/N <0.75) with a high ADA
concentration (>40 U/L) is suggestive of parainfective
effusions.
Thank You