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Editorials |1 August 1993

Skin Test Responses as Predictors of Tuberculous Infection and of Progression in HIV-infected Persons

Richard S. Kornbluth, MD, PhD

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Copyright 2004 by the American College of Physicians
2004
  • University of California, San Diego, CA 92093. Requests for Reprints: J. Allen McCutchan, MD, UCSD Treatment Center, 2760 Fifth Avenue, Suite 300, San Diego, CA 92103-6329. Grant Support: In part by NIH grants AI25316 and HL43523 (to RSK) and The California University-wide AIDS Research Program through the California Collaborative Treatment Group (to JAM).
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Three articles in this issue of Annals [1-3] address some difficult issues about delayed-type hypersensitivity (DTH) skin testing in patients with human immunodeficiency virus (HIV) infection. These issues include how to interpret reactions to purified protein derivative (PPD or tuberculin), how CD4 cell counts and reactions to other skin tests affect this interpretation, and whether skin test results are independent predictors of disease progression. Thus, these and other studies are providing a clearer picture that will help guide clinical decisions.
In 1990, the American Thoracic Society and the Centers for Disease Control and Prevention (CDC) recommended that the definition of a reactive PPD test be adjusted according to the likelihood of exposure and the ability to mount DTH [4]. For persons infected with HIV, the proposed cutoff value of 5 mm of induration has been supported by studies showing that using a lower threshold of PPD reactivity, as evidence of tuberculous infection, preserves sensitivity [5, 6]. In 1991, the CDC further advised that 1 year of isoniazid prophylaxis be considered for HIV-infected patients who are either PPD positive ( 5 mm) or who are anergic to control recall antigens and who come from a group with 10% prevalence of active or latent tuberculous infection [7]. This recommendation to treat anergic patients is supported by a decision analysis [8] and a prospective study of intravenous drug users in New York City. The drug users had a 20% prevalence of tuberculin reactivity and 9.7 active tuberculosis cases/100 patient-years were observed in those who did not receive isoniazid [9].
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Kornbluth RS. Skin Test Responses as Predictors of Tuberculous Infection and of Progression in HIV-infected Persons. Ann Intern Med. 1993;119:241–243. doi: 10.7326/0003-4819-119-3-199308010-00011

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Published: Ann Intern Med. 1993;119(3):241-243.

DOI: 10.7326/0003-4819-119-3-199308010-00011

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