Tuberculin, Purified Protein Derivative

( PPD )

Pronunciation: too-BURR-kyoo-lin
Class: In vivo diagnostic biological Tuberculin PPD Multiple Puncture Device

Trade Names

Aplitest
- Injection 5 tuberculin unit activity/test

Tine Test PPD
- Injection 5 tuberculin unit activity/test

Tuberculin Purified Protein Derivative

Aplisol
- Injection 5 tuberculin unit/0.1 mL

Tubersol
- Injection 1 tuberculin unit/0.1 mL
- Injection 5 tuberculin unit/0.1 mL
- Injection 250 tuberculin unit/0.1 mL

Pharmacology

Contains soluble products from mycobacterium, which react with lymphocytes to release mediators of cellular hypersensitivity. Some of these mediators induce inflammatory response. Positive reaction is consistent with previous or current tuberculosis infection or previous BCG vaccination.

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Indications and Usage

Detection of delayed hypersensitivity to Mycobacterium tuberculosis ; aid in diagnosis of infection with M. tuberculosis ; routine testing for tuberculosis; testing individuals suspected of having contact with active tuberculosis; follow-up verification testing in individuals who have had reactions to tuberculin multipuncture devices used as screening test.

Contraindications

People known to be tuberculin-positive reactors.

Dosage and Administration

Adults and Children

Intradermal 0.1 mL of 5 tuberculin unit/0.1 mL concentration (Mantoux test) or multiple puncture device.

Highly sensitized people

Intradermal 0.1 mL of 1 tuberculin unit/0.1 mL concentration.

Individuals who fail to react to previous injection of 5 tuberculin unit

Intradermal 0.1 mL of 250 tuberculin unit/0.1 mL concentration.

Routine Tuberculin Screening
Children

Perform at 12 mo, 4 to 6 yr, and 14 to 16 yr of age.

General Advice

  • For intradermal injection, use 26- or 27-gauge ½-inch needle to administer intradermal injection into flexor or dorsal surface of forearm, creating white bleb 6 to 10 mm in diameter. No dressing is required.
  • For multiple puncture device, apply unit firmly and without twisting to volar surface of upper 1/ 3 of forearm for 1 sec. Make sure all 4 tines penetrate skin.

Storage/Stability

PPD multipuncture devices should be stored at room temperature. PPD solution should be stored in refrigerator.

Drug Interactions

BCG vaccine, previous

May result in positive PPD test (see Precautions).

Corticosteroids or other immunosuppressive drugs

May suppress reactivity to any tuberculin test.

Recent immunization with live virus vaccines (including influenza, measles, mumps, rubella, polio virus, smallpox, yellow fever)

May suppress reactivity to any tuberculin test. If tuberculin skin testing is indicated, perform it either before or simultaneous with immunization or 4 to 6 wk after immunization.

Laboratory Test Interactions

None well documented.

Adverse Reactions

Dermatologic

Immediate erythematous reactions, vesiculation, pain, ulceration, necrosis, or scarring at administration site; bleeding at puncture site (tine test).

Precautions

Pregnancy

Category C . Use if needed. Unrecognized tuberculosis places infant in grave danger of tuberculosis and tuberculous meningitis. No adverse reactions on fetus from tuberculin have been reported.

Lactation

Undetermined.

Children

A child who has been exposed to tuberculosis must not be judged free of infection until there is negative tuberculin reaction at least 10 wk after ending contact with tuberculous person.

Elderly

Skin-test responsiveness may be delayed or reduced in magnitude among older people. Two-step testing is especially important in people 35 yr of age or older. Reactions may peak after 72 h.

BCG vaccine

People previously immunized with BCG vaccine may test positive to tuberculin skin test. Tuberculin reactions caused by BCG cannot reliably be distinguished from reactions caused by natural mycobacterial infections. Tuberculin reactivity in BCG vaccinees does not reliably predict protection against M. tuberculosis .

Bioequivalency

The various PPD solutions are generically equivalent but differ from PPD multipuncture devices and from old tuberculin (OT) products.

Immunodeficiency

Skin-test responsiveness may be suppressed during or for as much as 6 wk after viral infection, live viral vaccination, miliary or pulmonary tuberculosis infection, bacterial infection, severe febrile illness, malnutrition, sarcoidosis, malignancy or immunosuppression (eg, corticosteroids or other immunosuppressive pharmacotherapy). In most patients who are very sick with tuberculosis, a previously negative tuberculin test becomes positive after a few weeks of chemotherapy.

Interpretation of test results

Positive PPD reaction indicates hypersensitivity to tuberculin and implies past or present infection with M. tuberculosis . Positive reactions do not necessarily signify active disease. Further diagnostic procedures (eg, chest radiograph, microbiological examination of sputum) must be conducted before a diagnosis of tuberculosis can be made.

Multipuncture devices

Multipuncture devices are screening tools that aid in determining tuberculin hypersensitivity. They may contain either PPD or OT. These devices are comparable to 5 tuberculin unit of PPD but may yield false-positive reactions because quantity of tuberculin deposited into skin cannot be precisely controlled. Positive reactions to multipuncture devices must be confirmed with intradermal injection of PPD solution. OT cross-reacts with other mycobacteria (eg, Mycobacterium avium ). Multipuncture devices are useful in people who object to use of needle and syringe (eg, children).

Repeated testing of uninfected individuals

Does not sensitize to tuberculin.

Overdosage

Symptoms

Vesiculation, ulceration, necrosis.

Patient Information

  • Inform patient to return in 48 to 72 h for test interpretation or explain how to interpret skin results. Provide card for interpretation.
  • Advise patient of significance of test results and stress importance of reporting results.
  • If test results are positive, provide information on where patient can obtain further evaluation.

Copyright © 2009 Wolters Kluwer Health.

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