pasado y presente en el diagnóstico de la infección ......pasado y presente en el diagnóstico de...
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Pasado y presente en el diagnóstico de
la infección tuberculosa latente
J. DomínguezServei Microbiologia. Institut d’Investigació Germans Trias i Pujol
Badalona, Barcelona. ([email protected])
XVI Taller Internacional sobre Tuberculosis
UITB-2012
LTBI diagnosis: Tuberculin skin test
o TST has been until now the only tool available for the diagnosis of
LTBI and is commonly used as complementary test for diagnosis of
active TB.
o Intradermal reaction test.
o TST attempts to measure cell-mediated immunity in the form of a
delayed-type hypersensitivity response to PPD.
o PPD contains more than 200 antigens that are widely shared among
mycobacteria other than M. tuberculosis, including the vaccinal strain
of Mycobacterium bovis BCG and many NTM.
o 4th August 1890. R. Koch. X International Medicine Congress. Berlin
o 15th November 1890. German Medicine Journal.
o Between 1890-1891 doubtful curative effect.
o January 1891. Description of the substance production (Koch lymph,
Koch fluid, Bacillinum, Kochin).
o February 1891. The label of the product was: Tuberculin
o 1906 C. Von Pirquet demonstrated that the reactivity of the tuberculin
evidenced a previous contact with the bacteria
o Classical studies using tuberculin has allow to establish ratio of
infected individuals, and also the % of patients who developed active
TB at some time during their life.
Tuberculin origin
LTBI diagnosis: Tuberculin skin testMain drawbacks
Low specificity
o Individuals sensitised by previous exposure to NTM or vaccinatedwith BCG respond immunologically to PPD.
Low sensitivity
o Low sensitivity in detecting LTBI in individuals with a high risk ofprogression to active TB: immunosuppressed patients (especiallywith deficient cellular immunity) and young children.
Logistical problems
o Errors in the administration and subjective reading of the results.
o Second reading visit. Some patients do not return to the readingof the TST result.
LTBI diagnosis: IFN-γ releasedassays (IGRAs)
In vitro detection of IFN-γ released by sensitised T cells afterspecific M. tuberculosis antigens stimulation.
P. Andersen. Lancet 2000
Moving LTBI diagnosis from clinical departments to laboratory.
A more accurate diagnosis.
LTBI diagnosis
2002
Tuberculin skin testing IGRAs
LTBI diagnosis: IFN-γ assaysSpecific antigens
ESAT-6, CFP-10 and TB7.7
Proteins coded in the region of difference 1 and 11, which are
present in M. tuberculosis but not in any BCG strain nor in themajority of NTM.
Comparison between TST and IGRAs
Collection of blood sample
(3ml) in QFN tubes containing
MTB antigens
T-SPOT.TB QFN-G-IT
1/2
ho
ur
(h)
ha
nd
s-o
n t
ime
fo
r 1
sam
ple
4 h
ha
nd
s-o
n t
ime
fo
r 2
0 s
am
ple
s
No
ha
nd
s-on
time
1 h
ha
nd
s-o
n t
ime
fo
r
1 to
20
sa
mp
les
1 h h
an
ds-o
n tim
e
for 1 to
20
sam
ple
s
Overnight incubation
First day
Second day
ELISPOT
Count spots by naked eyeor using a plate reader
Centrifugation of tubesto harvest the IFN-gamma released
ELISA
Read the concentration of
IFN-gamma by means
of an automated reader
Collection of blood sample (8ml)
and centrifugation
Count PBMCs using a counting chamber
Addition of 250,000 cells per wellwith the MTB specific antigens
Isolation of PBMCs and washing
Overnight incubation
Higher specificity than TST
in BCG-vaccinated patients
Association with the degree of
exposure to a patient with active TB
Association with the degree of
exposure to a patient with active TB
De Souza-Galvao M. 2012.
Higher number of positive results
in immunosuppressed patients
IGRAs are less afected
by the immunosuppression than TST…
Latorre I. ERS. Amsterdam 2011
…although they are also affected
They followed a cohort of 954 contacts during 4 years. Among the 147 that did not
receive treatment with a positive QFN, 19 (12.9%) developed active TB,
while only 17 out of 551 (3,1%) with a TST>5mm developed active TB.
Positive and negative predictive value
Diel R. AJCCM 2010
Among the 824 contacts that did not receive treatment and with a negative QFN,
none of them progressed to disease, confirming the high NPV of the test.
Bakir. AIM 2008
908 children from contacts studies were included. During a period of 1.3 years of follow-up,
children with positive T-SPOT.TB had a risk of developing TB between 3 and 4 times higher
than patients with a negative T-SPOT.TB.
However, ratios of progression for T-SPOT-TB and TST were similar (3.86 vs 3.28).
Positive and negative predictive value
The PPV using commercial IGRAs was 2.7%,
compared with 1.5% for the TST (P<0.0001)
The PPV increased to 6.8% and 2.4%
for IGRAs and TST, respectively,
when only high-risk groups were considered
(P=0.0001)
The NPV for progression
for IGRAs was 99,7%,
and of 99.4% for the TST
(P=0.01)
668 Contacts
Follow-up during
30 months
284LTBI
TST positive and/orQFN positiveProphylaxis
98QFN & TST negativesPrimary prophylaxis
(in all cases a negative resultwas obtained two moths later)
286No LTBI
TST & QFN negatives,or positives but no
candidates x prophylaxis
8 active TB (All have
QFN i TST positive)
QFN-G-IT
• VPP=15%
• VPN=100%
PT
• VPP = 3%
• VPN = 99%
Positive and negative predictive value
Altet N. Submited 2012.
Remote infection?
147 HCWs
95 with
previous positive TST
T-SPOT.TB
(%)
POS45
(47.4)
NEG49
(51.6)
IND1
(1.1)
QFN-G-IT
(%)
POS34
(35.8)
NEG59
(62.1)
IND2
(2.1)
In 24 HCWs with both
IFN-gamma tests
negatives and non BCG
vaccinated PST was
performed (%)POS
2(20)
Test invalid in
14 cases
NEG8
(80)
IGRAs are not useful for diagnosing active TB
Diagnosis of active TB
Monitorization of the treatment
0 6 12 18 24 300
500
1000
1500
2000
Follow up, months
ES
AT
-6-s
pe
cif
ic I
FN
-g
SF
C /
10
6 P
BM
C
0 6 12 18 24 300
500
1000
1500
2000
Follow up, months
CF
P-1
0-s
pe
cif
ic I
FN
-g
SF
C /
10
6 P
BM
C
ESAT-6 CFP-10
There is a high inter-individual variability in the
celular response and in the amount of IFN-γ
released, during the treatment, and in addition, in a
substancial proportion of patients the results of the
IGRA remain positive althouhg they have finished
the treatmentMillington. J.Immunol 2007
Monitorization of the treatment
Conclusions
• Exposure and risk factor
association
• Higher specificity (no affected by BCG). Reduce unnecessary
prophylaxis.
• PPV higher/similar than TST and very good NPV
• Less afected by
immunosuppressor
treatments
IGRAs
• Improve positive predictive
value: differentiate between
those persons who will
develop TB and those who will not.
• Remote vs. recent infection
• Infection vs. active TB
• Monitoring of the treatment
• Severe immunosuppression
Waiting for the future…
The next generation of IGRAs
I have
a dream !
IGRAS
POSITIVE CONTROL
NEGATIVE CONTROL
SPECIFIC REMOTE
INFECTION ANTIGENS
SPECIFIC RECENT
INFECTION ANTIGENS
SPECIFIC ACTIVE TB ANTIGENS
PACIENT REMOTELY INFECTED
PACIENT RECENTLY INFECTED
PACIENT WITH ACTIVE
TB