Prevalence of tuberculin positivity and skin test anergy in HIV-1-seropositive and -seronegative intravenous drug users

• Published in: JAMA : the journal of the American Medical Association Vol. 267; no. 3; p. 369
• Main Authors: Graham, N M, Nelson, K E, Solomon, L, Bonds, M, Rizzo, R T, Scavotto, J, Astemborski, J, Vlahov, D
• Format: Journal Article
• Language: English
• Published: United States 15.01.1992
• Subjects: Adolescent; Adult; Candidiasis - diagnosis; Candidiasis - immunology; Case-Control Studies; Cross-Sectional Studies; Female; HIV Seropositivity - complications; HIV Seropositivity - immunology; HIV-1; Humans; Male; Multivariate Analysis; Mumps - diagnosis; Mumps - immunology; Prevalence; Skin Tests; Substance Abuse, Intravenous - complications; Substance Abuse, Intravenous - immunology; Tuberculin Test; Tuberculosis - complications; Tuberculosis - diagnosis
• ISSN: 0098-7484
• DOI: 10.1001/jama.1992.03480030047035

--To identify differences in purified protein derivative (PPD) tuberculin positivity and skin test anergy rates by human immunodeficiency virus (HIV) serostatus, CD4+ lymphocyte count, and other risk factors in intravenous drug users (IVDUs); and to evaluate the appropriateness of the Centers for Disease Control (CDC)--recommended definition for a positive PPD tuberculin skin test result in HIV-1-seropositive patients. --Nested case-control and cross-sectional analyses. --Community-based cohort of IVDUs. --Two hundred sixty HIV-1-seropositive and -seronegative IVDUs, drawn from an unselected cohort, were skin-tested for sensitivity to PPD tuberculin, mumps, and Candida antigens using the Mantoux method. --Positivity to PPD tuberculin, skin test anergy. --Even using the CDC definition of an induration 5 mm or greater in diameter in HIV-1 seropositives, this group was substantially less likely to be PPD tuberculin positive than HIV-1 seronegatives (13.8% vs 25.2%; P = .02). In the HIV-1 seropositives the relative odds of being PPD positive varied depending on whether 10 mm or greater (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2 to 0.7), 5 mm or greater (OR, 0.5; 95% CI, 0.2 to 0.9), or 2 mm or greater (OR, 0.7; 95% CI, 0.4 to 1.3) was used to define a positive test result. The mean diameter induration in the HIV-1-seropositive group was 2.6 mm vs 5.4 mm in the seronegative group (P = .005). Skin test anergy (to mumps and Candida) appeared to explain the differential. Anergy was substantially higher in the HIV-1 seropositive group and increased as the CD4+ lymphocyte count fell (chi 2 for linear trend, 24.5; P less than .0001). An inverse linear trend for PPD positivity and CD4+ lymphocyte count was also observed (chi 2 for trend, 6.1; P = .01). In multivariate analyses, being 35 years of age or older and being HIV-1 seronegative were significantly associated with PPD positivity, while history of previous police arrest was of borderline significance. Only HIV-1 seropositivity was significantly associated with anergy. --These findings show that CDC-recommended definition of an induration 5 mm or greater in diameter for PPD tuberculin positivity in HIV-1 seropositives significantly underestimates the "true" infection rate (using the PPD positivity rate in HIV-1 seronegatives as the criterion standard). A definition of 2 mm or greater would appear to be a better cutoff for reducing misclassification in HIV-1 seropositives. This study also confirms that delayed-type hypersensitivity is seriously depressed in HIV-1 seropositive IVDUs and that anergy testing is mandatory to properly assess a negative PPD test result.