Mantoux Skin
Testing
Sivagamy Kumaresan
1
THE MANTOUX TEST
The Mantoux test is the standard method of
determining whether a person is infected
with Mycobacterium tuberculosis.
The local skin reaction to Tuberculin Purified
Protein Derivative (PPD) injected into the skin is
used to assess the individual’s sensitivity to
tuberculin protein.
MANTOUX TEST
The mantoux test is given to :
Children aged 3 months to 6 years living
at high risk environments.
Infants and children under six years of age
with a history of residence or prolonged
stay (more than three months) in a country
of high endemic.
MANTOUX TEST
There is a history of TB in a
household contact in the
last five years.
Thosewho have had close
contact with a person with
known TB.
Administering the Mantoux
test
Tuberculin PPD RT 23 SSI, 2 T.U./0.1
ml, solution for injection:
1 dose = 0.1 ml contains 0.04
microgram Tuberculin PPD.
Store at 2°C -8°C, protected from
light
1ml graduated syringe fitted with a
short bevel 26G (0.45x10mm)
needle
1TU/0.1 5TU/0.1ml
ml
Injection site
The test is usually applied on
the middle third of the flexor
surface of the forearm, as a
reaction may be weaker near the
wrist or the elbow joint.
It is usually applied on the left
forearm.
Ensure adequate lighting.
Select an area of healthy skin
which is free of muscle
margins, heavy hair, veins,
sores, or scars.
Only visibly dirty skin needs to
be washed with soap and water
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Procedure
1)Use a 1mL syringe to
aspirate out 0.1 mL
of PPD RT 23.
2) Inject the PPD
intradermally on the volar
surface of the forearm.
Position the syringe at a 10-
15° to the forearm and
insert just below the
epidermis (about 2 mm).
3)Remove the needle
quickly. Do not massage
or use dressing. A well-
defined bleb of 6-10mm in
diameter should be formed
if injected correctly. If the
bleb is <6mm, repeat the
process 2.5cm from the
first site.
4) Mark down the site, date
and time of injection, both
on the forearm and in
patient’s record.
5)After 48 to 72 hours, read
the test result by marking
down the transverse
diameter of induration, not
erythema, by Sokal’s
ballpoint method.
6) Measure the largest
transverse diameter of
induration and note down in
millimeters
(mm).
READING THE MANTOUX TEST
The reaction should be
evaluated 48-72 hours
after the injection
Only the induration,
which is a hard, dense,
raised formation, is
measured.
The area of erythema
is not included in the
measurement.
Measure the diameter
of the induration
using a plastic
flexible millimetre
(mm) ruler.
POSITIVE PPD REACTION
5 or more millimeters 10 or more millimeters 15 or more millimeters
An induration of 5 or more millimeters is An induration of 10 or more millimeters is An induration of 15 or more millimeters is
considered positive for considered positive for considered positive for
People with HIV infection Foreign-born persons People with no risk factors
for TB
Close contacts HIV-negative persons who
inject illicit drugs
People who have had TB People with certain
disease before medical conditions
People who inject illicit Children younger than 4
drugs and whose HIV years old
status is unknown
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A healthy person whose immune
system is normal, induration
greater than or equal to 15 mm is
considered a positive skin test.
In most cases, people who have a
very small reaction or no reaction
probably do not have TB
infection.
Induration of less than 2 mm,
without blistering, is considered a
negative skin test.
FALSE PPD
REACTION
FALSE POSITIVE FALSE NEGATIVE
PPD REACTION PPD REACTION
False-Positive PPD Reactions
Sometimes people who are not infected
with M. tuberculosis will have a positive
reaction to the PPD tuberculin skin test.
This is called a false-positive reaction.
two most common reasons for false
positive PPD reactions are:-
infection with nontuberculous
mycobacteria (mycobacteria other than
M. tuberculosis)
vaccination with BCG (bacillus Calmette-
Gurin).
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False-Positive PPD Reactions
However, the reaction is more likely to be
truly caused by TB infection if any of the
following are true:
o The reaction is large
o The person was BCG-vaccinated a long
time ago
o The person comes from an area of the
world where TB is common
o The person has been exposed to
someone with infectious TB disease
o The person's family has a history of TB
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disease
False-Negative Reactions
Some people have a negative reaction to
the tuberculin skin test even though they
have TB infection. These are called false-
negative reactions.
False-negative reactions may be caused by
Anergy-absence of the normal immune
response to a particular antigen or
allergen.
Recent TB infection (within the past 10
weeks)
Very young age (younger than 6 months
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old)
Type of Reaction Possible Cause People at Risk Action to Take*
False-positive *Nontuberculous *People infected *Evaluate for TB
mycobacteria with nontuberculous disease if person
mycobacteria has TB symptoms
*BCG vaccination
*People vaccinated *Assess likelihood of
with BCG true TB infection
False-negative Anergy *HIV-infected *May do anergy
people, other testing
people with
weakened immune
Recent TB infection systems *Retest 10 weeks
*People infected after exposure to
with M. TB ended
Very young age tuberculosis within
the past 10 weeks *Retest when child
*Children younger is 6 months old and
than 6 months old 10 weeks after
exposure to TB
ended
ADVERSE EFFECT
Anaphylactic reaction and foreign body
reaction
Slight risk of having a severe reaction to the
test including swelling and redness of the
arm, particularly in people who have had TB
or been infected previously and in those who
have previously had the BCG vaccine
Local reactions such as regional lymphangitis
and adenitis may also occur on rare
occasions.
CONTRAINDICATION
severe reaction (e.g:necrosis, blistering,
anaphylactic shock, or ulcerations) to a previous
TST.
Care of the PPD Testing Solution
Liquid PPD is sensitive to light and temperature and may
become unstable if held in plastic syringes.
Should be stored in cool environment between 35 and
46 degrees Fahrenheit
PPD vial should be dated upon opening, and the
remainder discarded after 30 days, regardless of
expiration date
Syringes should not be prefilled in anticipation of
demand, but filled at time of need.
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