1. Diagnosis of pulmonary tuberculosis

2. Diagnosis of Pulmonary Tuberculosis
Mycobacteriology
Sputum examination, the AFB smear
Sputum culture
Amplicor Mycobacterium tuberculosis test
- DNA polymerase chain reaction amplification
Image
- Chest X-Ray, Chest CT
Whole-blood interferon-gamma assay
ELISA, eg, QuantiFERON assay [QFT-TB]
- ELISPOT, eg, T SPOT-TB assay

3. Sputum examination Three specimens optimal
Spot specimen on first visit; sputum container given to patient
Early morning collection by patient on next day
Spot specimen during second visit
Sputum induction with nebulized, hypertonic (three to five percent) saline.
Bronchoscopy.

4. Three sputum smears are optimal
10-13% %
World Health Organization; 1998.

5. Fluorochrome stain of sputum

6. Quantitation scale for acid-fast bacillus smears according to stain used
Am J Respir Crit Care Med Vol 161. pp 1376–1395, 2000

7. Sputum stained by Ziehl-Neelsen

8. Sputum smears 위음성 객담의 부적절한 채취 객담의 보관 잘못
(직사광, 자외선, 과한 열, 냉장 상태가 아닌 곳에서 1주 이상 보관)
적절한 객담 표본 채취 실패
도말 및 염색 잘못
검경 잘못
(검경 시간 부족, 소수 시야만 관찰)
검사자의 시력 및 정신적인 이유
기록 잘못
위양성
음식물 입자
섬유 (양모,면사,여과지,죽순)
화분 (소나무)
염료 결정, 오래된 염색 약
고초균 포자
슬라이드 긁힌 자국
염색 중 오염
토양이나 물의 비결핵 항산균 오염
기록 잘못
대한 결핵 및 호흡기 학회, 호흡기학, p841

9. Sputum Culture

10. Quantitation scale for mycobacterial growth on agar plates
Am J Respir Crit Care Med Vol 161. pp 1376–1395, 2000

11. Sputum Culture Solid media Ogawa, Lowenstein-Jensen
Middlebrook 7H10, 7H11
Eight weeks
Liquid media
BACTEC 460, MGIT
Seven days
Drug susceptibility testing

12. Tuberculosis direct amplified tests
Thorax 1996; 51:320.

13. Tuberculin skin test False negatives Technical factors Application
Reading
Improper storage of PPD
Biological factors
Poor nutrition
Infection
Immunosuppressive drugs
Malignancy
Age
Stress
False positives
Infection with nontuberculous mycobacteria
BCG vaccination

14. Quanti-FERON-TB Gold It can be used in all circumstances in which the TST is used, including
Ongoing potential close contact with cases of active TB
HIV infection
Evaluation of recent immigrants who have had BCG vaccination
Member of a medically underserved, low-income population
(eg, homeless, injection drug users)
Presence of an incidentally discovered fibrotic lung lesion
Residence in a long term care facility
Others undergoing serial evaluation for M. tuberculosis infection
CDC, MMWR, December 16, 2005 / Vol. 54 / No. RR-15, pp

15. Quanti-FERON-TB Gold Interferon Gamma Release

16. Quanti-FERON-TB Gold
In vitro test using whole blood specimen , Interferon γ release assay
TB infection, whether latent or active
The recognition process
-> interferon-γ, a specific cytokine for cell mediated immune response
Synthetic peptide antigens (ESAT-6, CFP-10)
-> simulate mycobacterial proteins to generate the immune response

17. Quanti-FERON-TB Gold Assay

18. Results and Interpretation of Quanti-FERON-TB Gold
CDC, MMWR, December 16, 2005 / Vol. 54 / No. RR-15, pp

19. Specificity Estimates of Quanti-FERON-TB Gold
216 healthy individuals, no identified risk for TB infection, all BCG (+)
Specificity = 98% (213/216 = QFT- Gold negative)
AJRCCM 2004;170:59-64
532 with no identified risk for TB infection among Navy recruits
Specificity = 99.8% (531/532 = QFT- Gold negative)
CDC; publication in preparation 2005
99 healthy individuals with no identified risk for TB infection, all BCG (+)
Specificity = 96% (95/99 = QFT negative)
JAMA 2005;293:

20. Sensitivity Estimates of Quanti-FERON-TB Gold
118 culture confirmed TB disease,
85% untreated, 15% treated < 7 days
65.8% had positive TST (5mm); Sensitivity 105/118 = 89% for QFT
Mori, et al. AJRCCM 2004;170:59-64
48 culture confirmed TB disease, 71% untreated
Sensitivity 41/48 = 85.4%
Ravn, et al. Clin Diag Lab Immunol 2005;12:
54 culture confirmed TB disease
Sensitivity 44/54 = 81.5%; TST = 77.8%
Kang, et al. JAMA 2005;293:

21. Characteristic of the Quanti-FERON-TB Gold
Am J Respir Crit Care Med Vol 174. pp 736–742, 2006

22. Quanti-FERON-TB Gold Species Specificity of ESAT-6 and CFP-10