Anergy testing in nursing home residents

Skin response to delayed hypersensitivity testing in persons with unilateral stroke-related paresis: implications for people with spinal cord injury

BACKGROUND

Vaccination rates among individuals with spinal cord injury (SCI) could be improved if it can be shown that vaccination performed on insensate areas is effective. This would eliminate the the risk of discomfort and soreness at the injection site.

OBJECTIVE

To determine whether immune responsiveness varies between areas with intact and impaired innervation in patients with stroke-related paresis.

DESIGN

Prospective trial in which each subject served as his or her own control.

SETTING

Rehabilitation wards and long-term care units at a Veterans Affairs Medical Center.

PATIENTS

Individuals with a history of cerebrovascular accident (CVA) affecting 1 side of the body.

METHODS

The Multitest cell-mediated immunity (CMI) and purified protein derivative (PPD) of tuberculin were administered intradermally to each arm of each subject.

MAIN OUTCOME MEASURES

Total millimeters of induration in response to either test and positive vs negative responses to either test were compared between the 2 arms of each subject.

RESULTS

Response to delayed hypersensitivity testing did not differ between the arms affected and unaffected by CVA in each subject, and the time since CVA also did not affect the magnitude of the skin response.

CONCLUSIONS

Skin testing for delayed hypersensitivity can be effectively administered in the paretic arms of persons who have experienced CVA. Although this study was performed in patients with stroke-related impairment, it has implications for vaccine administration in individuals with SCI-related neurologic deficits.

Tuberculin skin test reactivity, anergy, and HIV infection in hospitalized patients. Longcope Firm of the Osler Medical Housestaff

PURPOSE

Detection of latent tuberculosis infection is an important step in the control of tuberculosis because high-risk persons may be given preventive therapy. The value of tuberculin skin testing in individuals with human immunodeficiency virus (HIV) infection, however, is limited by anergy. We evaluated the prevalence of tuberculin skin test reactivity, anergy, and HIV infection in a group of hospitalized patients in an area where both tuberculosis and HIV infection are prevalent.

PATIENTS AND METHODS

Three hundred fifty-one patients consecutively admitted to a medical service of a large urban teaching hospital were enrolled in the study. All those with no documented history of a positive tuberculin skin test were evaluated on admission with purified protein derivative (PPD) by the Mantoux test, and with anergy testing using a multiple-puncture device. HIV testing was offered to all patients who did not have a known history of HIV infection, and was performed when informed consent was obtained.

RESULTS

Forty-one patients (12%) had a documented history of a positive PPD. Of the remaining 310 patients, 62 (20%) had a PPD response of > or = 10 mm induration. Fifty-two (15%) of the 351 patients were HIV positive. None of the HIV-infected patients was PPD positive. Anergy was found in 63% of the HIV-infected patients and 28% of the HIV-seronegative patients. Independent risk factors for a positive PPD included age > 55, male sex, and hypertension. HIV infection, current steroid use, and a history of cancer were associated with a negative PPD. Independent risk factors for anergy included HIV infection, current corticosteroid use, renal failure pneumonia, and a history of cancer. Of the 62 new PPD-positive patients, 30 (48%) were candidates for chemoprophylaxis. Additionally, 30 (63%) of 48 HIV-seropositive patients who were completed testing were anergic and might be candidates for chemoprophylaxis. Almost all of the patients eligible for chemoprophylactic therapy would have been detected if only patients at increased risk for developing tuberculosis were screened.

CONCLUSIONS

Tuberculosis infection, HIV infection, and anergy were common in patients admitted to this medical service. Interpretation of PPD reactivity was confounded by a high prevalence of anergy, particularly in HIV-infected patients. A large proportion of patients tested were candidates for chemoprophylaxis. Routine tuberculin skin testing with anergy testing for high-risk patients on admission to the hospital is useful for identifying patients who might benefit from prophylaxis to help control the spread of tuberculosis.

Infection and immune response in the elderly

A number of immunologic functions have been shown to decline in an age-related fashion, particularly cell-mediated immunity and antibody response to an immunogen. Underlying degenerative diseases and medications further contribute to the immunologic abnormalities noted in the elderly. The elderly in hospitals and nursing homes are a particularly vulnerable subset, with a high incidence of institutionally acquired infection. Aspects of disease prevention in the elderly are discussed.

Tuberculosis in the elderly: incidence, manifestations, PPD skin tests, and preventive therapy

Tuberculosis is a chronic infection caused by Mycobacterium tuberculosis. The incidence of tuberculosis has declined dramatically over the past decades, but it is still highly prevalent in the geriatric population. This report describes the etiology, clinical manifestations, and immunologic changes of tuberculosis in the elderly. The basis for tuberculin skin testing and its interpretation in patients over 65 years of age are discussed, as well as the controversies regarding preventive therapy with isoniazid in the elderly. Guidelines for tuberculosis screening in long-term care facilities are proposed.