Medication Summary

PPD, which has been used to evaluate exposure to M tuberculosis, and Candida Ag are the only currently available US Food and Drug Administration (FDA)-approved Ags for delayed—type hypersensitivity (DTH) skin testing. The most clinically informative Ags used for DTH responses are Candida and tetanus Ags, because most individuals are exposed to these Ags as infants. By age 9-12 months, more than 80% of immunocompetent children mount positive responses to these Ags.

Previously available DTH Ags that were withdrawn from clinical use include the Cell-mediated immunity (CMI) multitest, coccidioidin, mumps, and histoplasmin. Mumps Ag is a relatively poor Ag in eliciting a positive DTH reactivity. Studies have shown only 60% of previously mumps infected adults to have a positive DTH reactivity. An even lower response is predicted when the only exposure to mumps is by MMR immunization.

Class Summary

These agents are used to detect infection with M tuberculosis.

Tuberculin, purified protein derivative (PPD Mantoux test, Aplisol, Tubersol)

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The standard skin test uses 5 U of PPD in a volume of 0.1 mL. A lower concentration of 1 U/0.1 mL is used when a high exposure to antigen, as in caseating tuberculosis, is suspected; 250 U can be used if standard test result is negative and person is known to be immunocompromised. A negative DTH reaction does not rule out infection but may indicate disseminated infection as in miliary tuberculosis.

Class Summary

These are used to assess cell mediated immunity (CMI) following the primary series of diphtheria-tetanus-a cellular pertussis (DTaP) vaccine (3 doses). Conventionally, it has also been used as a control for tuberculin testing in patients who are immunocompromised or suspected to have disseminated tuberculosis.

Tetanus toxoid adsorbed or fluid

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The standard TD vaccine is diluted to 1:100 or 1:10. A positive DTH reaction indicates recognition by cell-mediated immunity; protection correlates with antibody responses.

Class Summary

Most infants have been exposed to Candida antigen (Ag) even without clinical thrush or Candida diaper dermatitis. Japanese studies showed that 80% of children had positive DTH responses by age 1 year; therefore, Candida is a conventional Ag used as a positive control for tuberculin skin testing in individuals who are immunocompromised or when disseminated tuberculosis is suspected.

Candida skin test antigen (Candin, NDC#38697-200-1; Allermed)

Also known as Dermatophytin. It is diluted 1:10 or 1:100 with sterile water.

Follow-up

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