December 20, 2016

Diagnosis of Tuberculosis in Adults and

Children
Thomas Glck, MD reviewing Lewinsohn DM et al. Clin Infect Dis 2016 Dec 8.
Recommendations on TB testing incorporate recent evidence on using an interferongamma release assay for latent TB and nucleic acid amplification testing for active TB.

Target Population: Clinicians, laboratory workers,

staff in medical offices, academic training programs,
medical schools, and others involved in the
management of patients with latent or suspected
tuberculosis (TB)
Sponsoring Organizations: American Thoracic
Society, Infectious Diseases Society of America,
Centers for Disease Control and Prevention
Background and Objective
These evidence-based consensus guidelines were
formulated using the Grading, Recommendations,
Assessment, Development, and Evaluation (GRADE)
approach.
Key Points

TB is a leading cause of infectious disease

morbidity and mortality worldwide but,
unfortunately, has many diagnostic uncertainties.

For testing an individual suspected of having

latent TB infection, an interferon-gamma release
assay (IGRA) is preferred over a tuberculin skin test
(TST) except in people at high risk for progression
(for whom either test is appropriate) and in children
younger than 5 years. However, a TST is considered
an acceptable alternative.

For diagnosis of suspected pulmonary TB, a

sputum volume of at least 3 mL (optimally, 510 mL)
is required. Sputum induction rather than flexible
bronchoscopic sampling is suggested for individuals
unable to expectorate sputum or whose
expectorated sputum is acid-fast bacilli (AFB) smear
microscopy negative, leaving bronchoscopy for those
unable to provide induced sputum.

Three specimens from each patient with

suspected TB should be examined microscopically for
AFB. Both liquid and solid mycobacterial cultures
should be performed for every specimen, and
recovered isolates should be identified according to
standard criteria.

A nucleic acid amplification test (NAAT) is

recommended in AFB-positive patients and in AFBnegative patients with high suspicion of pulmonary
TB.

Rapid molecular drug susceptibility testing for

rifampin and, optionally, for isoniazid is
recommended in AFB-positive or patients with a
positive NAAT who are at risk for drug-resistant
tuberculosis.

For suspected extrapulmonary TB, the diagnostic

approach is similar to that for pulmonary TB. Patients
with suspected pleural, peritoneal, pericardial, or
central nervous system TB also should have
adenosine deaminase and/or free IFN- levels
determined in liquid specimens; in addition, tissue
biopsies should be examined histologically.

From each patient with confirmed TB, an isolate

should be genotyped for epidemiological reasons.

COMMENT
Most of the recommendations in this guideline
represent current practice, but the preference of the
IGRA over the TST for diagnosing latent TB and the
high rating of the NAATs in the diagnosis of active TB
are novel. Even though the authors stated that they
did not intend to impose a standard of care, this
guideline provides the basis for rational decisions in
the diagnostic evaluation of patients with possible
latent TB or suspected active TB.