Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You and Your Team.

Learn More →

Instability of Delayed-type Hypersensitivity Skin Test Anergy in Human Immunodeficiency Virus Infection

Instability of Delayed-type Hypersensitivity Skin Test Anergy in Human Immunodeficiency Virus... Abstract Objective: To evaluate stability of delayed-type hypersensitivity (DTH) skin test over time in human immunodeficiency virus (HIV)—seropositive and HIV-seronegative injecting drug users. Method: A community-based cohort of injecting drug users who had serial skin testing with purified protein derivative tuberculin, mumps, and Candida albicans antigen. Delayed-type hypersensitivity anergy was defined as a skin test result of less than 3 mm for all three antigens; DTH positivity was a skin test result of 3 mm or greater for at least one antigen (Centers for Disease Control and Prevention, Atlanta, Ga, 1993). Results: At baseline, 36% of HIV-seropositive subjects (n=401) were anergic as compared with 14% of HIV-seronegative subjects (n=552; P<.001). During follow-up, fewer HIV-seropositive subjects remained DTH positive (42%) and more remained anergic (19%) than of HIV-seronegative subjects (67% and 7%, respectively). Twenty-four percent of HIV-seropositive subjects who were initially DTH positive became anergic as compared with 15.3% of the HIV-seronegative subjects. However, the proportion changing from anergy to DTH positivity was greater among HIV-seropositive subjects (15%) than HIV-seronegative subjects (12%). In comparison to those who remained DTH positive, HIV-seropositive subjects with CD4 cell counts of less than 0.50×109/L (odds ratio=6.4) and less than 0.35×109/L (odds ratio=11.2) were more likely to remain anergic than those who had CD4 cell counts above 0.50×109/L or were HIV seronegative. Conclusions: Although the prevalence and incidence of DTH anergy were higher in HIV-seropositive subjects, high rates of change in DTH status occurred in both directions. This suggests that instability of DTH skin testing is substantial and only partially dependent on HIV status. Although a single test may be an unreliable indicator of HIV-induced immunosuppression, two consecutive anergic readings were strongly associated with a CD4 cell count below 0.50×109/L and particularly below 0.35×109/L. For determining false negativity of tuberculin tests, persistent DTH anergy is more reliable than a single test among HIV-seropositive injecting drug users. Anergy testing appears to be unnecessary with CD4 cell counts greater than 0.50×109/L.(Arch Intern Med. 1995;155:2111-2117) References 1. Centers for Disease Control and Prevention. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR Morb Mortal Wkly Rep . 1991;40( (suppl RR-5) ):27-33. 2. Furcolow ML, Emge ME, Bunnell IL. Depression of tuberculin and histoplasmin sensitivity associated with critical illness. Public Health Rep . 1948;63:1290-1298.Crossref 3. World Health Organization. Tuberculin reaction on five consecutive days. Bull World Health Organ . 1955;12:189-196. 4. Atuk NO, Hunt EH. Serial tuberculin testing and isoniazid therapy in general hospital employees. JAMA . 1971;218:1795-1798.Crossref 5. Creditor MC, Smith EC, Gallai JB, Baumann M, Nelson KE. Tuberculosis, tuberculin reactivity, and delayed cutaneous hypersensitivity in nursing home residents. J Gerontol . 1988;43:M97-100.Crossref 6. Gordin FM, Perez-Stable EJ, Reid M, et al. Stability of positive tuberculin tests: are boosted reactions valid? Am Rev Respir Dis . 1991;144:560-563.Crossref 7. Perez-Stable EJ, Flaherty D, Schecter G, Slutkin G, Hopewell PC. Conversion and reversion of tuberculin reactions in nursing home residents. Am Rev Respir Dis . 1988;137:801-804.Crossref 8. Thompson NJ, Glassroth JL, Snider DE, Farer LS. The booster phenomena in serial tuberculin testing. Am Rev Respir Dis . 1979;119:587-597. 9. Huebner RE, Schein MF, Hall CA, Barnes SA. Delayed-type hypersensitivity anergy in human immunodeficiency virus-infected persons screened for infection with Mycobacterium tuberculosis. Clin Infect Dis . 1994;19:26-32.Crossref 10. Graham NMH, Nelson KE, Solomon L, et al. Prevalence of tuberculin positivity and skin test anergy in HIV-1-seropositive and -seronegative intravenous drug users. JAMA . 1992;267:369-373.Crossref 11. Sears SD, Fox R, Brookmeyer R, Leavitt R, Polk BF. Delayed hypersensitivity skin testing and anergy in a population of gay men. Clin Immunol Immunopathol . 1987;45:177-183.Crossref 12. Blatt SP, Hendrix CW, Butzin CA, et al. Delayed-type hypersensitivity skin testing predicts progression to AIDS in HIV-infected patients. Ann Intern Med . 1993;119:177-184.Crossref 13. Markowitz N, Hansen NI, Wilcosky TC, et al. Tuberculin and anergy testing in HIV-seropositive and HIV-seronegative persons. Ann Intern Med . 1993;119:185-193.Crossref 14. Selwyn PA, Sckell BM, Alcabes P, Friedland GH, Klein RS, Schoenbaum EE. High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy. JAMA . 1992;268:504-509.Crossref 15. Moreno S, Baraia-Etxaburu J, Bouza E, et al. Risk for developing tuberculosis among anergic patients infected with HIV. Ann Intern Med . 1993;119:194-198.Crossref 16. Girardi E, Antonucci G, Ippolito G, Armignacco O, Grupo Italino dl Studio Tuberculosi e AIDS (GISTA). Prospective evaluation of risk of tuberculosis in HIV-infected persons by tuberculin reaction size. In: Abstracts of the 10th International Conference on AIDS ; August 7-12, 1994; Yokohama, Japan. Abstract 405B. 17. Huebner RE, Schein MF, Bass JB. The tuberculin skin test. Clin Infect Dis . 1993;17:968-975.Crossref 18. Comstock GW, Woolpert SF. Tuberculin conversions: true or false? Am Rev Respir Dis . 1978;118:215-217. 19. Vlahov D, Anthony JC, Munoz A, Margolick JB, Nelson KE, Polk BF. The ALIVE Study, a longitudinal study of HIV infection among intravenous drug users: description of methods and characteristics of participants. J Drug Issues . 1991;21:755-771. 20. Giorgi JV, Cheng HL, Margolick JB, et al. Quality control in the flow cytometric measurement of T-lymphocyte subsets: the Multicenter AIDS Cohort study (MACS) experience. Clin Immunol Immunopathol . 1990;55:173-186.Crossref 21. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika . 1986;73:13-22.Crossref 22. Centers for Disease Control and Prevention. Update: acquired immunodeficiency syndrome—United States. MMWR Morb Mortal Wkly Rep . 1992;41:462-468. 23. Colebunders RL, Legughe I, Nzila N, et al. Cutaneous delayed-type hypersensitivity in patients with human immunodeficiency virus infection in Zaire. J Acquir Immune Defic Syndr . 1989;2:576-578. 24. Kornbluth RS, McCutchan JA. Skin test responses as predictors of tuberculous infection and of progression in HIV-infected persons. Ann Intern Med . 1993;119:241-243.Crossref 25. Galai N, Graham NMH, Chaisson R, Nelson KE, Vlahov D, Lewis J. Multidrug-resistant tuberculosis. N Engl J Med . 1992;327:1172-1173.Crossref 26. Graham NMH, Astermboski J, Galai N, Cohn S, Nelson KE, Vlahov D. Incidence of mycobacterial infection and disease in HIV+ and HIV-IVDUs. Read before the 13th Scientific Meeting of the International Epidemiological Association; September 28, 1993; Sydney, Australia. 27. Graham NMH. Anergy skin testing guidelines for HIV-infected patients. Read before the American Committee for the Elimination of Tuberculosis Meeting (ACET/CDC/ATS); June 26, 1994; Atlanta, Ga. 28. Dvorak HF, Galli SJ, Dvorak AM. Expression of cell-mediated hypersensitivity in vivo: recent advances. Int Rev Exp Pathol . 1980;21:119-194. 29. Ryan J, Geczy CL. Macrophage procoagulant-inducing factor: in vivo properties and chemotactic activity for phagocytic cells. J Immunol . 1988;141:2110-2117. 30. Gregory SA, Kornbluth RS, Helin H, Remold HG, Edgington TS. Monocyte procoagulant inducing factor: a lymphokine involved in the T cell-instructed monocyte procoagulant response to antigen. J Immunol . 1986;137:3231-3239. 31. Fan ST, Glasebrook AL, Edgington TS. Clonal analysis of CD4+ T helper cell subsets that induce the monocyte procoagulant response. Cell Immunol . 1990; 128:52-62.Crossref 32. Mosmann TR, Coffman RL. TH1 and TH2 cells: different patterns of lymphokine secretion lead to different functional properties. Annu Rev Immunol . 1989; 7:145-173.Crossref 33. Richards NM, Nelson KE, Batt MD, Hackbarth D, Heindenreich JG. Tuberculin test conversion during repeated skin testing, associated with sensitivity to non-tuberculous mycobacteria. Am Rev Respir Dis . 1979;120:59-65. 34. Clerici M, Shearer GM. A TH1-TH2 switch is a critical step in the etiology of HIV infection. Immunol Today . 1993;14:107-111.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Instability of Delayed-type Hypersensitivity Skin Test Anergy in Human Immunodeficiency Virus Infection

Loading next page...
 
/lp/american-medical-association/instability-of-delayed-type-hypersensitivity-skin-test-anergy-in-human-1Zu7QbMOsc
Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430190107015
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To evaluate stability of delayed-type hypersensitivity (DTH) skin test over time in human immunodeficiency virus (HIV)—seropositive and HIV-seronegative injecting drug users. Method: A community-based cohort of injecting drug users who had serial skin testing with purified protein derivative tuberculin, mumps, and Candida albicans antigen. Delayed-type hypersensitivity anergy was defined as a skin test result of less than 3 mm for all three antigens; DTH positivity was a skin test result of 3 mm or greater for at least one antigen (Centers for Disease Control and Prevention, Atlanta, Ga, 1993). Results: At baseline, 36% of HIV-seropositive subjects (n=401) were anergic as compared with 14% of HIV-seronegative subjects (n=552; P<.001). During follow-up, fewer HIV-seropositive subjects remained DTH positive (42%) and more remained anergic (19%) than of HIV-seronegative subjects (67% and 7%, respectively). Twenty-four percent of HIV-seropositive subjects who were initially DTH positive became anergic as compared with 15.3% of the HIV-seronegative subjects. However, the proportion changing from anergy to DTH positivity was greater among HIV-seropositive subjects (15%) than HIV-seronegative subjects (12%). In comparison to those who remained DTH positive, HIV-seropositive subjects with CD4 cell counts of less than 0.50×109/L (odds ratio=6.4) and less than 0.35×109/L (odds ratio=11.2) were more likely to remain anergic than those who had CD4 cell counts above 0.50×109/L or were HIV seronegative. Conclusions: Although the prevalence and incidence of DTH anergy were higher in HIV-seropositive subjects, high rates of change in DTH status occurred in both directions. This suggests that instability of DTH skin testing is substantial and only partially dependent on HIV status. Although a single test may be an unreliable indicator of HIV-induced immunosuppression, two consecutive anergic readings were strongly associated with a CD4 cell count below 0.50×109/L and particularly below 0.35×109/L. For determining false negativity of tuberculin tests, persistent DTH anergy is more reliable than a single test among HIV-seropositive injecting drug users. Anergy testing appears to be unnecessary with CD4 cell counts greater than 0.50×109/L.(Arch Intern Med. 1995;155:2111-2117) References 1. Centers for Disease Control and Prevention. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR Morb Mortal Wkly Rep . 1991;40( (suppl RR-5) ):27-33. 2. Furcolow ML, Emge ME, Bunnell IL. Depression of tuberculin and histoplasmin sensitivity associated with critical illness. Public Health Rep . 1948;63:1290-1298.Crossref 3. World Health Organization. Tuberculin reaction on five consecutive days. Bull World Health Organ . 1955;12:189-196. 4. Atuk NO, Hunt EH. Serial tuberculin testing and isoniazid therapy in general hospital employees. JAMA . 1971;218:1795-1798.Crossref 5. Creditor MC, Smith EC, Gallai JB, Baumann M, Nelson KE. Tuberculosis, tuberculin reactivity, and delayed cutaneous hypersensitivity in nursing home residents. J Gerontol . 1988;43:M97-100.Crossref 6. Gordin FM, Perez-Stable EJ, Reid M, et al. Stability of positive tuberculin tests: are boosted reactions valid? Am Rev Respir Dis . 1991;144:560-563.Crossref 7. Perez-Stable EJ, Flaherty D, Schecter G, Slutkin G, Hopewell PC. Conversion and reversion of tuberculin reactions in nursing home residents. Am Rev Respir Dis . 1988;137:801-804.Crossref 8. Thompson NJ, Glassroth JL, Snider DE, Farer LS. The booster phenomena in serial tuberculin testing. Am Rev Respir Dis . 1979;119:587-597. 9. Huebner RE, Schein MF, Hall CA, Barnes SA. Delayed-type hypersensitivity anergy in human immunodeficiency virus-infected persons screened for infection with Mycobacterium tuberculosis. Clin Infect Dis . 1994;19:26-32.Crossref 10. Graham NMH, Nelson KE, Solomon L, et al. Prevalence of tuberculin positivity and skin test anergy in HIV-1-seropositive and -seronegative intravenous drug users. JAMA . 1992;267:369-373.Crossref 11. Sears SD, Fox R, Brookmeyer R, Leavitt R, Polk BF. Delayed hypersensitivity skin testing and anergy in a population of gay men. Clin Immunol Immunopathol . 1987;45:177-183.Crossref 12. Blatt SP, Hendrix CW, Butzin CA, et al. Delayed-type hypersensitivity skin testing predicts progression to AIDS in HIV-infected patients. Ann Intern Med . 1993;119:177-184.Crossref 13. Markowitz N, Hansen NI, Wilcosky TC, et al. Tuberculin and anergy testing in HIV-seropositive and HIV-seronegative persons. Ann Intern Med . 1993;119:185-193.Crossref 14. Selwyn PA, Sckell BM, Alcabes P, Friedland GH, Klein RS, Schoenbaum EE. High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy. JAMA . 1992;268:504-509.Crossref 15. Moreno S, Baraia-Etxaburu J, Bouza E, et al. Risk for developing tuberculosis among anergic patients infected with HIV. Ann Intern Med . 1993;119:194-198.Crossref 16. Girardi E, Antonucci G, Ippolito G, Armignacco O, Grupo Italino dl Studio Tuberculosi e AIDS (GISTA). Prospective evaluation of risk of tuberculosis in HIV-infected persons by tuberculin reaction size. In: Abstracts of the 10th International Conference on AIDS ; August 7-12, 1994; Yokohama, Japan. Abstract 405B. 17. Huebner RE, Schein MF, Bass JB. The tuberculin skin test. Clin Infect Dis . 1993;17:968-975.Crossref 18. Comstock GW, Woolpert SF. Tuberculin conversions: true or false? Am Rev Respir Dis . 1978;118:215-217. 19. Vlahov D, Anthony JC, Munoz A, Margolick JB, Nelson KE, Polk BF. The ALIVE Study, a longitudinal study of HIV infection among intravenous drug users: description of methods and characteristics of participants. J Drug Issues . 1991;21:755-771. 20. Giorgi JV, Cheng HL, Margolick JB, et al. Quality control in the flow cytometric measurement of T-lymphocyte subsets: the Multicenter AIDS Cohort study (MACS) experience. Clin Immunol Immunopathol . 1990;55:173-186.Crossref 21. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika . 1986;73:13-22.Crossref 22. Centers for Disease Control and Prevention. Update: acquired immunodeficiency syndrome—United States. MMWR Morb Mortal Wkly Rep . 1992;41:462-468. 23. Colebunders RL, Legughe I, Nzila N, et al. Cutaneous delayed-type hypersensitivity in patients with human immunodeficiency virus infection in Zaire. J Acquir Immune Defic Syndr . 1989;2:576-578. 24. Kornbluth RS, McCutchan JA. Skin test responses as predictors of tuberculous infection and of progression in HIV-infected persons. Ann Intern Med . 1993;119:241-243.Crossref 25. Galai N, Graham NMH, Chaisson R, Nelson KE, Vlahov D, Lewis J. Multidrug-resistant tuberculosis. N Engl J Med . 1992;327:1172-1173.Crossref 26. Graham NMH, Astermboski J, Galai N, Cohn S, Nelson KE, Vlahov D. Incidence of mycobacterial infection and disease in HIV+ and HIV-IVDUs. Read before the 13th Scientific Meeting of the International Epidemiological Association; September 28, 1993; Sydney, Australia. 27. Graham NMH. Anergy skin testing guidelines for HIV-infected patients. Read before the American Committee for the Elimination of Tuberculosis Meeting (ACET/CDC/ATS); June 26, 1994; Atlanta, Ga. 28. Dvorak HF, Galli SJ, Dvorak AM. Expression of cell-mediated hypersensitivity in vivo: recent advances. Int Rev Exp Pathol . 1980;21:119-194. 29. Ryan J, Geczy CL. Macrophage procoagulant-inducing factor: in vivo properties and chemotactic activity for phagocytic cells. J Immunol . 1988;141:2110-2117. 30. Gregory SA, Kornbluth RS, Helin H, Remold HG, Edgington TS. Monocyte procoagulant inducing factor: a lymphokine involved in the T cell-instructed monocyte procoagulant response to antigen. J Immunol . 1986;137:3231-3239. 31. Fan ST, Glasebrook AL, Edgington TS. Clonal analysis of CD4+ T helper cell subsets that induce the monocyte procoagulant response. Cell Immunol . 1990; 128:52-62.Crossref 32. Mosmann TR, Coffman RL. TH1 and TH2 cells: different patterns of lymphokine secretion lead to different functional properties. Annu Rev Immunol . 1989; 7:145-173.Crossref 33. Richards NM, Nelson KE, Batt MD, Hackbarth D, Heindenreich JG. Tuberculin test conversion during repeated skin testing, associated with sensitivity to non-tuberculous mycobacteria. Am Rev Respir Dis . 1979;120:59-65. 34. Clerici M, Shearer GM. A TH1-TH2 switch is a critical step in the etiology of HIV infection. Immunol Today . 1993;14:107-111.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 23, 1995

References