Editorial

Annals of Internal Medicine

Using Tests for Latent Tuberculous Infection to Diagnose Active Tuberculosis: Can We Eat Our Cake and Have It Too?
apid diagnosis of active tuberculosis is challenging. The only rapid test for active tuberculosis is smear microscopy, which has poor sensitivity for both extrapulmonary and less extensive pulmonary forms of tuberculosis (1). Nucleic acid amplication tests have somewhat better but still suboptimal sensitivity (2), whereas mycobacterial cultures are sensitive but require several weeks before results are available (1). The tuberculin skin test (TST) and the new interferon- release assays (3, 4) detect a cellular immune response to tuberculosis antigens. On the basis of numerous longitudinal studies (5), the TST is considered to have good sensitivity for the detection of latent tuberculous infection. The interferon- release assays appear to have similar sensitivity but improved specicity for latent infection (4, 6). Use of these tests for the diagnosis of active tuberculosis is based on the logic that one must have tuberculous infection in order to have tuberculosis disease. However, these tests have 2 fundamental problems when used to diagnose active tuberculosis. First, they measure the host immune response to tuberculosis, not the presence of the microorganisms themselves (3, 4). Because reactivation of latent tuberculous infection reects an impaired immune response, at least temporarily, these tests may be falsely negative at the time of development of disease (3). In a recent meta-analysis, the sensitivity of both TST and the commercially available interferon- release assays ranged from 73% to 88% for the diagnosis of active disease (6), implying a substantial proportion of false-negative results. The greater problem with using TST or interferon- release assays to diagnose active tuberculosis is their poor specicity for disease, because these tests cannot distinguish an immune response to reactivated tuberculosis from a response to tuberculous infection that remains latent. The prevalence of latent tuberculosis exceeds 50% among adults in countries with a high incidence of tuberculosis, as well as high-risk populations in countries with a low incidence of tuberculosis, such as foreign-born persons or close contacts of patients with active tuberculosis (5). Therefore, when active tuberculosis is suspected in someone from these populations, the TST and interferon- release assays will be positive in at least half of all persons testedthe vast majority of whom will prove to have latent tuberculous infection and an unrelated, nontuberculous active pulmonary disease. Given this low specicity, positive results would not change the probability of disease very much and, because they would be so frequent, would most likely result in many unnecessary investigations. In this issue, Dosanjh and colleagues (7) present results from using a combination of TST and an interferonrelease assay for the diagnosis of active tuberculosis. An in-house ELISpotPLUS assay (a noncommercial assay that
398 2008 American College of Physicians

was developed and used in a research laboratory), which contained 35 early secretory antigenic target-6 and culture ltrate protein-10 peptides with 17 peptides from Rv3879c, had a sensitivity of 89%, compared with 83% for TST. Sensitivity was 99% in patients with positive TST or ELISpotPLUS results, yielding a negative likelihood ratio of 0.02 if both tests yielded negative results. When the negative likelihood ratio is 0.02, the odds of active tuberculosis drop to 2% of the pretest odds (if the pretest odds were 1:1, the posttest odds would be 1:50, which corresponds to a probability of 2%). The study has important strengths: The design was prospective, no patients were excluded, technicians were blinded to clinical information, and clinicians did not use the ELISpotPLUS results when they formulated a nal diagnosis. All patients were being investigated for possible tuberculosis, and all were carefully characterized. However, the study also has several limitations. Most notably, tuberculin test results were missing in 17% of all participants. In another 27%, the investigators used the Heaf test for tuberculin testing; because the Heaf test has now been discontinued and had only moderate agreement (8) with the Mantoux testthe internationally accepted standardthe results are difcult to generalize. Of all cases, 21% were not microbiologically conrmed, which could have introduced some diagnostic misclassication. Test performance could have been overestimated through the exclusion of 35 patients with undiagnosed disease, representing 10% of the total, and the use of negative TST results to exclude active tuberculosis, making them part of the diagnostic gold standard criteria. Despite these limitations, the very high sensitivity of 99% for the diagnosis of active tuberculosis if the results of either TST or ELISpotPLUS were positive deserves consideration. Does this mean that one can use these tests to diagnose active tuberculosis? As Dosanjh and colleagues point out (7), the very high sensitivity of the combined tests resulted in a negative likelihood ratio of 0.02, considered a large and often conclusive decrease in the likelihood of disease (9). In other words, if the pretest probability was low and both tests were negative, one could exclude active tuberculosis with near certainty. In patients at very high risk for disease (high pretest probability), active tuberculosis could not be ruled out with as much certainty, even with negative results on 2 different tests. For example, if the pretest probability was 80%, the posttest probability would be about 8% if both TST and ELISpotPLUS had negative results. Even though interferon- release assays and TST are believed to measure cell-mediated immune response to tuberculosis antigens (3), they do so by different means.

Using Tests for Latent Tuberculous Infection to Diagnose Tuberculosis

Editorial

Tuberculin testing measures an in vivo, multimediator inammatory response to multiple tuberculin antigens (5). The interferon- release assays measure ex vivo interferon- production by the patients circulating lymphocytes in response to stimulation with a few Mycobacterium tuberculosisspecic antigens (3, 4). Because the 2 tests measure related but different biological phenomena, discordant results (a positive result from one test and a negative result from the other) for the same patient is neither surprising nor uncommon (6). This discordance will improve the sensitivity of a combination test (TST and interferon- release assay) if only 1 of the 2 tests needs be positive to call the combination test result positive, as Dosanjh and colleagues demonstrate (7). This enhancement of sensitivity by using a combination of 2 complementary tests has a very important drawback: We dont understand the mechanism (6). Dosanjh and colleagues (7) explored the reasons for discordant results but found an explanation for only 30% of the TSTnegative, ELISpotPLUS-positive discordant results. If the results of the 2 tests were completely independent, meaning discordance occurred at random, both tests would have been negative in 1.9% of patientsa rate remarkably close to what was found (1.0%). Was the high sensitivity in Dosanjh and colleagues study the result of random discordance? The question is not merely academic. If the results of the 2 tests were perfectly concordant, the combined sensitivity would have been only 89%, yielding a negative likelihood ratio of 0.22implying, according to Bayes theorem, only a small decrease in likelihood of disease (9). Instead, the 2 tests produced a fortunate combination of discordant positive results that dramatically enhance sensitivity. Given that neither Dosanjh and colleagues (7) nor others (5) can explain this discordance, it is hard to be condent that other investigators will replicate these results. Several studies and a systematic review and metaanalysis are required before we can be condent that the sensitivity is as high as shown by Dosanjh and colleagues (7). In the meantime, the physician who strongly suspects tuberculosis despite negative results on both TST and ELISpotPLUS should follow the patient closely before ruling out tuberculosis. Where does this leave us? Positive test results for latent tuberculous infectionwhether from old tests (TST) or new (interferon- release assays)will be most useful to clinch a diagnosis of active tuberculosis when the pretest probability of active tuberculosis is high and the pretest probability of latent infection is low. This combination of risks is most likely in persons born in low-incidence coun-

tries after 1950 who do not have risk factors for tuberculosis exposure but have clinical manifestations of active tuberculosis. Clinicians should retain a healthy skepticism about the dramatically enhanced sensitivity of a combination of tests, as shown in Dosanjh and colleagues study (7), until other researchers conrm the nding. And, of note, the posttest probability after a negative result on both of these tests may still exceed some physicians threshold probability for starting treatment of patients with a high pretest probability of active tuberculous infection. Populations with a high prevalence of tuberculous infection bear more than 95% of the burden of tuberculosis worldwide (10). In these populations, the search for a rapid accurate test must go on.
Dick Menzies, MD, MSc McGill University Montreal, Quebec, Canada H2X 2P4
Potential Financial Conflicts of Interest: None disclosed. Requests for Single Reprints: Dick Menzies, MD, MSc, Respiratory

Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, 3650 St. Urbain Street, Room K1.24, Montreal, Quebec H2X 2P4, Canada; e-mail, dick.menzies@mcgill.ca. Ann Intern Med. 2008;148:398-399.

References
1. Brodie D, Schluger NW. The diagnosis of tuberculosis. Clin Chest Med. 2005;26:247-71, vi. [PMID: 15837109] 2. Pai M, Kalantri S, Dheda K. New tools and emerging technologies for the diagnosis of tuberculosis: part I. Latent tuberculosis. Expert Rev Mol Diagn. 2006;6:413-22. [PMID: 16706743] 3. Andersen P, Munk ME, Pollock JM, Doherty TM. Specic immune-based diagnosis of tuberculosis. Lancet. 2000;356:1099-104. [PMID: 11009160] 4. Pai M, Riley LW, Colford JM Jr. Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review. Lancet Infect Dis. 2004;4:761-76. [PMID: 15567126] 5. Menzies D, Doherty TM. Diagnosis of latent tuberculosis infection. In: Raviglione MC, ed. Reichman and Hershelds Tuberculosis, A Comprehensive International Approach. New York: Informa Healthcare USA; 2006:215-63. 6. Menzies D, Pai M, Comstock G. Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research. Ann Intern Med. 2007;146:340-54. [PMID: 17339619] 7. Dosanjh DP, Hinks TS, Innes JA, Deeks JJ, Pasvol G, Hackforth S, et al. Improved diagnostic evaluation of suspected tuberculosis. Ann Intern Med. 2008;148:325-336. 8. Katz J, Krasnitz A, Kunofsky S. Comparative study of the Heaf and Mantoux tests. Am Rev Respir Dis. 1967;96:1033-8. [PMID: 6059188] 9. Ebell MH. Likelihood ratios. 2007. Accessed at www.poems.msu.edu/Info Mastery/Diagnosis/Diagnosis.htm on 20 December 2007. 10. World Health Organization. Global Tuberculosis Control. Surveillance, Planning, Financing. WHO/HTM/TB/2006.362. Geneva: World Health Organization; 2007.

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4 March 2008 Annals of Internal Medicine Volume 148 Number 5 399