Background: The immune status of children is always affected by nutrition. Sometime severe malnutrition is associated with falsenegative Mantoux test. There is a need to study to observe the effect of nutritional status on the size of indurations in Mantoux positivechildren. Study Design: Observational analytical cross-sectional study. Methods: The study population consisted of 310 patients,belonging to both sexes and age of 1-14 years, attending the outpatient department of UP Rural Institute of Medical Sciences andResearch, Saifai, Etawah. Only Mantoux positive cases were included in the study. Their sizes of indurations of skin reaction weremeasured and recorded in mm. The nutritional status was calculated as the weight for age and height for age standard (Z-score), usingthe NCHS charts of for males and females. Results: Out of 800 children screened for tuberculosis, 310 children had positive Mantouxtest and were recruited in the study. Mean induration (20 mm) was similar in all the groups. However, the size of indurations rangedfrom 10-40 mm, 11-33 mm, and 12-24 among normal weight, underweight, and overweight Z-score groups. Mean induration was same(20 mm) in two Z-score height for age groups (normal height, stunting), while it was 20.6 mm in the over-height group. Although, therange of Mantoux positivity ranges from 10-35 mm, 11-40 mm, and 18-22 mm among normal height, stunting, and over height Z-scoregroups. Conclusion: Although, nutritional status can affect the positivity of Mantoux test; in Mantoux positive children, the size ofindurations does not depend on their nutritional status

Kumar, Dinesh

Kumar, Durgesh

Lata, Kusum

Shukla, K M

Singh, Mukesh Vir

Varshney, Sangeeta

English

Atharva Scientific Publications (E-Jounals)

Vol 2 | Issue 4 | Oct - Dec 2015 Indian J Child Health 196
Singh et al. Induration of positive mantoux test and nutritional status
Original Article
Sizes of induration and nutritional status in children with positive Mantoux test
Mukesh Vir Singh, Durgesh Kumar, Dinesh Kumar, Kusum Lata, K M Shukla, Sangeeta Varshney
From Department of Pediatrics, UP Rural Institute of Medical Sciences and Research, Saifai, Etawah, Utter Pradesh, India
Correspondence to: Dr. Mukesh Vir Singh, Department of Pediatrics, UP Rural Institute of Medical Sciences and Research, Saifai, 
Etawah, Utter Pradesh, India. E-mail: mukeshvirsingh@gmail.com
Received – 18 August 2015 Initial Review – 07 September 2015 Published Online – 30 October 2015
Abstract
Background: The immune status of children is always affected by nutrition. Sometime severe malnutrition is associated with false 
negative Mantoux test. There is a need to study to observe the effect of nutritional status on the size of indurations in Mantoux positive 
children. Study Design: Observational analytical cross-sectional study. Methods: The study population consisted of 310 patients, 
belonging to both sexes and age of 1-14 years, attending the outpatient department of UP Rural Institute of Medical Sciences and 
Research, Saifai, Etawah. Only Mantoux positive cases were included in the study. Their sizes of indurations of skin reaction were 
measured and recorded in mm. The nutritional status was calculated as the weight for age and height for age standard (Z-score), using 
the NCHS charts of for males and females. Results: Out of 800 children screened for tuberculosis, 310 children had positive Mantoux 
test and were recruited in the study. Mean induration (20 mm) was similar in all the groups. However, the size of indurations ranged 
from 10-40 mm, 11-33 mm, and 12-24 among normal weight, underweight, and overweight Z-score groups. Mean induration was same 
(20 mm) in two Z-score height for age groups (normal height, stunting), while it was 20.6 mm in the over-height group. Although, the 
range of Mantoux positivity ranges from 10-35 mm, 11-40 mm, and 18-22 mm among normal height, stunting, and over height Z-score 
groups. Conclusion: Although, nutritional status can affect the positivity of Mantoux test; in Mantoux positive children, the size of 
indurations does not depend on their nutritional status.
Key words: Indurations, Mantoux test, Nutritional status, Z-score
Mantoux positivity in tuberculosis (TB) infection depends on the immune response of the host in terms of degree of cell-mediated immunity. 
The immune response is affected by multiple variables in 
relation to the host as well as bacteria. Nutritional status, age, 
vaccination status, and previous exposure to mycobacteria 
play a significant role in the ultimate host response [1]. 
The Mantoux test does not measure the immunity to TB 
rather a degree of hypersensitivity to tuberculin. There is no 
correlation between the size of induration and likelihood of 
current active TB disease, but the reaction size is correlated 
with the future risk of developing TB disease. The test 
has a poor positive predictive value for current active 
disease [2].
Undernourishment suppresses the tuberculin skin test, 
as well as the whole immune response of the organism [3]. 
Sometime severe malnutrition is associated with false negative 
Mantoux test. However, the effect of nutritional status on the 
size of indurations in Mantoux positive children is not well-
established. Therefore, we planned this study to correlate the 
size of indurations in Mantoux positive children with their 
nutritional status.
SUBJECTS AND METHODS
This observational analytic cross-sectional study was conducted 
from July 2013 to December 2014 in Department of Pediatrics 
at UP Rural Institute of Medical Sciences and Research, Saifai, 
Etawah at a tertiary-care referral teaching hospital. Ethical 
approval was obtained from Institute’s Ethics Committee. 
The study included children aged 1-14 years of both sexes 
who presented with a history suggestive of TB. Following 
symptoms were taken as suggestive of TB, i.e., persistent fever 
and/or a cough >2 weeks, loss of weight/no weight gain, history 
of contact with infectious TB case.
Written informed consent was taken from parents/
guardian prior to investigation. The patient not willing to 
participate in the study, hemodynamically unstable patients, 
those received steroids in the last 3 months, children with 
severe acute malnutrition with unstable vitals and HIV-
infected patients were excluded from the study. A detailed 
history was taken and thorough clinical examination done in 
all the recruited cases. Standard Mantoux test and sputum 
examination for acid-fast bacilli were performed in all these 
children.
Vol 2 | Issue 4 | Oct - Dec 2015 Indian J Child Health 197
Singh et al. Induration of positive mantoux test and nutritional status
A pilot study was conducted on 20 Mantoux positive 
subjects to find out mean induration and standard deviation. 
Mean induration of Mantoux positivity was 18.76±6.40 mm. 
With an allowable error of 1, the final sample size was 
calculated as 172.
Mantoux Testing and Reading [4,5]
A standard dose of purified protein derivative-RT 23 with 
Tween 80 of strength, two tuberculin units 0.1 ml was 
injected intradermally into the volar surface of the long axis 
of the forearm skin and read 48-72 h later. The reading was 
made in good light with forearm slightly flexed at the elbow. 
Presence or absence of induration was determined either by 
palpation or the pen method. A ballpoint pen slightly ran 
transversely from the side of the arm toward the indurated 
area starting approximately 4 cm away. When the border of 
the induration was reached, a slight resistance felt, and the 
pen was lifted. The diameter of induration was measured 
transversely and recorded in millimeter. A positive Mantoux 
test was defined as an induration of 10 mm or more, measured 
48-72 h later.
Nutritional Assessment
The nutritional status was calculated as the weight for age and 
height for age standard (Z-score), using the NCHS Charts for 
male and females. A Z-score <−2 shows undernourishment 
and stunting. A Z-score −2 to +2 shows normal weight and 
height. A Z-score >2 shows overweight and over height [6]. 
Weight was recorded by digital type of weighing machine. The 
children were weighed in minimal clothing. The weighing scale 
was checked for zero error each time the subject is weighed.
In children age more than 2 years, height was recorded by 
stadiometer fitted against the wall. A child without shoes and 
socks was to stand with feet parallel on the even flat platform, 
arm hanging on this sides, buttocks and heels touching against 
the wall. The head was held comfortable, erect, with the lower 
border of the orbit of the eye in the same horizontal plane as 
the external canal of the ear (Frankfort) plane. The head piece 
of the measuring device which should gently lower to make 
contact with the top of the head. The height was recorded in 
centimeters. Length was measured in children below 2 years 
by infantometer which has an acrylic base with one sliding side 
as per length of a baby with dual scale for direct reading in cm 
from 0-45 and 45-90.
Data Analysis
Data were analyzed using SPSS software version 17.0. To 
describe nominal data, simple percentages were used. Mean and 
standard deviations were used to describe normally distributed 
data. The Spearman rank correlation test was used to determine 
the relationship between different continuous variables.
RESULTS
Total 800 children were screened for TB during the study period 
and of these, 310 children had positive Mantoux test and were 
recruited in the study (Fig. 1). Out of 310 patients, enrolled 
in the study, 202 (65.2%) were male, and 108 (34.8%) were 
female. Mean age of the patients was 7.73±3.52 years (range: 
1-14 years). Mean weight was 20.4±8.75 kg and mean height
was 116.76±21.36 cm.
Study Design
Mean size of induration in Mantoux positive case was 
20.11±6.65 mm. According to Z-score weight for age, 
approximately half (50.3%) of the children were having normal 
weight (−2 to +2 SD), 47.1% were underweight (<−2 SD), 
and 2.6% were overweight (>2 SD). Similarly, according to 
Z-score height for age, 68.4% children were having normal
height (between −2 to +2 SD), 29.7% were stunted (<−2 SD),
and 1.9% were having over height (>2 SD).
Boxpol diagram (Fig. 1) is showing the relation of Mantoux 
positivity with sex of subjects. Both male and female subjects 
are having Mantoux same mean induration (20 mm). Although, 
the range of Mantoux positivity ranges from 10-40 mm among 
males and 10-32 mm among females.
Boxpol diagram (Fig. 2) is showing the relation of Mantoux 
positivity with Z-score weight for age groups (nutritional 
status). All Z-score weight for age groups are having Mantoux 
same mean induration (20 mm). Although, the range of 
Mantoux positivity ranges from 10-40 mm, 11-33 mm, and 
12-24 among normal weight, underweight, and overweight
Z-score groups.
Vol 2 | Issue 4 | Oct - Dec 2015 Indian J Child Health 198
Singh et al. Induration of positive mantoux test and nutritional status
Boxpol diagram (Fig. 3) is showing the relation of Mantoux 
positivity with Z-score height for age groups. Two Z-score 
height for age groups (normal height, stunting) are having same 
mean Mantoux induration (20 mm) while over height group 
is having 20.6 mm mean Mantoux induration. Although, the 
range of Mantoux positivity ranges from 10-35 mm, 11-40 mm, 
and 18-22 mm among normal height, stunting, and over height 
Z-score groups.
DISCUSSION
In our study, all weight for age and height for age groups had 
same mean induration on Mantoux testing. Therefore, we 
can conclude that in Mantoux positive children, the size of 
induration did not depend on their nutritional status. Existing 
studies showed severe malnutrition are usually associated with 
negative Mantoux induration. Kiwanuka [6] and Ganapathy 
and Chakraborty [7] also reported no influence of nutritional 
status on the size of induration of positive Mantoux test. Collet 
et al. [8] and Reyes et al. [9] also showed similar results.
Chandra and Ojha [10] observed that Mantoux test 
was positive in only one-third of the subjects with severe 
malnutrition, but three grades of induration of Mantoux test 
were comparable to all three grades of nutritional status. Piñeiro 
et al. [11] reported that there was no difference in Mantoux test 
results among different nutritional status children. Mantoux test 
could be positive or negative depending on the nutritional status 
of children. Once it becomes positive, the size of induration did 
not depend on nutritional status. A possible reason behind that 
malnutrition does not suppress caloric immune reaction to TB 
antigen until unless very severe.
Contradictory to above observations, only a few authors 
showed that malnutrition affects the induration of Mantoux 
test. Jenum et al. [12] reported that a positive Mantoux test 
was reduced with a weight-for-height Z-score within the lowest 
quartile. The limiting factor of our study was consideration 
of only Mantoux positive subjects irrespective of tubercular 
disease status. Since it was a hospital-based study among 
children with age 1-10 years, the finding can be generalized 
after multicentric and large community-based studies.
CONCLU SION
In Mantoux positive children, the size of indurations does not 
depend on their nutritional status. However, nutritional status 
can affect the positivity of the test.
REFERENCES
1. Amdekar YK, Khare RD, Chokhani RR. Lessons from the
Ground Rounds a Pediatric Approach. 1st ed. New Delhi: Jaypee;
2010. p. 47.
2. Al Zahrani K, Al Jahdali H, Menzies D. Does size matter? Utility
of size of tuberculin reactions for the diagnosis of mycobacterial
disease. Am J Respir Crit Care Med. 2000;162(1):1419-22.
3. Taushanova B, Pavlovska I, Arsevska E. Cut-off value of
mantoux induration in tuberculous Children in R. Macedonia and
their nutritional status. Contrib Sec Biol Med Sci MASA XXXII.
2011;1:257-68.
Figure 1: Relation of Mantoux positivity with the gender of 
subjects
Figure 2: Relation of Mantoux positivity with Z-score 
weight for age groups (nutritional status).
Figure 3: Relation of Mantoux positivity with Z-score 
height for age groups
Vol 2 | Issue 4 | Oct - Dec 2015 Indian J Child Health 199
Singh et al. Induration of positive mantoux test and nutritional status
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Singh MV, Kumar D, Kumar D, Lata K, 
Shukla KM, Varshney S. Sizes of induration and nutritional status 
in children with positive Mantoux test. Indian J Child Health. 
Indian J Child Health. 2015;2(4):196-199.
4. Seth V, Lodha R. Tuberculin test. In: Kabra SK, editor. Essentials
of Tuberculosis in Children. 4th ed. New Delhi: Jaypee; 2011.
p. 269-309.
5. Kumar A, Gupta D, Nagaraja SB, Singh V, Sethi GR. Updated
National Guidelines for Pediatric Tuberculosis in India, 2012.
Indian Paediatr. 2013;50:301-6.
6. Kiwanuka JP. Interpretation of tuberculin skin-test results
in the diagnosis of tuberculosis in children. Afr Health Sci.
2005;5(2):152-6.
7. Ganapathy KT, Chakraborty AK. Does malnutrition affect
tuberculin hypersensitivity reaction in the community. Indian J
Pediatr. 1982;49(398):377-82.
8. Collet E, Krahenbuhl JD, Gehri M, Bissery A, Zellweger JP.
Risk factors for positive tuberculin skin tests among migrant and
resident children in Lausanne, Switzerland. Swiss Med Wkly.
2005;135(47-48):703-9.
9. Reyes CM, Sanchez L, Ong-Lim AL, Gonzales LM. A paired
comparison of tuberculin test results in children with clinical
manifestations using 2 TU and 5 TU tuberculins. PIDSP J.
2011;12(2):56-66.
10. Chandra RK, Ojha C. Malnutrition and immunity; effect of
nutritional status on systemic and local immunity: Diarrhoea and 
malnutrition in childhood: In: Walker-Smith JA, Mc Neish AS, 
editor. Textbook. 1st ed. Norwich England: Butterworth; 1986. 
p. 602-8.
11. Piñeiro R, Cilleruelo MJ, García-Hortelano M, García-Ascaso M,
Medina-Claros A, Mellado MJ. Effect of nutritional status on
Tuberculin skin testing. Indian J Pediatr. 2013;80(4):271-5.
12. Jenum S, Selvam S, Mahelai D, Jesuraj N, Cárdenas V, Kenneth J,
et al. Influence of age and nutritional status on the performance
of the tuberculin skin test and QuantiFERON-TB gold in-tube
in young children evaluated for tuberculosis in Southern India.
Pediatr Infect Dis J. 2014;33(10):e260-9.


Sizes of induration and nutritional status in children with positive Mantoux test

https://atharvapub.net/IJCH/article/download/561/488/

Sizes of induration and nutritional status in children with positive Mantoux test

Abstract

Similar works

Full text

Available Versions

Atharva Scientific Publications (E-Jounals)