the method of studying of contamination of an organism mycobacteria of tuberculosis, and also reactivity of an organism of the infected or vaccinated people based on use of tuberkulinovy tests.
For the first time the condition of the changed sensitivity of an organism to repeated introduction of mycobacteria of tuberculosis was described by R. Koch and received the name of a phenomenon of Koch.
A turning point of specific diagnosis of tuberculosis was receiving in 1890 by Koch of tuberculine (see).
In broad practice of T. it began to be applied since 1907 when the Austrian scientist To. The tuberculine test was offered by the cutaneous skarifikatsponny method of administration of tuberculine called afterwards a Pirquet's test.
In a crust, time tuberkulinovy tests apply to diagnosis and differential diagnosis of tuberculosis, especially at children; for identification of risk group of a disease of tuberculosis; for definition in epidemiol. the purposes of indicators of contamination and risk of infection with tuberculosis of the population, and also at selection of the contingents of the population (generally children and teenagers) for a revaccination of BTsZh (see).
The mechanism of development of tuberkulinovy reactions is based on interaction between tuberculine and the antibodies fixed on cells (lymphocytes, mononukleara). As a result of this interaction a part of cells — carriers of antibodies perishes and arises an inflammation (positive tuberkulinovy reaction). Pathomorphologically positive tuberkulinovy reaction is characterized by hypostasis of all layers of skin in the first 24 hours after administration of tuberculine, and in later terms (72 hours) — mononuclear reaction with a large number of histiocytes (see Tuberkulinovaya an allergy). The infiltrate (papule) which is formed at the same time is caused by a trichangiectasia, transuding of an intercellular lymph, accumulation of neutrophils, monocytes, epithelial and colossal cells. At giperergichesky reactions with the expressed necrosis find elements of a specific inflammation with epithelioid hillocks.
Tuberkulinovy tests differ by a method of administration of tuberculine in a human body and by name the researchers who offered them are called.
Most often T. it is carried out by means of skin tuberkulinovy tests — cutaneous, intradermal (see. Skin tests), and also hypodermic test of Koch.
Carry a Pirquet's test (through a drop of 100% of the tuberculine applied on skin make one scarification) and its modifications to cutaneous tuberkulinovy tests: a Pirquet's test — Parsley (tuberculine is rubbed in the scarified surface of skin), the scarifying graduated tuberkulinovy test of Grinchar — Karpilovsky (with tuberculine of various concentration — 100, 25, 5 and 1%), and also branded test of Moro using tuberkulinovy ointment.
Carry the tuberkulinovy Mantoux reaction offered in 1910 by Mantu and Mendel to intradermal (Ch. Mantoux, F. Mendel), and ukoloch-ny test of Giff. Mantoux reaction is more sensitive, than cutaneous tuberkulinovy tests. It allows to dose tuberculine precisely. Especially widely Mantoux reaction began to be applied recently when sensitivity of people to tuberculine considerably decreased. In the nek-ry countries apply a prick internal test of Giff: the special device make multiple pricks of skin through a drop of the tuberculine applied on it. In the USSR at mass T. even more often began to use a needleless method of intradermal administration of tuberculine by means of a mechanical injektor of BI-1M (see Injektor needleless) loaded with a certain dose of tuberculine.
Mantoux reaction is applied as the main method T. at the mass annual examinations conducted for the purpose of identification of primary infection of children and teenagers, a cut determine by a bend of tuberkulinovy reactions (transition earlier negative in positive or sharp strengthening of reaction in comparison with previous, reflecting a postvaccinal allergy), before the next revaccination of BTsZh, and also for a wedge, diagnoses. Doses of the tuberculine applied at the same time are various — - from 1 to 10 tuberkulinovy units (TU). To the USSR Mantoux reaction is carried out about 2 THOSE standard tuberculine (PPD-L).
Reaction to tuberculine is considered negative in the absence of infiltrate in 72 hours or in the presence of only ukolochny reaction (0 — 1 mm), doubtful at the daddy to dia. 2 — 4 mm and positive at the daddy to dia. 5 mm and more. Negative reaction to administration of tuberculine is observed at healthy nein-fitsirovanny people, and also at severe common forms of tuberculosis (e.g., tubercular meningitis, miliary tuberculosis). In the latter case speak about a tuberkulinovy anergy. Positive reactions to tuberculine happen weak (gipergichesky), moderate (normergichesky) and strong (gi-perergichesk them). Carried ik at l onek r from the and-chesky reactions caused by introduction 2 THOSE standard tuberculine, or reaction with
a size of infiltrate of 21 mm and more (children and teenagers have 17 mm and more) consider giperergi-chesky. The infected persons with giperergichesky reactions to tuberculine get sick with tuberculosis much more often, than the persons having normergichesky reactions.
Definition of contamination of the population at mass vaccination
of BTsZh is possible before the next revaccination when the level of a postvaccinal allergy the lowest. At the same time Mantoux reaction about
2 THOSE standard tuberculine is carried out at an interval of
1 year twice. Then retrospectively compare expressiveness of reaction by the sizes of infiltrate — they remained former or increased (see Tuberkulinovaya an allergy).
For a wedge, diagnoses in antitubercular clinics and hospitals Mantoux reaction with various doses of tuberculine, in doubtful cases other methods can be applied: the scarifying graduated test Green Chara — Karpilovsky, hypodermic test of Koch, definition of a tuberkulinovy caption, eozinofilnotuberkulinovy, a haemo tubercle inovy,
Mantoux reaction with lower doses of tuberculine in clinic is applied by hl. obr. for definition of limit of sensibility of an organism to tuberculine at appointment a tubercle of an inoterapiya.
In a hospital or an antitubercular clinic inspection is often begun with statement of the scarifying graduated tuberkulinovy test of Grinchar — Karpilovsky. According to the offer N. And. Shmelyova, at her interpretation not only the level of tuberkulinovy sensitivity, but also the nature of reaction define that allows to consider different extent of response of an organism to various concentration of tuberculine, a cut can be adequate or inadequate. Inadequate reaction, in turn, happens leveling (identical reactions to various concentration of tuberculine) and paradoxical (more expressed reaction to smaller concentration of tuberculine). At the healthy infected faces the graduated cutaneous test adequate, i.e. with reduction of concentration of tuberculine decreases intensity of reaction. At TB patients, especially proceeding chronically, inadequate reactions can be noted. At a negative take of test of Grinchar — Karpilovsky apply Mantoux reaction since 2 THOSE standard tuberculine, and at a negative take of the last — Mantoux reaction about 100 THOSE standard tuberculine.
At difficulties in diagnosis of tuberculosis, especially in cases of its extra pulmonary localization, apply more sensitive hypodermic test of Koch, using from 10 to 50 THOSE PPD-L. In some cases apply ATK — so-called old tuberculine of Koch (see Tuberculine). At children Koch's test apply less often (in a dose 10 — 20 THOSE standard tuberculine) and only at a negative Mantoux test about
At statement of test of Koch consider local (in the field of administration of tuberculine), focal (in the field of the center of specific defeat) and the general reactions of an organism, and also change in blood (gemotuberku-linovy and proteinotuberkulinovy tests). Previously indicators of blood and plasma define before administration of tuberculine and in 24 and 48 hours after it. In the presence of focal reaction in the place of specific defeat, napr, pulmonary fabric, it is possible to assume a specific etiology of a disease.
Gemotuberkulinovy test is considered positive if acceleration of ROE on 3 mm an hour and more, increase in quantity of leukocytes on 1000 and more, a deviation to the left, reduction of quantity of lymphocytes by 10% and more is noted. Positive eosinophilic tuberkulinovaya test is characterized by reduction of number of eosinophils by 10% and more at calculation of their absolute number. Proteinotuberkulinovy test is regarded as positive if decrease in albumine, increase a2-and at - globulins not less than for 10% is noted.
Koch's test is used also for identification of shifts in reactions of T - and V-systems of immunity (a blast transformation, migrations of lymphocytes, etc.) for the purpose of differential diagnosis and definition of activity of process.
During the studying of dynamics of tuberkulinovy reactions it is impossible to repeat often tuberkulinovy tests since the zone of a hyper sensitization of skin remains a long time that can lead to artificial increase or decrease in sensitivity to tuberculine. The interval between statement of tuberkulinovy tests shall be not less than 2 — 3 months, and it is better to repeat them on skin of a shoulder, but not a forearm.
Mass T. at children and teenagers medics of the general network will see off. High quality of its carrying out is provided at a teamwork of work. Children's policlinics create the prepared crews (2 nurses and the doctor) of the available states, to-rye work according to the approved schedule in children's collectives (day nursery gardens, schools, etc.) * At unorganized children of preschool age of T. carries out medical staff of an inoculative office of policlinic. At schools along with T. crews carry out a revaccination of BTsZh (see Tuberculosis, specific prevention).
Bibliography: Mev E. B. Tuberculinodiagnosis, Minsk, 1970, bibliogr.; The multivolume guide to tuberculosis, under the editorship of V. JI. Einys, t. 1, page 411, M., 1959; Pokhitonova M. P. Clinic, treatment and prevention of tuberculosis at children, M., 1965; The Slave to fish soup of N A. E. Tuberkulez of a respiratory organs at adults, M., 1976; P i r q u e t of Page P. Tuberkulin-diagnose durch cutane Impfung, Berl. klin. Wschr., S. 644, 1907. L. A. Mitinskaya.