Gianmarco D'Alessio

MANTOUX or TST test: the tuberculin test on the arm

updates 24 october 2022

you can book your MANTOUX test here (click here)

Apply for your TB test (MANTOUX or TST – IGRA or QUANTIFERON) at the CESMET Traveller’s Clinic – Etimedica authorised by the Lazio region (GU. N-G11683 of 09/10/20).
The centre is authorised to carry out tests for university, school, armed forces and public competitions (for the Convention for Universities and Competitions ask the secretariat directly). The answer is accompanied by an infectious diseases assessment and certification.

You can write and leave your details here to book. or call +390639030481

In order to identify a ‘latent tubercular infection’ or to study your immune status against the Tuberculous Bacillus, i.e. to undergo a screening test, you can use and request two different tests that are able to provide you with precise information on ‘possible contacts’ or possible ‘contagion’ with the ‘tuberculous bacterium’, being able to assess your ‘cell-mediated immune status’.  Naturally, the tests are used to help the clinician diagnose any latent or ongoing tuberculosis.

Let us consider the mantoux test – an in vivo test, with a reading of the cellular response in situ, where the tubercular antigen is injected, a more sensitive and more interpretable test, related to the person’s clinical parameters.
The QUANTIFERON test replaces skin tests (Tine-Test, Mantoux intradermal test) and detects the amount of cytokine ‘Interferon Gamma’ released following stimulation of T lymphocytes with two highly specific TB antigens (ESAT-6 and CFP-10).
The in vitro response, although specific and quantitative, does not replace the cellular reaction in response to antigens inoculated into the forearm.

Where to do the tst test or mantoux test
You can request the tst test or mantoux test at Cesmet-Clinica del Viaggiatore – Etimedica. The medical centre specialising in infectious, tropical diseases and parasitology is officially authorised by the Region of Lazio by decree published in the official gazette (OJ. N-G11683 of 09/10/20). The reports and certifications attesting the test result are therefore officially recognised for competitions, university institutions and other official requests. Naturally, the test is used to provide an answer in cases where tuberculosis is suspected. Agreements are in place for university and public competitions.
The performance of the test, assessment of the skin reaction, and interpretation is performed by experienced infectious disease physicians. Click here for information, leaving your details and the reason for the booking call, or phone the centre’s secretariat +390639030481

The tests you can undergo are:
(1) tuberculin skin test (Mantoux Test)
(2) interferon gamma release serum test (IGRA), which includes the Quantiferon test.

The test is performed to identify a ‘latent state’ at an early stage, which is possible in those who have lived for a long time in hyperendemic environments, i.e. where a lot of Mycobacterium is found, particularly in areas of tropical countries. These findings enable early treatment of latent tuberculous infection (LTBI), and greatly reduce the possible risk of reactivation of tuberculous disease.
This is why carrying out tubercular tests, first the skin test and eventually the confirmation test, can be important for the protection of your health.
Testing and possible treatment for LTBI, in the event of a positive result, should be performed in the categories of persons considered to be at risk. Among
these doctors, healthcare personnel, healthcare workers.
International travellers to areas where Mycobacterium is present should perform the Mantoux test before leaving and upon return from their trip.  This is because they work in risky situations or in healthcare environments or because of repeated work and contact with local people and workers, especially in closed and crowded environments. Teachers, volunteers, religious, workers of all kinds in contact with counterparts.
If you fall into one of these categories, you should consider taking an initial and periodic test.

The tuberculin skin test (TST or MANTOUX) evaluates the delayed intradermal response, i.e. under the skin, from hypersensitivity to the administered antigen, a purified protein derivative (PPD) from Mycobacterium tuberculosis.
Normally, a period of up to two to three months is necessary, after any contact and infection with the tubercle bacillus, for the conversion of the tuberculin skin test to occur, i.e. for this test to become positive and signal contact with the bacterium.
In the case of international travellers in the categories identified above, it would be desirable to carry out a MANTOUX test before travelling and 2 months after returning. In the case of prolonged stays, in working environments where prolonged contact is encouraged, it would be advisable to perform the test once a year.
For immuno-compromised persons, with weak or compromised immune defences, who have recently had close contact with known infectious cases of tuberculosis, treatment for LTBI may be initiated even if the TST is negative.
Patients who test positive for TST or IGRA should undergo clinical evaluation to exclude active tuberculosis and to assess the possible need for therapy against latent infection. A clinical evaluation of symptoms, pulmonary and systemic objectivity is always necessary, followed by a chest X-ray examination, after a positive Mantoux test.

TUBERCULIN SKIN TEST
The tuberculin skin test is considered the main test to detect infection or contact with the tuberculosis (or TB) bacterium.
Tuberculin is a fraction of the tubercle bacillus that, when injected, provokes an immune response in the body, which is manifested by an inflammatory reaction on the skin.
The test is harmless and safe and has no health consequences. If positive, it may provoke an even intense reaction at the site of inoculation characterised by swelling, soreness and a few lines of fever.
It is performed to find out whether there has been contact in the past with ‘Mycobacterium Tubercolosis’, the bacterium responsible for tuberculosis disease. A positive test indicates past or recent contact with the tuberculosis bacterium, but this is not the same as being ill.

How it is performed:
A small area of the forearm is chosen and disinfected and a dose of tuberculin is injected superficially with an insulin syringe with a very fine needle. A pompho on the skin appears, which slowly reabsorbs (Mantoux intradermal reaction). The skin response occurs 48 to 72 hours after inoculation.
A negative test leaves no trace, in the case of a positive test an area of inflamed skin with a central indurated papule appears.

The response is classified as follows

negative: absence of induration and erythema of less than 2 mm in diameter;
doubtful: with appearance of induration and erythema between 2 and 4 mm in diameter;
positive: with evident dermal induration and erythema greater than 5 mm in diameter.
intensely positive: if the papule necrotises centrally and the inflammatory reaction is very evident.

The negative test shows absence of contact with the tuberculosis bacillus.

The positive test shows contact with the tubercle bacillus and the response is proportional to the state of disease activity. In any case it must be emphasised that the test does not diagnose tuberculosis but only highlights the presence of an immunological response, the diagnosis being purely clinical with the aid of the radiological picture.

A clear contribution to the interpretation of the Mantoux test

1) Countries at risk of transmission

*In these countries, the risk of transmission is limited to certain areas.

Africa:

Angola
Benin
Burkina Faso
Burundi
Cameroon
Chad*
Congo, Rep
Ivory Coast
Ethiopia*
Gabon
Gambia
Ghana
Guinea
Guinea Bissau
Equatorial Guinea
Kenya*
Liberia
Mali*
Mauritania*
Niger*
Nigeria
Central African Republic
Democratic Republic of Congo*
Senegal
Sierra Leone
Sudan*
South Sudan
Togo
Uganda

America

Argentina*
Bolivia*
Brazil*
Colombia*
Ecuador*
Guyana
French Guiana
Panama*
Paraguay
Peru*
Suriname
Trinidad and Tobago*
Venezuela*

2) Countries at low risk of transmission

 Eritrea
 Rwanda
 Sao Tome
 Somalia
 Tanzania
 Zambia

INFORMATION services in Telemedicine are available daily by requesting :
– Online consultations before travelling;
– advice on infectious diarrhoeas: how to prevent them, how to treat them, what to do when travelling;
– INFO on Chemoprophylaxis for malaria online;
– Online consultations for INFO on COVID19 and LONG COVID;
– Online consultations Infectious and Tropical Diseases.
These services can be requested (CLICK HERE) or by writing a request to seg.cesmet@gmail.com , or by sending a WhatsApp message to +39 346 6000899.

Comparing drugs for Traveller’s Diarrhoea – Bassado and Normix a winning combination

Information and advice, examinations and tests. Book at Cesmet

Diarrhoea, traveller’s diarrhoea, dysentery, abdominal discomfort, gastro enteritis, enterocolitis. First symptoms, immediate use of drugs such as Bassado (doxycycline) and Normix (rifaximin). From the classic bellyache with lots of air inside, to unbearable colic with very high fever. Antibacterial drugs are of first choice. Bimixin, now a second-rate drug. Imodium a symptomatic drug to watch out for.

Traveller’s diarrhoea: more than 60% of all travellers worldwide are affected by this problem. The World Health Organisation (WHO) provides us with accurate data and descriptions of what happens worldwide. Countries most affected, favourable environments, risk behaviour.  Traveller’s diarrhoea can affect any of us, anywhere, in any city or country. We have to prevent it, first and foremost, and if necessary, nullify the symptoms right from the start. Bassado as prevention or treatment, normix to be added in case of symptoms. Bimixin used less and less and imodium, locked in the drawer.  Of each drug we have put the package leaflets.
But reality is experienced in the field. And on the basis of years of experience I want to give you a few pointers.

DIARRHEA according to WHO

Some rules before travelling: to protect our health.

• Think about fair and correct information. Know the risks, the characteristics of the environment where you are travelling, the weather situation and the occurrence of illnesses, and how to behave to maintain good health. Then ask for specialised and direct advice that answers your doubts and questions.
• Go to an international vaccination centre and request, wherever you go, the 3 basic vaccinations to protect your gut from even serious infections.
  Vaccinate against Hepatitis A, a ubiquitous and aggressive virus; vaccinate also against Typhoid Fever, i.e. Salmonella, a ubiquitous, dangerous and particularly drug-resistant bacterium; vaccinate especially against Traveller’s Diarrhoea, i.e. against those bacteria that are enemies of our intestines, i.e. pathogenic E. Coli, as well as against the Vibrio cholerae, i.e. (Dukoral), an oral vaccine that is particularly effective and useful at all ages.
• Then prepare your ‘Travel Pharmacy’ by including some ‘drugs to prevent or treat’ diarrhoea, and its worsening to the presence of blood and mucus (dysentery) with fevers and particularly severe symptoms.
  Doxycycline 100 mg, an old tetracycline, widely used in the prevention of many bacterial forms, especially intestinal aggression by enterobacteria; but also in the treatment of particularly aggressive forms, up to the treatment of Cholera.  You can find it in pharmacies under the trade name Bassado or Miraclin

Normix 200 mg, is a strong intestinal antiseptic and therefore anti-diarrhoeal drug. Both for prevention of bacterial attacks and also as a treatment for diarrhoea. You can find it in pharmacies under the trade name Normix; Rifaximin has a broad spectrum of action on both aerobic and anaerobic gram-positive and gram-negative species. It is poorly absorbed in the body and therefore carries out bactericidal activity exclusively in the intestinal canal, avoiding toxic problems in the body resulting from absorption.
Doxycycline is preferred to Rifaximin, during travel, because of its multiple covers; from efficacy on skin infections, to prevention and treatment for tick bite infections and many other infections. Among the most effective drugs as an antimalarial.
Neomycin and Bacitracin, a combination drug, Bimixin, has become obsolete since bacteria no longer respond to the action of Neomycin; it is still in high demand and prescribed, but is really not very effective; in the past it had a broad spectrum of action, which has now almost disappeared;

Loperamide, is the active ingredient in the famous Imodium, a drug found in most travellers’ luggage. It is frequently used at the first diarrhoeal discharge. Nothing could be more negative. Imodium should not be taken alone, but always in combination with antibacterial drugs. It decreases intestinal muscle motility, slows down the transit of food and water and liquids, facilitates absorption at the level of the villi, decreasing the frequency of discharges. It decreases colon movements by reducing the gastrocolic reflex and thus the urge to evacuate. But all this facilitates the stagnation of liquids and thus of bacteria that increase in number, to the point of worsening the infection.

When you travel, whether to Italy or to any country in the world, take your ‘little travel pharmacy’ first of all with you your packet of Doxycycline 100 mg, for all the coverage and efficacy in many infections; supplement this drug with Normix (Rifaximin) to increase its efficacy in treating diarrhoea; Bimixin I no longer recommend because of its reduced efficacy; never use Imodium alone to treat infectious type diarrhoea as it can have the unwanted effect of strengthening enteropathogenic bacteria causing a worsening of the already delicate intestinal situation. If it is really necessary, and this is rare, add it to Doxycycline or Rifaximin.

Read also Normix- Package Leaflet
Read also Bimixin leaflet
Read also Imodium – Package Leaflet
Read also Rifacol – Package Leaflet

INTRODUCTION

Malaria is an acute infectious disease caused by infection with a parasite, Plasmodium, transmitted by the bite of a mosquito called Anopheles. This is widespread in most equatorial tropical territories, where the humid, warm environment and the presence of water, especially stagnant water, favor its reproduction and growth.

Many different symptoms of malaria occur with increasing gradations and levels. After the bite of the infected mosquito, most individuals, especially those who have always lived in at-risk areas, remain asymptomatic, that is, although infected, they do not manifest any symptoms. Other individuals, however, manifest the disease with a crescendo of symptoms and increasingly strong and severe manifestations. Delay in diagnosis and treatment can cause symptoms to worsen to the point of death. This may be due to “brain” forms, kidney failure, or other internal deficits. Speed in dealing with this disease can be vital. Waiting and letting time pass unnecessarily can be lethal, as is often the case.

MALARIA IN RESIDENTS OF ENDEMIC AREAS AND TRAVELERS

Living in endemic areas, where infected Anopheles coexist with humans, sting to feed on their blood, and inoculate Plasmodium frequently, means fostering a mechanism for eliciting the cellular immune or antibody response, a protective factor against the parasite. Repeated and symptomless infections are typical situations for those living in malarial areas. In contrast, in these areas, infants and young children, who have not yet developed full immunity against malaria, are at serious risk of disease and are the age groups with the greatest deaths.

In travelers coming from areas where the malarial parasite is absent, the bite of an infected mosquito can cause an infection that, without immune coverage, allows Plasmodium to develop and invade with the “erythrocyte cycle the blood cells,” with gradually exponential growth.

The presence or absence of symptoms and their “degree” of manifestation is greatly conditioned by the response of the immune system.

THE VARIETY OF SYMPTOMS

Worsening malaise; a sense of dizziness; increasing headaches; fatigue and muscle aches; these may be the first symptoms that occur after a few days to those who have been bitten by an infected mosquito. After a few days, heaviness and soreness in the nape of the neck and neck may appear; dull, severe pain in the muscles of the legs and arms; initial sensation of moist skin, particularly noticeable in the abdomen and back. Approximately one week after the first Plasmodium infestation a fever may begin, not always, to present first, accompanied by mild chills; increased sweating and fronto-occipital headache; these symptoms in the following hours or days tend to increase, with an asthenia that does not allow arms and legs to move. Lightheadedness increases and fever may begin to disappear and to reappear with an undulating characteristic every three to four days. Over the next few days, if no action is taken, the sufferer may present with a heavy, reddish, sometimes dark urine; a feeling of heaviness and swelling in the upper abdomen, spleen and liver; worsening mental confusion to a semi-comatose state and eventually irreversible coma and death due to blockage of cerebral circulation by encephalic microthrombosis.

Irritative abdominal symptoms such as even watery diarrhea and feeling of nausea and vomiting are common at the onset of the disease.

 

All of these symptoms can rarely occur simultaneously. It is more common for a few, the less severe, to occur with a widely varying degree of intensity. Fever, considered a pathognomonic symptom, often does not appear or occurs late. The typical symptom and almost always present is the generalized feeling of malaise and headache, in the early stage with that sense of head muffling.

Malaria is called the “great deceiver” precisely because of this variety of such different symptoms and unpredictable gradations.

As mentioned earlier, fever, mild or very high, is considered the typical symptom of malaria, accompanied by chills and sweating. This set of symptoms result from the body’s response to the lysis of blood cells, the release of endotoxins, catabolites and the release of parasites into the circulatory stream with a defensive reaction of the body’s systems. But this set of symptoms, regularly taken as the only clinical evidence of the presence of plasmodium, is to be considered unreliable in diagnosing the disease because it is often not present. That is, the absence of these symptoms does not rule out diagnostic doubt. “Algid malarias,” i.e., those without fever, are very common, especially in individuals who have had malaria, in those who live for long periods in risk areas, and in those who have developed specific immunity.

The life of the different types of Plasmodium within the organism; their presence and long cohabitation in blood cells and in those within the “liver acini,” which are cell formations that constitute the internal structure of the liver; the presence within certain families of lymphatic cells; all these events affecting the presence of the parasite in the human organism is strongly conditioned by the immune response of each individual.

The reproductive cycles of Plasmodium in the liver and blood cells occur with well-timed and well-timed but conditioned by the response and modulation of the immune system, which also regulates the occurrence of symptoms.

Native populations, living in areas densely populated by Anopheles, due to the constant bites of infected mosquitoes and the constant presence of the malarial parasite in the “red and white” blood cells and also in the lymphocyte organs, constantly reinforce their defensive capacity against Plasmodium. This situation, typical of malarial territories, of “attack” (Plasmodium) and defense (immunity), permanent, allows to arrive at a coexistence between the two

organisms (parasite and host).

Individuals then coexist in malarial environments with mosquitoes and parasites in a form of “commensalism” (peaceful living) but which should not be considered long-lasting. It only takes a decrease in defense systems due to other infections, or traveling to areas where Anopheles and Plasmodium are not present, to lose immunity and defense. This is a typical phenomenon of those living in infected areas: (1) suffering from periodic states of fatigue; (2) experiencing generalized malaise; (3) losing muscle strength; (4) losing work capacity; and (5) slowing down body activities.

In this period of climate change, long dry spells condition the presence of Anopheles in the environment for long periods. The arid climate prevents mosquito life. Then sudden floods, a frequent phenomenon after long periods of drought, induce new reproductive waves of insects. All this favors the disappearance and presence of Plasmodium in these countries with multiple, periodic infections that, due to the periodic loss of defenses, produce serious and often fatal malaria in the population, especially children, which is unforeseen and unpredictable.

This is the same phenomenon that happens to people who expatriate for medium to long periods from their countries and lose their resistance to Plasmodium. Back home they are just as likely to get sick, even with severe forms as any traveler from areas free of the Malaria Plasmodium.

“The great deception of malaria,” with the most diverse symptoms in type and gradation thus stems from the relationship between the immune system and the parasite and explains the onset of different symptoms, and the progression of the disease to increasingly aggressive situations.

 

From the above it is good to reflect on the following:

– Anyone traveling to malarial areas, coming from countries with this disease, is subject to infection. The manifestation of the disease and symptoms depends on his or her immune response;

– The most important defense against malaria is definitely the use of natural (Neem) or chemical (DEET) repellents that ward off the risk of mosquito bites;

– Prophylaxis with suitable and effective drugs helps decrease the incidence of the disease by chemically attacking Plasmodium. But it is important to know that a weak “natural and innate immune response of the individual” increases the chance of manifesting symptoms after Plasmodium inoculation; (The Covid example is emblematic. During the pandemic, the induced reduction of immune defenses caused a sharp increase in malaria symptoms and even deaths in indigenous populations – WHO statistics 2022). This demonstrates the defensive power of the immune system.

– During the stay and also upon return from a trip from malaria-prone areas, the occurrence of discomfort, such as those described above, even nuanced, should kindle doubt that one has been infected with Plasmodium. The event should be considered possible and probable even for short or very short stays in areas with the presence of Anopheles. Even a few hours is enough to receive infected stings;

– Returning from a trip from malarial-risk areas, if there is discomfort, headache, fever, or other symptoms, first think of the malarial risk and rule out the disease, then think of any other disease you may have developed.

– The statement that in the presence of symptoms of suspected malaria, laboratory tests are always positive, including the highly sensitive PCR, is not true.

“If the slide read in the laboratory is negative, malaria is not there.” This statement is not true and is dangerous. Significant immunity present in an individual can make the presence of the parasite negative. A slide reading made by inexperienced or hasty eyes can give a negative answer even though the parasite is present.  The clinical diagnosis, derived from an evaluation of symptoms, cannot be erased by a negative test, the answer to which is not always true.

– A symptomatic individual, with symptoms that worsen over time and with typical manifestations, even with presumed negative tests, should be treated with effective medicine.

– “Intervening as early as possible saves and does no harm, waiting can kill.”

 

Update: January 2023                                                                         Book your vaccination here

Vaccination against Yellow Fever (or Anti-Amharillic Vaccine), an acute viral disease transmitted by mosquito bite, is the only preventive practice that can be mandatorily required by a country’s health authorities in order to enter through border crossings. This occurs irrespective of the presence of manifest cases or epidemic outbreaks of the disease, but is an international provision designed to prevent the spread of the disease when the vector insect (Aedes aegypti) is still present in the country. The example is the Asian countries where the virus is absent but the vector, i.e. the mosquito, is present. Remember that Yellow Fever is a zoonosis (disease of animals – monkeys) that can be transmitted to humans through the bite of the Aedes type mosquito.

This is why vaccination is made compulsory in some cases, and in any case is strongly recommended in countries where the virus is present with the vector. It is necessary, before leaving for a country considered to be at risk, to find out about the international regulations adopted in this regard. Regardless of this, however, it is a good idea to check with experts where there is a real risk of infection or where the presence of infected animals is likely, and therefore in which cases vaccination is recommended before travelling. Currently, the areas at risk of transmission are in Central and South America, as well as in many countries in Africa. In Asia, the presence of this virus is not reported.

Vaccination is risk-free; it rarely produces a fever after 24 hours at most, which is easily controlled with antipyretics
It is not recommended for individuals allergic to egg proteins.
Can be administered from the age of 6 months.
Use during pregnancy: not recommended.

Period of activity of the live attenuated virus once injected with the vaccine

During the first 48/72 hours, the live attenuated virus, which is harmless to the organism, reproduces and activates the defence system, simulating the disease. The immunological cellular part is activated and anti-virus antibodies (neutralising the virus) are formed. This fact serves to disprove the urban legend that the harmful action of the ‘live attenuated virus’ present in the vaccine is active for 3 or even 6 months (one cannot conceive for this length of time). It is reiterated that already after two to three days the virus is neutralised by the immune response, which reaches its maximum cellular response as early as the seventh day. Its action therefore on the product of conception is practically non-existent. Therefore, all women who think they might become pregnant in the immediate future can be vaccinated without any problem after vaccination.

To learn about the disease please visit our disease fact sheet on Yellow Fever.

To find out about the vaccination please visit our Yellow Fever vaccination factsheet

If you would like further information, please contact us by e-mail at seg.cesmet@gmail.com or phone +39 06/39030481, or whatsapp +393466000899

IRELAND: The Health Protection Surveillance Centre has confirmed 4 recent cases of meningitis/meningococcal septicaemia reported in the last week of October in the country.
Three cases have already been confirmed and one is under investigation. The three confirmed cases are all caused by meningococcal serogroup B. The cases were reported from different regions of the country and have no known links to each other. Three of the cases concern young adults between 12 and 18 years of age and one case is less than ten years old. The public health authorities have identified close contacts, who will be placed under close surveillance and under preventive antibiotic treatment. The latest information gives 2 deaths from the cases reported.

Meningitis

Meningococcal meningitis and septicaemia are caused by various serogroups of Neisseria meningitidis (meningococcus), an encapsulated aerobic Gram-negative bacterium. There are at least 12 serotypes of meningococcus, of which groups A, B and C account for about 90% of meningococcal disease, together with strains Y and W135.
TRANSMISSION: Meningococcus is transmitted by aerosol or by direct contact with the respiratory secretions of infected persons and healthy carriers. The disease occurs mainly in children, adolescents and persons with risk factors.
INCUBATION: The incubation period is different for each organism and can vary from two to ten days for bacterial meningitis.
SYMPTOMS: Generally, signs and symptoms may include: severe headache, stiff or sore neck, high fever, photosensitivity, confusion, convulsions, rash, joint pain, vomiting.
In children, signs may include: difficult feeding, excessive tiredness, irritable state, difficulty breathing, fever, stiff neck, convulsions, vomiting, rash, pale or blotchy skin.
PREVENTION: Vaccination is, without doubt, the most effective tool for preventing bacterial meningitis.

Several types of anti-meningococcal vaccine are available in Italy:

the conjugate vaccine against meningococcal serogroup C (MenC): this is the most frequently used and only protects against serogroup C
the tetravalent conjugate vaccine: protects against serogroups A, C, W and Y
the serogroup B meningococcal vaccine: protects against this serogroup only.
The vaccination card currently in force provides for vaccination against meningococcus C or ACWY in children over one year of age, while a booster with tetravalent vaccine A, C, W, Y is recommended for adolescents. The tetravalent vaccine is also recommended for adults with risk factors and those travelling to countries endemic for these serogroups.

The vaccine against meningococcal B meningitis is especially recommended for children within the first year of age.
Meningococcal B disease is prevented by vaccination.
The MenB vaccine was introduced for all children born on or after 1 October 2016 because children under one year of age are at a higher risk of meningococcal B disease. All children are offered the MenB vaccine at 2 and 4 months of age with a booster dose of the MenB vaccine given at 12 months.