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Joint Bone Spine
Volume 78, n° 4
pages 352-357 (juillet 2011)
Doi : 10.1016/j.jbspin.2010.12.001
accepted : 6 September 2010
Role for interferon-gamma release assays in latent tuberculosis screening before TNF-⍺ antagonist therapy

Huguette Lioté a, , b , Frédéric Lioté c, d, e
a Service de pneumologie et réanimation respiratoire, centre de compétence « Maladies rares pulmonaires », hôpital Tenon, Assistance publique–Hôpitaux de Paris (AP–HP), 4, rue de la Chine, 75970 Paris cedex 20, France 
b Département de santé publique, hôpital Tenon, Assistance publique–Hôpitaux de Paris (AP–HP), 4, rue de la Chine, 75970 Paris cedex 20, France 
c Fédération de rhumatologie (centre Viggo-Petersen), pôle appareil locomoteur, hôpital Lariboisière, AP–HP, 2, rue Ambroise-Paré, 75010 Paris, France 
d UFR de médecine, université Paris-Diderot, 10, avenue de Verdun, 75010 Paris, France 
e Inserm-S606, institut Claude-Bernard, PRES Sorbonne Paris–Cité, 2, rue A.-Paré, 75010 Paris, France 

Corresponding author. Tel.: +33 1 56 01 82 93; fax: +33 1 56 01 70 02.

TNF-⍺ antagonist therapy is associated with a risk of severe, extrapulmonary, disseminated tuberculosis, which is fatal in 10% of cases. The risk of tuberculosis is increased four-fold in patients on TNF-⍺ antagonist therapy. The main risk factors are a history of untreated or inadequately treated primary tuberculosis, recent contact with a tuberculosis patient, and residence in or travel to a high-endemicity region. Infection surveillance agencies throughout the world have issued recommendations to ensure the detection and treatment of latent tuberculosis before TNF-⍺ antagonist initiation. These recommendations have returned the incidence of tuberculosis to the level seen before the introduction of TNF-⍺ antagonists. Nevertheless, there is still room for improvement. Recommendations about latent tuberculosis screening include the use of tuberculin skin tests. However, these tests are positive in individuals vaccinated with the BCG vaccine, which leads to overuse of tuberculosis chemoprophylaxis and, therefore, to unnecessary patient exposure to hepatotoxic effects. Furthermore, tuberculin skin tests may be falsely negative in immunosuppressed patients, leading to underuse of tuberculosis prophylaxis. These shortcomings of tuberculin skin tests have generated interest in interferon-gamma release assays (IGRAs). In patients with overt tuberculosis, IGRAs are more sensitive and more specific than tuberculin skin tests. However, the accuracy of IGRAs for diagnosing latent tuberculosis remains unknown, because no reference standard is available. In addition, patients taking immunosuppressant agents to treat systemic disease may exhibit anergia, which complicates the interpretation of IGRAs. Until additional data become available, caution requires that IGRAs be used only when a positive or negative result, as assessed on a case-by-case basis, will help to decide whether tuberculosis chemoprophylaxis is in order.

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Keywords : Tuberculosis, TNF-⍺ antagonists, Skin test, Interferon-gamma release assays

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