As a family practitioner in a solo practice, I am occasionally asked to do TB screening tests. The requests are so infrequent that it is difficult to rationalize intradermal purified protein derivative (PPD) testing because the multidose vial expires within 30 days of using the first dose. I’d like to use tine testing as a screen with definitive intradermal testing for those who test positive, but I’ve been told this is frowned upon. What would you recommend?
—Peter G. Brassard, MD, East Providence, R.I.

Unfortunately, the “tine” test, which uses multiple small spikes (tines) coated with concentrated tuberculin to introduce the antigen subcutaneously, is no longer recommended by the American Thoracic Society (ATS). The amount of tuberculin administered by this method cannot be controlled, so PPD testing is preferred. In fact, in the ATS guideline entitled Diagnostic Standards and Classification of Tuberculosis in Adults and Children (Am J Respir Crit Care Med. 2000;161[4 Pt 1]:1376-1395), the authors note that “if a multiple puncture test has been placed, the test should be repeated using the Mantoux method, regardless of the result of the multiple puncture test.” I, too, would recommend against tine testing.
—Daniel G. Tobin, MD (109-22)

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