Positive PPD and starting residency

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leopanther

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Looks like I may have a positive PPD for the first time and I'm supposed to be starting residency in July. What happens then? Will I be able to start on time? Thanks.

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In evaluation of TB clinical history is more important like contact with known TB patient or travel or BCG vaccination etc.

I think your program/hospital/occupational health department will do chest Xray and depending upon its results you may have to take INH for several months.
 
if its a new conversion to +ppd you will be started on INH and have to get a chest xray. many people do this it should not be a problem. if you have symptoms or an abnormal cxr obviously its more complicated and you would need to start treatment antibiotics and in that case its unclear if/when you would be allowed to start.
 
Thanks for your response. I had no known exposures over the past year, no travel, and have not had BCG vaccine (always been negative before). I assume I won't be actually prevented from starting residency because of this? Also, are healthcare workers required to take INH to keep working?
 
How positive were you? How many mm?
 
About 15 mm in largest dimension. It doesn't feel hard but I feel induration at the edges. It's only been 12 hours though.
 
Thanks for your response. I had no known exposures over the past year, no travel, and have not had BCG vaccine (always been negative before). I assume I won't be actually prevented from starting residency because of this? Also, are healthcare workers required to take INH to keep working?

15mm is definitely positive. You could have been exposed anywhere - in the hospital, on an airplane, in a restaurant. I would be surprised if they actually prevented you from starting if you refused to take it as long as you get a chest xray. But it will probably make your life easier if you just take so it is documented as treated in your records and you don't have to explain every year that you didn't complete treatment. You can't drink for 6 months tho :(
 
15 mm is quite positive. You would have to take chest X-ray. I have seen doctors
wearing masks all the time while on service after + ve ppd test. But then I don't know their
whole story.
 
Is it common for a seemingly +ppd at 12 hours to be read as negative at 48-72 hr?
 
First of all you should stop poking over your ppd skin area as it will make it more worse.

Are you sure if this is redness or induration? Have you seen how ppd is measured or have you seen someone's arm with positive ppd.

No once positive it will stay positive for some time.
 
I think all you need is that cxr. you don't need to take INH if your cxr is negative and you will be good to go. If the cxr is +, you likely have latent TB--so then take INH for 9 months of course. I think they may still let you work, but im not sure. you would have to contact your program to see if they will let you work. If you have positive sputum for AFB then you should be worried and put in isolation, but i dont think that is the case. not to mention you still have to get that second PPD for confirmation. good luck!:xf:
 
I think all you need is that cxr. you don't need to take INH if your cxr is negative and you will be good to go. If the cxr is +, you likely have latent TB--so then take INH for 9 months of course. I think they may still let you work, but im not sure. you would have to contact your program to see if they will let you work. If you have positive sputum for AFB then you should be worried and put in isolation, but i dont think that is the case. not to mention you still have to get that second PPD for confirmation. good luck!:xf:

You might want to review the diagnosis and Tx of LTBI.

Pt's (new converter's) with a positive skin test (5/10/15mm induration, this varies depending on your risk status, HIV, which country you come from, etc., we memorized this for step1,2) undergo clinical evaluation to rule out active disease, physical exam and chest xray. If these are negative (ie. no active disease), then they are treated with INH x9 months because they have LTBI infection and are at risk for reactivation infection. Additionally, you can work with patient's while being treated for LTBI.
 
true, Latent TB can occur if you have a negative chest xray and even this requires treatment. sorry about that!!

Even if you had the BCG in the past especially if it was as a child, you are still prone to get latent TB, and thus you still have to take the INH.
 
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You might want to review the diagnosis and Tx of LTBI.

Pt's (new converter's) with a positive skin test (5/10/15mm induration, this varies depending on your risk status, HIV, which country you come from, etc., we memorized this for step1,2) undergo clinical evaluation to rule out active disease, physical exam and chest xray. If these are negative (ie. no active disease), then they are treated with INH x9 months because they have LTBI infection and are at risk for reactivation infection. Additionally, you can work with patient's while being treated for LTBI.

This is correct. I also had a positive PPD yesterday with a negative chest x-ray. I had to go down to the local health department to have them measure and confirm. I have a latent TB infection. I am not contagious and never have been because I was never symptomatic. Therefore, I am allowed to continue rotations without a problem. As far as the INH, I was told that although I am not "required" to do it LTBI has a 5-15% chance of becoming active every year and it is most likely in the first 2 years you are infected. Therefore, as a healthcare worker it is HIGHLY recommended that I do the INH course. As well, I talked to an attending at one of the residencies that I am interested in. She told me that I should definitely do the INH and keep documentation. That way when I apply for residency and do all of the paperwork for my hospital privileges, there is no question that I went through all of the right steps and there shouldn't be a concern that I have an ATBI.
My PPD was also positive at 24 hours. I asked the health department and my attending if there was a chance that it would go away before the 48-72 hour reading period and I was told no. Just be sure that you are measuring the induration ONLY and measuring width wise. Do not measure length wise, that is what the health department's TB nurse told me. Lastly, if $ is an issue for you the health department can manage your case, provide your LFT's, CXR and meds free of charge. The biggest problem I can see for you is if you are moving to a new city and especially state during your treatment just because you want to make sure that you don't lapse on your meds.
 
Seems like there would be time for you to start medication and become noncontagious, if it comes to that.

It happens. One of my med school classmates got TB during surgery residency. It wasn't found on routine PPD, but he developed a persistent cough and it was found as a result of that. If I recall, he was out for two weeks to start meds and then back to work. It wasn't a huge issue.
 
Even if you had the BCG in the past especially if it was as a child, you are still prone to get latent TB, and thus you still have to take the INH.


The end part of your sentence is no longer correct.
 
Seems like there would be time for you to start medication and become noncontagious, if it comes to that.

It happens. One of my med school classmates got TB during surgery residency. It wasn't found on routine PPD, but he developed a persistent cough and it was found as a result of that. If I recall, he was out for two weeks to start meds and then back to work. It wasn't a huge issue.

If your CXR is clear and you have never developed symptoms than you have LTBI and have never been contagious nor are you currently. Therefore, there is no reason for you take any time off. The two weeks to get on meds is for ATBI. Just an FYI
 
Is it common for a seemingly +ppd at 12 hours to be read as negative at 48-72 hr?

Don't sweat it yet, this happens to me EVERY time I get a ppd. I am red and swollen for the first day, and the next day its gone.

One time the nurse that placed it did it and it caused a bruise. (Its supposed to be intradermal not subcutaneous like she did!) I told the nurse when I went 72 hours later that it was bruised and she didn't believe me and tried to put in my record that it was positive. I went to one of the pulmonologists to get his opinion and he agreed that it was not positive and wrote a note to employee health for me. If you think that it was incorrectly placed, repeat it in a week and see.
 
Don't sweat it yet, this happens to me EVERY time I get a ppd. I am red and swollen for the first day, and the next day its gone.

"Red and swollen" i.e. erythema do not indicate positivity, even at 48-72h. There is a palpable area of induration (if you do not know what that word means, please look it up, so many people just conflate the term with erythema). There is a whole lot of misinformation being propagated on this thread regarding this test - I would not really trust a nurse to read or interpret this test unless specifically trained to do so.

As for "where do you get these guidelines, they seem to be changing all the time!", please check the CDC website.

Many places have started using the Quantiferon Gold test, which I feel should become the standard since even physicians (as evidenced here) still have tenuous knowledge about the PPD.
 
"Red and swollen" i.e. erythema do not indicate positivity, even at 48-72h. There is a palpable area of induration (if you do not know what that word means, please look it up, so many people just conflate the term with erythema). There is a whole lot of misinformation being propagated on this thread regarding this test - I would not really trust a nurse to read or interpret this test unless specifically trained to do so.

As for "where do you get these guidelines, they seem to be changing all the time!", please check the CDC website.

Many places have started using the Quantiferon Gold test, which I feel should become the standard since even physicians (as evidenced here) still have tenuous knowledge about the PPD.

Not sure why you are quoting me saying that the guidelines change all the time. I never said that.

This was not meant to start any debate, don't turn it into one. MD's and RN's alike who have never seen positive PPD's make the mistake of calling it positive if it isn't. Some facilities don't allow any MD other than pulmonologists to read them because of this.

I know how to read a PPD and I understand what induration means. Swelling and erythema can look and feel like induration, and until that 72 hours pass, it can be misinterpreted. I was under the impression from the OP that the student was reading his/her own at 12 hours. The OP was concerned about internship being delayed due to a "positive" PPD. I was trying to assure him/her that other people have similar looking PPD's that don't turn out positive and not to worry about it until they get there.
 
Not sure why you are quoting me saying that the guidelines change all the time. I never said that.

This was not meant to start any debate, don't turn it into one. MD's and RN's alike who have never seen positive PPD's make the mistake of calling it positive if it isn't. Some facilities don't allow any MD other than pulmonologists to read them because of this.

I know how to read a PPD and I understand what induration means. Swelling and erythema can look and feel like induration, and until that 72 hours pass, it can be misinterpreted. I was under the impression from the OP that the student was reading his/her own at 12 hours. The OP was concerned about internship being delayed due to a "positive" PPD. I was trying to assure him/her that other people have similar looking PPD's that don't turn out positive and not to worry about it until they get there.

Sorry, I was lazy, and the "guidelines" part was meant for another poster who had commented on that. I didn't want to make two posts. Please provide examples where "only" pulmonologists are allowed to read PPD's, I strongly disbelieve you and feel that this is another example of nurses citing rules which don't exist. For one, it would be laughable if such a facility did not "allow" a pathologist (i.e. the people responsible for laboratory medicine) to read the test, as this is essentially a medical test (not to mention the exemplar for the Type IV hypersensitivity reaction). Every physician should know how to interpret a positive PPD, as this is expected of us on all our licensure exams. Also, how can something "look" like induration when induration is a quality observed on palpation? I do agree with you, though, that the original poster should wait some more time before freaking out.
 
To the OP,

I think it is best if you ask your workplace whether you can work or not and about when to take the meds, instead of asking on SDN. Your work place has their own rules, etc. and if they say it is positive, double check it with a pulmonologist to be sure.

Good luck!
 
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Sorry, I was lazy, and the "guidelines" part was meant for another poster who had commented on that. I didn't want to make two posts. Please provide examples where "only" pulmonologists are allowed to read PPD's, I strongly disbelieve you and feel that this is another example of nurses citing rules which don't exist. For one, it would be laughable if such a facility did not "allow" a pathologist (i.e. the people responsible for laboratory medicine) to read the test, as this is essentially a medical test (not to mention the exemplar for the Type IV hypersensitivity reaction). Every physician should know how to interpret a positive PPD, as this is expected of us on all our licensure exams. Also, how can something "look" like induration when induration is a quality observed on palpation? I do agree with you, though, that the original poster should wait some more time before freaking out.

It can feel like induration initially, until the initial reaction goes away. If the PPD was placed SQ accidentaly, it can form a hematoma that feels like induration. That happened to me. If you have someone who doesn't know what a + PPD looks like (no matter if that person is an RN or MD), they will mark you off as having a + PPD. I asked one of our pulmonologists to look at it, and if he agreed that it was not positive to please write me a note saying it was checked by him and not in fact +.

I'm making things up? Your gonna feel pretty stupid when I prove you wrong. My friend is a travel nurse who has worked all over NYC for the past few years and one hospital she worked at required all new employees to have the PPD checked by a pulmonologist only. I believe it was Bellevue, but I will find out for sure and update this post when I find out for sure. Then any residents on here can verify that this is true and not just "nurses" making things up.
 
To the OP,

I think it is best if you ask your workplace whether you can work or not and about when to take the meds, instead of asking on SDN. Your work place has their own rules, etc. and if they say it is positive, double check it with a pulmonologist to be sure.

Good luck!
:thumbup:
 
It can feel like induration initially, until the initial reaction goes away. If the PPD was placed SQ accidentaly, it can form a hematoma that feels like induration. That happened to me. If you have someone who doesn't know what a + PPD looks like (no matter if that person is an RN or MD), they will mark you off as having a + PPD. I asked one of our pulmonologists to look at it, and if he agreed that it was not positive to please write me a note saying it was checked by him and not in fact +.

I'm making things up? Your gonna feel pretty stupid when I prove you wrong. My friend is a travel nurse who has worked all over NYC for the past few years and one hospital she worked at required all new employees to have the PPD checked by a pulmonologist only. I believe it was Bellevue, but I will find out for sure and update this post when I find out for sure. Then any residents on here can verify that this is true and not just "nurses" making things up.

Not only do I not feel stupid, I don't anticipate feeling that way either - at the very least because I know the difference between "your" and "you're". I believe all the hospitals in the HHS system, yes, including Bellevue, use the Quantiferon Gold test, at least they do for outside physician and student rotators. Furthermore, all physicians should know how to interpret a PPD and know what induration is and contrast it from erythema; your point about RN vs MD is irrelevant as this is a basic skill that all physicians should possess. Your point about time delay is also a given, since the very first chapter of every physician's course in pathology deals with delayed-type (IV) hypersensitivity: even if a physician had never seen a +PPD, by history alone, s/he should be able to rule out any sort of immediate reaction as positive due to pure basic science. Please post an official policy if you ever manage to get one.
 
Not only do I not feel stupid, I don't anticipate feeling that way either - at the very least because I know the difference between "your" and "you're". I believe all the hospitals in the HHS system, yes, including Bellevue, use the Quantiferon Gold test, at least they do for outside physician and student rotators. Furthermore, all physicians should know how to interpret a PPD and know what induration is and contrast it from erythema; your point about RN vs MD is irrelevant as this is a basic skill that all physicians should possess. Your point about time delay is also a given, since the very first chapter of every physician's course in pathology deals with delayed-type (IV) hypersensitivity: even if a physician had never seen a +PPD, by history alone, s/he should be able to rule out any sort of immediate reaction as positive due to pure basic science. Please post an official policy if you ever manage to get one.

Sorry I can't break into the computer system at Bellevue to post the policy here. You claimed I was lying. Just because you don't agree with it, doesn't mean that its not true. I spoke to the nurse that worked there, and she was required to get the PPD read at employee health by the NP (there is no MD in employee health), OR by a pulmonologist. Bellevue has a high rate of employee conversion and that is why they have the rules they do. All MD's SHOULD know how to read them, but apparently there has been a problem in doing so now that they do not allow them to sign off on them. Are you saying that you have never seen a +PPD but you will know exactly how to read one if you do? Tell your attendings that you know how to do anything you come across because you read it in a book.

Anyway, this is not fair to the OP. They came on here to ask a question, and some people had to turn it into a debate.
 
Why don't you actually wait until the test is suppose to be read, to see if it's actually positive with induration, instead of fretting until that time. I once had a positive looking test at 12 hours, but at 48-72 hours was entirely negative. Just anecdotal evidence for you with a N=1.
 
12 hrs is too early to decide whether the test is positive or not. I often have rednes AND induration initially, that slowly resolves. It sounds like other people have had the same issue, or at least just redness which may freak out someone that isn't familiar with the test. Just relax and quit poking it for now. If it comes up as positive, just contact your program and get the info from them on how it will affect your start date.
 
Hey guys,

I have been told that I have LTBI after a blood test. I am really nervous about taking this drug since of all the side effects. I am already struggling with my courses. I would love to hear from someone who has taken this drug. Thanks
 
i just had a new + ppd conversion, from 10 years of borderline ppds. i was offered INH, but i declined and my CXR was negative. You do not have to take INH, and they wont keep you from seeing patients as long as your CXR is negative.
 
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