Tuberculosis, tuberculin reactivity, and delayed cutaneous hypersensitivity in nursing home residents

When all residents of a 460-bed nursing home were tuberculin tested after discovery of a fatal case of pulmonary tuberculosis, 34% reacted, including 6% who gave boosted reactions. Twenty-four of 262 (9.2%) nonreactors converted to tuberculin reactors 6 months after exposure. Six of the convertors were among the 21% of the residents who were originally considered anergic on the basis of negative Candida and Trichophyton skin tests. These results confirm the observation that aged nursing home residents have lower rates of tuberculin reactivity than earlier in their lives, and that tuberculosis is a nosocomial infection in nursing homes. However, generalized immune senescence cannot be invoked as a reason for apparent susceptibility because the very marker of infection--the development of tuberculin reaction--is evidence of some degree of immune competence. Furthermore, the presence of cutaneous anergy as clinically determined does not predict inability to develop an immune response to the tubercle bacillus.