Interferon-gamma release assays for diagnosing extrapulmonary tuberculosis in adults: a systematic review and Meta-analysis

doi:10.19982/j.issn.1000-6621.20260145

Abstract

Abstract:

Objective: To systematically evaluate the diagnostic accuracy of interferon-γ release assays (IGRA) for extrapulmonary tuberculosis (EPTB) in adults across different specimen types and assay methods, and to provide evidence-based guidance for optimizing clinical diagnostic pathways. Methods: A systematic search was conducted across PubMed, Web of Science, and the Cochrane Library databases from January 2014 to May 2025, to identify studies comparing the diagnostic accuracy of commercial IGRA (T-SPOT.TB or QuantiFERON-TB Gold series) with composite reference standards (culture and/or clinical diagnosis). Bivariate random effect models were used to combine sensitivity and specificity, and subgroup analyses (specimen type, detection method, disease type, etc.) and meta-regression were conducted. Results: A total of 28 studies (32573 participants) were included. The overall pooled sensitivity, specificity, and area under curve (AUC) values were 0.83 (95%CI: 0.79-0.87), 0.86 (95%CI: 0.82-0.90), and 0.9089, respectively. The sensitivity of IGRA for detecting body fluid samples was comparable to that of blood samples (0.86 vs. 0.84), but the specificity was higher (0.92 vs. 0.81). The enzyme-linked immunospot assay (ELISPOT) demonstrated superior specificity compared to the enzyme-linked immunosorbent assay (ELISA)(0.86 vs. 0.81). For tuberculous pleurisy, the AUC value of pleural effusion ELISPOT detection was 0.972, which was superior to that of blood detection (AUC=0.909). Blood ELISPOT detection showed good diagnostic performance in the lymph node tuberculosis subgroup (AUC=0.936). IGRA had limited diagnostic value for osteoarticular tuberculosis (AUC=0.734). Conclusion: IGRA is an effective auxiliary tool for diagnosing EPTB, but its detection performance depends on the type of specimen and the detection method. Evidence suggests that for patients suspected of having tuberculous pleurisy, pleural effusion ELISPOT testing should be prioritized, while for lymph node tuberculosis, blood ELISPOT testing should be preferred. In the diagnosis of osteoarticular tuberculosis, IGRA results should be interpreted with caution.

Key words: Interferons, Diagnostic techniques and procedures, Extrapulmonary tuberculosis, Evaluation studies, Meta-analysis

CLC Number:

Guo Chenhao, Liu Xinyu, Zhan Sirui, Wang Lili, Ma Mengting, Li Xiumei, Qi Linping, Li Weiping. Interferon-gamma release assays for diagnosing extrapulmonary tuberculosis in adults: a systematic review and Meta-analysis[J]. Chinese Journal of Antituberculosis, 2026, 48(6): 803-812. doi: 10.19982/j.issn.1000-6621.20260145

Figures/Tables 9

References 45

[1]	World Health Organization.Global tuberculosis reports 2025. Geneva: World Health Organization, 2025.
[2]	Zumla A, Raviglione M, Hafner R, et al. Tuberculosis. N Engl J Med, 2013, 368(8):745-755. doi:10.1056/NEJMra1200894.
[3]	Pai M, Behr MA, Dowdy D, et al. Tuberculosis. Nat Rev Dis Primers, 2016, 2:16076. doi:10.1038/nrdp.2016.76.
[4]	Goletti D, Lee MR, Wang JY, et al. Update on tuberculosis biomarkers: From correlates of risk, to correlates of active disease and of cure from disease. Respirology, 2018, 23(5):455-466. doi:10.1111/resp.13272.
[5]	Pai M, Denkinger CM, Kik SV, et al. Gamma interferon release assays for detection of Mycobacterium tuberculosis infection. Clin Microbiol Rev, 2014, 27(1): 3-20. doi:10.1128/CMR.00034-13.
[6]	Luo Y, Xue Y, Guo X, et al. Diagnostic value of pleural fluid T-SPOT for tuberculous pleurisy: An updated meta-analysis. Tuberculosis (Edinb), 2020, 122:101941. doi:10.1016/j.tube.2020.101941.
[7]	Lan Y, Chen W, Yan Q, et al. Interferon-γ release assays for tuberculous meningitis diagnosis: a meta-analysis. Arch Med Sci, 2020, 17(5): 1241-1250. doi:10.5114/aoms.2019.86994.
[8]	Liu Q, Li W, Chen Y, et al. Performance of interferon-yrelease assay in the diagnosis of tuberculous lymphadenitis : ameta-analysis. Peer J, 2017, 5:e3136. doi:10.7717/peerj.3136.
[9]	Wang F, Hou HY, Wu SJ, et al. Using the TBAg/PHA ratio in the T-SPOT(®).TB assay to distinguish TB disease from LTBI in an endemic area. Int J Tuberc Lung Dis, 2016, 20(4):487-493. doi:10.5588/ijtld.15.0756.
[10]	Wen A, Leng EL, Liu SM, et al. Diagnostic Accuracy of Interferon-Gamma Release Assays for Tuberculous Meningitis: A Systematic Review and Meta-Analysis. Front Cell Infect Microbiol, 2022, 12:788692. doi:10.3389/fcimb.2022.788692.
[11]	McInnes MDF, Moher D, Thombs BD, et al. Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies: The PRISMA-DTA Statement. JAMA, 2018, 319(4):388-396. doi:10.1001/jama.2017.19163.
[12]	Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med, 2011, 155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009.
[13]	Azghay M, Bouchaud O, Mechaï F, et al. Utility of Quanti-FERON-TB Gold In-Tube assay in adult, pulmonary and extrapulmonary, active tuberculosis diagnosis. Int J Infect Dis, 2016, 44:25-30. doi:10.1016/j.ijid.2016.01.004.
[14]	Shi X, Zhang L, Zhang Y, et al. Utility of T-Cell Interferon-γ Release Assays for Etiological Diagnosis of Classic Fever of Unknown Origin in a High Tuberculosis Endemic Area-a pilot prospective cohort. PLoS One, 2016, 11(1):e0146879. doi:10.1371/journal.pone.0146879.
[15]	Ji L, Lou YL, Wu ZX, et al. Usefulness of interferon-γ release assay for the diagnosis of sputum smear-negative pulmonary and extra-pulmonary TB in Zhejiang Province, China. Infect Dis Poverty, 2017, 6(1):121. doi:10.1186/s40249-017-0331-1.
[16]	Kim YJ, Kang JY, Kim SI, et al. Predictors for false-negative QuantiFERON-TB Gold assay results in patients with extrapulmonary tuberculosis. BMC Infect Dis, 2018, 18(1):457. doi:10.1186/s12879-018-3344-x.
[17]	Lee YM, Kim SM, Park SJ, et al. Factors Associated with a Strong Response to the T-SPOT.TB in Patients with Extrapulmonary Tuberculosis. Infect Chemother, 2014, 46(4):248-252. doi:10.3947/ic.2014.46.4.248.
[18]	Li S, Lin L, Zhang F, et al. A retrospective study on Xpert MTB/RIF for detection of tuberculosis in a teaching hospital in China. BMC Infect Dis, 2020, 20(1):362. doi:10.1186/s12879-020-05004-8.
[19]	Liang L, Shi R, Liu X, et al. Interferon-gamma response to the treatment of active pulmonary and extra-pulmonary tuberculosis. Int J Tuberc Lung Dis, 2017, 21(10):1145-1149. doi:10.5588/ijtld.16.0880.
[20]	Liu Q, Gao Y, Ou Q, et al. Differential expression of CD 64 in patients with Mycobacterium tuberculosis infection: A potential biomarker for clinical diagnosis and prognosis. J Cell Mol Med, 2020, 24(23):13961-13972. doi:10.1111/jcmm.16004.
[21]	Lv D, Liu Y, Guo F, et al. Combining interferon-γ release assays with lymphocyte enumeration for diagnosis of Mycobacterium tuberculosis infection. J Int Med Res, 2020, 48(6):300060520925660. doi:10.1177/0300060520925660.
[22]	Ma Y, Li R, Shen J, et al. Clinical effect of T-SPOT.TB test for the diagnosis of tuberculosis. BMC Infect Dis, 2019, 19(1):993. doi:10.1186/s12879-019-4597-8.
[23]	Mamishi S, Pourakbari B, Hosseinpour Sadeghi R, et al. Diagnostic accuracy of the IFN-γ release assay using RD1 immunodominant T-cell antigens for diagnosis of extrapulmonary tuberculosis. FEMS Microbiol Lett, 2024, 371:fnae023. doi:10.1093/femsle/fnae023.
[24]	Masood KI, Jamil B, Akber A, et al. Testing for Mycobacterium tuberculosis infection using the QuantiFERON-TB GOLD assay in patients with comorbid conditions in a tertiary care endemic setting. Trop Dis Travel Med Vaccines, 2020, 6:3. doi:10.1186/s40794-020-0102-z.
[25]	Pan L, Jia H, Liu F, et al. Risk factors for false-negative T-SPOT.TB assay results in patients with pulmonary and extra-pulmonary TB. J Infect, 2015, 70(4):367-380. doi:10.1016/j.jinf.2014.12.018.
[26]	Rumende CM, Hadi EJ, Tanjung G, et al. The Benefit of Interferon-Gamma Release Assay for Diagnosis of Extrapulmonary Tuberculosis. Acta Med Indones, 2018, 50(2):138-143.
[27]	Shin JA, Chang YS, Kim HJ, et al. Diagnostic utility of interferon-gamma release assay in extrapulmonary tuberculosis. Diagn Microbiol Infect Dis, 2015, 82(1):44-48. doi:10.1016/j.diagmicrobio.2015.02.002.
[28]	Wang F, Yu J, Zhou Y, et al. The Use of TB-Specific Antigen/Phytohemagglutinin Ratio for Diagnosis and Treatment Monitoring of Extrapulmonary Tuberculosis. Front Immunol, 2018, 9:1047. doi:10.3389/fimmu.2018.01047.
[29]	Wang L, Yu Y, Chen W, et al. Evaluation of the characteristics of the enzyme-linked immunospot assay for diagnosis of active tuberculosis in China. Clin Vaccine Immunol, 2015, 22(5):510-515. doi:10.1128/CVI.00023-15.
[30]	Yan L, Xiao H, Han M, et al. Diagnostic value of T-SPOT.TB interferon-γ release assays for active tuberculosis. Exp Ther Med, 2015, 10(1):345-351. doi:10.3892/etm.2015.2463.
[31]	Yang C, Zhang S, Yao L, et al. Evaluation of risk factors for false-negative results with an antigen-specific peripheral blood-based quantitative T cell assay (T-SPOT^®. TB) in the diagnosis of active tuberculosis: A large-scale retrospective study in China. J Int Med Res, 2018, 46(5):1815-1825. doi:10.1177/0300060518757381.
[32]	Zhong H, Wu H, Yu Z, et al. Clinical evaluation of the T-SPOT.TB test for detection of tuberculosis infection in northeastern Guangdong Province, China. J Int Med Res, 2020, 48(5): 300060520923534. doi:10.1177/0300060520923534.
[33]	Zhu C, Liu Z, Li Z, et al. The performance and limitation of T-SPOT.TB for the diagnosis of TB in a high prevalence setting. J Thorac Dis, 2014, 6(6):713-719. doi:10.3978/j.issn.2072-1439.2014.04.38.
[34]	Qin L, Zhang L, Zhang Y, et al. Diagnostic Value of T-Cell Interferon-γ Release Assays on Cerebrospinal Fluid for Tuberculous Meningitis. PLoS One, 2015, 10(11):e0141814. doi:10.1371/journal.pone.0141814.
[35]	Hashim Z, Nath A, Agarwal V, et al. Use of pleural fluid interferon-gamma enzyme-linked immunospot (ELISPOT) assay in the evaluation of undiagnosed pleural effusion. Eur Respir J, 2018, 52(suppl 62): PA2760. doi:10.1183/13993003.congress-2018.PA2760.
[36]	Lee LN, Chou CH, Wang JY, et al. Enzyme-linked immunospot assay for interferon-gamma in the diagnosis of tuberculous pleurisy. Clin Microbiol Infect, 2009, 15(2):173-179. doi:10.1111/j.1469-0691.2008.02655.x
[37]	Lu D, Chen C, Yu S, et al. Diagnosis of Tuberculous Meningitis Using a Combination of Peripheral Blood T-SPOT.TB and Cerebrospinal Fluid Interferon-γ Detection Methods. Lab Med, 2016, 47(1):6-12. doi:10.1093/labmed/lmv010.
[38]	Luo Y, Yan F, Xue Y, et al. Diagnostic utility of pleural fluid T-SPOT and interferon-gamma for tuberculous pleurisy: A two-center prospective cohort study in China. Int J Infect Dis, 2020, 99:515-521. doi:10.1016/j.ijid.2020.08.007.
[39]	Zhang L, Zhang Y, Shi X, et al. Utility of T-cell interferon-γ release assays for diagnosing tuberculous serositis: a prospective study in Beijing, China. PLoS One, 2014, 9(1):e85030. doi:10.1371/journal.pone.0085030.
[40]	Pan L, Liu F, Zhang J, et al. Interferon-Gamma Release Assay Performance of Cerebrospinal Fluid and Peripheral Blood in Tuberculous Meningitis in China. Biomed Res Int, 2017, 2017:8198505. doi:10.1155/2017/8198505.
[41]	Fan L, Chen Z, Hao XH, et al. Interferon-gamma release assays for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. FEMS Immunol Med Microbiol, 2012, 65(3):456-466. doi:10.1111/j.1574-695X.2012.00972.x
[42]	Pathan AA, Wilkinson KA, Klenerman P, et al. Direct ex vivo analysis of antigen-specific IFN-gamma-secreting CD4 T cells in Mycobacterium tuberculosis-infected individuals: associations with clinical disease state and effect of treatment. J Immunol, 2001, 167(9):5217-5225. doi:10.4049/jimmunol.167.9.5217.
[43]	Lalvani A. Diagnosing tuberculosis infection in the 21st century: new tools to tackle an old enemy. Chest, 2007, 131(6):1898-1906. doi:10.1378/chest.06-2471.
[44]	Sethy SS, Deep G, Sudhakar PV, et al. Tissue-specific immunity in osteoarticular tuberculosis. Indian J Orthop, 2025, 59(6):768-773. doi:10.1007/s43465-025-01371-z.
[45]	Ren C, Tang J, Xia L. Interferon gamma release assays for diagnosis of osteoarticular tuberculosis: A systematic review and meta-analysis. PLoS One, 2022, 17(6):e0269234. doi:10.1371/journal.pone.0269234.

评价领域	偏倚风险[项(构成比,%)]			适用性问题[项(构成比,%)]
评价领域	低风险	高风险	不明确	低风险	高风险	不明确
患者选择	18(64.28)	5(17.86)	5(17.86)	27(96.43)	0(0.00)	1(3.57)
指标检测	11(39.29)	1(3.57)	16(57.14)	28(100.00)	0(0.00)	0(0.00)
参考标准	22(78.57)	1(3.57)	5(17.86)	28(100.00)	0(0.00)	0(0.00)
流程与时间	25(89.29)	2(7.14)	1(3.57)	-	-	-

亚组	研究数量(篇)	测试结果(例)				合并敏感度 (95%CI)	Meta回归 P值	合并特异度 (95%CI)	Meta回归 P值
亚组	研究数量(篇)	TP	FP	FN	TN	合并敏感度 (95%CI)	Meta回归 P值	合并特异度 (95%CI)	Meta回归 P值
样本类型							0.010		<0.001
体液	9	155	44	35	416	0.86(0.77~0.95)		0.92(0.87~0.96)
血液	26	3354	3727	647	21557	0.84(0.79~0.89)		0.81(0.77~0.86)
检测方法							P<0.001		<0.001
ELISA	11	545	327	153	1221	0.84(0.77~0.92)		0.81(0.74~0.89)
ELISPOT	24	2964	3444	529	20752	0.85(0.80~0.90)		0.86(0.81~0.90)

协变量	研究数量(篇)	回归系数	RDOR(95%CI)值	P值
体液
检测方法
ELISA	2	-0.488	0.61(0.12~3.03)	0.483
ELISPOT	7	-	1.00(参照)	-
疾病类型
结核性脑膜炎	3	-	1.00(参照)	-
结核性胸膜炎	3	0.874	2.40(0.46~12.54)	0.244
诊断类型(ELISPOT)
确诊队列	7	-0.220	0.80(0.25~2.53)	0.682
疑似队列	7	-	1.00(参照)	-
血液
检测方法
ELISA	9	-0.233	0.79(0.26~2.46)	0.674
ELISPOT	17	-	1.00(参照)	-
疾病类型
结核性脑膜炎	5	-	1.00(参照)	-
结核性胸膜炎	8	-0.156	0.86(0.22~3.39)	0.819
结核性淋巴结炎	6	-0.259	0.77(0.20~2.96)	0.696
诊断类型(ELISPOT)
确诊队列	17	-0.111	0.90(0.21~3.78)	0.874
疑似队列	6	-	1.00(参照)	-
诊断类型(ELISA)
确诊队列	9	0.083	1.09(0.24~4.85)	0.906
疑似队列	6	-	1.00(参照)	-
地区背景
高结核负担地区	21	-0.163	0.85(0.20~3.59)	0.817
低结核负担地区	5	-	1.00(参照)	-

组别	研究数量 (篇)	敏感度 (95%CI)	特异度 (95%CI)	阳性似然比 (95%CI)	阴性似然比 (95%CI)	诊断比值比 (95%CI)	AUC值
血液ELISPOT	17	0.85 (0.84~0.86)	0.86 (0.85~0.86)	4.40 (2.81~6.91)	0.22 (0.15~0.33)	24.48 (11.48~52.23)	0.899
血液ELISA	9	0.77 (0.74~0.81)	0.78 (0.76~0.80)	3.61 (2.73~4.79)	0.22 (0.13~0.38)	17.91 (8.34~38.49)	0.879
体液ELISPOT	7	0.80 (0.72~0.86)	0.91 (0.88~0.94)	8.96 (6.30~12.73)	0.17 (0.07~0.43)	78.97 (35.73~176.6)	0.962