Endobronchial ultrasound experience in a high tuberculosis prevalence setting

Approaching a patient with poststernal pain after eating: A case report

This article reports a case of mediastinal lymph node tuberculosis with no obvious symptoms and a concealed focus. This patient, a 33-year-old male, suffered from pain behind the sternum after eating. He underwent three gastroscopic examinations and two fine needle punctures guided by ultrasound gastroscopy but was not diagnosed. Chest-enhanced CT revealed a mediastinal mass compressing the adjacent esophagus, suggesting the possibility of enlarged lymph nodes. Furthermore, T cells from patients infected with tuberculosis tested positive. Ultrasound bronchoscopy revealed enlarged lymph nodes in area 7, and then EBUS-TBNA was performed in that region. Only a few scattered lymphocytes and necrotic tissue were found under the biopsy microscope. The EBUS-TBNA biopsy Xpert MTB/RIF showed low positive results, and the EBUS-TBNA puncture fluid Xpert MTB/RIF was positive. Therefore, he was diagnosed with mediastinal lymph node tuberculosis. After antituberculosis treatment with the 2HREZ/10HRE regimen, the patient's pain behind the sternum gradually alleviated, and the enlarged mediastinal lymph nodes gradually narrowed.

Early detection of pleuro-pulmonary tuberculosis by bedside lung ultrasound: A case report and review of literature

We present a case in which lung ultrasound (LUS) was relevant to reach an early diagnosis of lung tuberculosis and to manage the patient in the right setting. Moreover, ultrasound allowed to detect and treat massive pleural effusion through an ultrasound-guided thoracentesis.

Primary mediastinal lymph node tuberculosis diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration: Literature review and case report

Tuberculosis bacilli can enter the human body through the respiratory system, digestive system, or skin and mucous membranes, with the respiratory tract representing the primary point of entry. Once inside the body, tuberculosis bacilli can enter the bloodstream and attack other organs, including the lymphatic system. One manifestation associated with lymphatic tuberculosis infiltration is the presence of large hilar and mediastinal lymph nodes, which are common in children and classified as primary tuberculosis. A diagnosis of primary tuberculosis in adults is often overlooked by doctors due to its low frequency. When a single enlarged mediastinal lymph node is observed, most doctors suspect other causes, especially malignancy. Determining the correct diagnosis for enlarged hilar and mediastinal lymph nodes can be difficult because diagnostic interventions in this area are challenging to perform. We report a clinical case of primary lymph node tuberculosis in an adult, confirmed by endobronchial ultrasound-guided transbronchial needle aspiration. We aim to provide doctors with a more comprehensive approach for diagnosing this disease.

Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature

Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.

The Clinicopathological Features of Mediastinal Tuberculous Lymphadenitis in Cancer Patients and the Diagnostic Role of Endobronchial Ultrasound

Introduction

Mediastinal lymphadenopathy in cancer patients can be of both malignant and non-malignant (including infectious) etiology. Tuberculosis (TB) is an important differential in this regard, particularly in regions with high TB endemicity.

Objectives

To determine the incidence and clinical characteristics of mediastinal tuberculous lymphadenitis (MTBLA) in cancer patients of a TB-endemic region, and the diagnostic role of endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) in such patients, utilizing both cytopathological and microbiological parameters for diagnosing TB.

Materials and methods

We retrospectively analyzed the relevant clinical data of all cancer patients diagnosed with MTBLA after undergoing EBUS-TBNA at our center, between July 2013 till July 2018 (total five years). The diagnostic yield, sensitivity and specificity of cytopathological and microbiological investigations (including TB culture and Mycobacterium tuberculosis Gene Xpert assay) for diagnosis of MTBLA were determined.

Results

Of the total 493 cancer patients, MTBLA was diagnosed in 54 (11%), with mean age of 48 ± 12 years, and predominantly male gender (59.3%). Thirty-three (61.1%) patients were clinically asymptomatic at the time of presentation, while cough was reported by 13 (24.7%) patients and weight loss, shortness of breath and fever by only six (11.1%), six (11.1%) and five (9.2%) patients, respectively. Total 53% had an underlying gastrointestinal malignancy. Chest imaging revealed bilateral versus unilateral hilar lymph node enlargement in 32 (59.3%) against 22 (40.7%) patients, respectively, while only 14 (25.9%) had accompanying lung parenchymal findings. Granulomatous TBNA cytology was detected in 41 (77.3%) patients, giving a diagnostic yield of 70.3% for MTBLA, with an estimated sensitivity and specificity of 79.2% and 99%, respectively. TB culture and Gene Xpert had a respective sensitivity of 48% and 53%, with the combined diagnostic yield of 64.8%. Treatment response was achieved in 51 (94%) patients, based on which EBUS was estimated to have sensitivity and specificity of 89% and 99% respectively, with no reported complications.

Conclusion

Mediastinal TB can have diverse manifestations among cancer patients and can often be clinically occult, with overlapping radiological impressions. EBUS-TBNA can serve as a safe and reliable diagnostic tool in this regard.

Distinct miRNA Gene Expression Profiles Among the Nodule Tissues of Lung Sarcoidosis, Tuberculous Lymphadenitis and Normal Healthy Control Individuals

Background: Sarcoidosis and tuberculosis share similarities in clinical manifestations and histopathological features. We aimed to identify the microRNA (miRNA) profiles of the lymph nodes of individuals with sarcoidosis and of those with tuberculous lymphadenitis to investigate the value of miRNAs in the differential diagnosis of sarcoidosis and tuberculous lymphadenitis.

Methods: The miRNA profiles of the lymph nodes of individuals with sarcoidosis, those with tuberculous lymphadenitis (TBLN) and controls were detected by miRNA microarray analysis in the age- and sex-matched development group of the controls (n = 3), patients with TBLN (n = 3) and patients with sarcoidosis (n = 3), and the results were validated by quantitative real-time polymerase chain reaction in the validation group of the controls (n = 30), TBLN (n = 30) and patients with sarcoidosis (n = 31). The relationship between miRNA expression and the clinical parameters of sarcoidosis was analyzed.

Results: miR-145, miR-185-5p, miR-301, miR-425-5P, miR-449b and miR-885-5P were differentially expressed between individuals with sarcoidosis and controls (P < 0.0001, P < 0.0001, P = 0.0008, P = 0.0002, P = 0.0018, and P < 0.0001, respectively), and the same six miRNAs were differentially expressed between individuals with tuberculous lymphadenitis and controls (P = 0.0002, P = 0.0004, P = 0.0238, P = 0.0006, P = 0.0149, and P = 0.0045, respectively). miR-185-5p was differentially expressed between individuals with tuberculous lymphadenitis and those with sarcoidosis (P = 0.0101). The area under the receiver operating characteristic curve calculated for miR-185-5p was 0.6860, and the sensitivity and specificity of miR-185-5p for the differential diagnosis of sarcoidosis from TBLN were 61 and 80%, respectively. The levels of miR-145, miR-301, miR-425-5P, and miR-885-5P were positively correlated with CD4+/CD8+ T lymphocytes in bronchoalveolar lavage fluid.

Conclusions: miRNAs in lymph nodes show similar expression patterns between individuals with sarcoidosis and those with tuberculous lymphadenitis, which were experimentally selected. miR-185-5p in the lymph nodes can be used as an auxiliary marker for the differential diagnosis of sarcoidosis and tuberculous lymphadenitis.

Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology

CONTEXT.—

The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples.

OBJECTIVE.—

To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies.

METHODS.—

The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered.

RESULTS.—

Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples.

CONCLUSIONS.—

Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in isolated intrathoracic lymphadenopathy in non-neoplastic patients: a common dilemma in clinical practice

Objective:

To determine the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in non-neoplastic patients with isolated intrathoracic lymphadenopathy (IL).

Methods:

This was a retrospective study of patients with isolated IL referred for EBUS-TBNA. We calculated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EBUS-TBNA in the diagnosis of granulomatous, reactive, and neoplastic lymphadenopathy. In cases of nonspecific granulomas, reactive lymphadenopathy, or inconclusive results, a definitive diagnosis was established by other diagnostic procedures or during a follow-up period of at least 18 months.

Results:

Among the 58 patients included in the study, EBUS-TBNA established a diagnosis of granulomatous disease in 22 (38%), reactive lymphadenopathy in 15 (26%), cancer in 8 (14%), and other diseases in 3 (5%). Results were inconclusive in 10 (17%), the diagnosis being established by other bronchoscopic procedures in 2 (20%) and by surgical procedures in 8 (80%). A final diagnosis of reactive lymphadenopathy was established in 12. Of those, 11 (92%) had their diagnosis confirmed during follow-up and 1 (8%) had their diagnosis confirmed by mediastinoscopy. In another 3, a final diagnosis of sarcoidosis or neoplasm was established. For the diagnosis of granulomatous disease, neoplasms, and reactive lymphadenopathy, EBUS-TBNA was found to have a sensitivity of 73%, 68%, and 92%, respectively; a specificity of 100%, 100%, and 93%, respectively; an accuracy of 86%, 93%, and 93%, respectively; a PPV of 100%, 100%, and 80%, respectively; and an NPV of 78%, 92%, and 98%, respectively.

Conclusions:

In non-neoplastic patients, granulomatous disease and reactive lymphadenopathy appear to be common causes of isolated IL. EBUS-TBNA shows promising results as a first-line minimally invasive diagnostic procedure. The results obtained by EBUS-TBNA can be optimized by examining clinical and radiological findings during follow-up or by comparison with the results obtained with other bronchoscopic methods.

EBUS-TBNA in the rapid microbiological diagnosis of drug-resistant mediastinal tuberculous lymphadenopathy

This study aimed to examine the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the rapid diagnosis of mediastinal tuberculous lymphadenitis and drug-resistant mediastinal tuberculous lymphadenitis. A diagnosis of TB was confirmed by a positive Xpert MTB/RIF test or Mycobacterium tuberculosis culture. Rifampicin-resistant TB (RR-TB) or multidrug-resistant TB (MDR-TB) was diagnosed upon the detection of rifampicin resistance by Xpert MTB/RIF or resistance to rifampicin and isoniazid by phenotypic drug susceptibility testing (DST). Xpert MTB/RIF was positive in 43 of 56 patients (77%) and TB culture was positive in 31 of 56 patients (55%). Of these 56 patients, 25 (45%) were Xpert MTB/RIF positive and TB culture negative, 13 (23%) were Xpert MTB/RIF negative and TB culture positive, and 18 (32%) were Xpert MTB/RIF positive and TB culture positive. 11 patients (20%) had drug-resistant TB: seven with RR/MDR-TB, one with pre-extensively drug-resistant (XDR) TB, two with XDR-TB and one with isoniazid mono-resistance. An Xpert MTB/RIF assay carried out on EBUS-TBNA specimens provides rapid diagnosis of TB. Xpert MTB/RIF testing appears to have additional and more rapid sensitivity compared with culture alone. Culture-based DST provides an additional exclusive yield and the full resistance profile in addition to or instead of rifampicin resistance.

Role of Endobronchial Ultrasound Guided Transbronchial Needle Aspiration in the Diagnosis of Intraocular Inflammation in India - Our Experience

Purpose: To report our experience of using Endobronchial ultrasound-guided transbronchial lymph node aspiration (EBUS-TBNA) in assessing the etiology in uveitis from two tertiary eye-care centers in India. Materials & Methods: Retrospective interventional case series. Results: A total of 99 patients of uveitis who underwent EBUS-TBNA were included in the study. Mycobacterium tuberculosis (MTb) was detected on culture in 5 cases, 3 cases by polymerase chain reaction and caseating granulomas in 25 cases. None of these patients had any symptoms of systemic tuberculosis (TB). Biopsy was inconclusive in eight cases. Granulomatous inflammation was seen in 91 cases. In 51 cases, it was difficult to differentiate between sarcoidosis and TB on biopsy. None of the patients had any significant complications. There was a fair agreement between the biopsy diagnosis and the final ocular diagnosis. Conclusions: In high TB endemic countries, procedures like EBUS-TBNA are useful in obtaining tissue diagnosis of TB when ocular diagnosis may be inconclusive due to paucity of ocular tissue.