Fine-Needle Aspiration Cytology in the Diagnosis of Tuberculous Lesions

Cyto-morphological and clinical approach to infections presenting with discharging sinuses mimicking malignancy

INTRODUCTION

Discharging sinuses is a form of chronic unhealed infection that can present at any site due to a variety of infectious organisms. These discharging sinuses may be associated with mass lesions and lymphadenopathy to mimic some neoplastic processes. Identifying these infections with accuracy and promptness is essential, as the treatment regimens are specific. Fine-needle aspiration (FNA) of these lesions, along with appropriate cytochemical stains, aids in the rapid and precise diagnosis of these infections and excludes neoplasms at these sites. Also, material for culture and other studies can be obtained by FNA.

MATERIAL AND METHODS

This retrospective study was conducted in the Department of pathology from 2018 to 2020. A total of 179 patients with similar clinical presentation and confirmed infection on cytology were identified. On the evaluation of the requisition forms, 32 (18%) patients were identified with discharging sinus associated along with swelling.

RESULTS

The five infections (32 cases) that were identified, included 18 cases of tuberculosis (56.25%) followed by 9 cases of actinomycosis (28.12%), 3 cases of pheohypomycosis (9.37%), and one case each of Nocardia (3.12%) and eumycetoma (3.12%) which presented as swelling with discharging sinus. Special stains were performed in all cases for confirmation. Histopathological/Microbiological correlation was done whenever available.

CONCLUSION

Infections presenting as swelling with discharging sinuses mimicking malignancy can be diagnosed on FNAC with good accuracy.

Diagnosis of abdominal tuberculosis: lessons learned over 30 years: pectoral assay

Diagnosing abdominal tuberculosis remains a great challenge even for experienced clinicians. It is a great mimicker that has unusual presentations. A high index of suspicion is essential for reaching its diagnosis. Clinical and radiological findings of abdominal tuberculosis are non-specific. Herein, we report the lessons we have learned over the last 30 years stemming from our own mistakes in diagnosing abdominal tuberculosis supported by illustrative challenging clinical cases. Furthermore, we report our diagnostic algorithm for abdominal tuberculosis. This diagnostic algorithm will help in reaching the proper diagnosis by histopathology or microbiology. Our diagnostic workup depends on categorizing the clinical and radiological findings of abdominal tuberculosis into five different categories including (1) gastrointestinal, (2) solid organ lesions, (3) lymphadenopathy, (4) wet peritonitis, and (5) dry/fixed peritonitis. The diagnosis in gastrointestinal tuberculosis and dry peritonitis can be reached by endoscopy. The diagnosis in solid organ lesions can be reached by ultrasound-guided aspiration. The diagnosis in wet peritonitis and lymphadenopathy can be reached by ultrasound-guided aspiration followed by laparoscopy if needed. Diagnostic laparotomy should be kept as the last option for achieving a histological diagnosis. Capsule endoscopy and enteroscopy were not included in the diagnostic algorithm because of the limited data of using these modalities in abdominal tuberculosis. They need special expertise, and rarely used in low- and middle-income countries. Furthermore, capsule endoscopy may cause complete intestinal obstruction in small bowel strictures. A definite diagnosis can be reached in only 80% of the patients. Therapeutic diagnosis should be tried in the remaining 20%.

CBNAAT: A Boon for Early Diagnosis of Tuberculosis-Head and Neck

Tuberculosis of head and neck has been an under diagnosed entity due to large number of smear negative cases, which results in missing out the positive cases, further increasing the burden of TB. The role of cartridge- based nucleic acid amplification test (CBNAAT) with a potential to diagnose TB and rifampicin resistance within 2 h is promising. The study highlights the extended implications of CBNAAT in infectious lesions of head and neck, where the pus or aspirate was subjected to this test, along with other investigations which have been routinely used for detection of extra pulmonary tuberculosis. Twelve patients with infective lesions of head and neck were included in this prospective study, conducted in Department of Otorhinolaryngology, Netaji Subhash Chandra Bose Medical College and hospital, Jabalpur from September 2016 to March 2017. They were investigated for pulmonary and extra pulmonary TB. CBNAAT, microscopy, FNAC and HPR from the site of lesion were done. Nine out of twelve patients were diagnosed positive for Tuberculosis. Microscopy (ZN staining) could detect only two such cases, whereas FNAC showed granulomatous lesion in 3 cases (33.3%). CBNAAT was positive in 77.7% of the total positive cases. Histopathological examination showed 100% results but was feasible only in selected number of cases (4 in this study). CBNAAT provides a promising role in early diagnosis of TB in head and neck. Its high sensitivity and less time taking procedure makes it an excellent tool for timely diagnosis of such cases.

Lung Infections

A review of pulmonary infections of all types with diagnostic and morphological features.

GeneXpert MTB/RIF Assay for the Diagnosis of Tuberculous Lymphadenitis on Concentrated Fine Needle Aspirates in High Tuberculosis Burden Settings

INTRODUCTION

The diagnosis of tuberculous lymphadenitis (TBL) remains challenging. The routinely used methods (cytology and smear microscopy) have sub-optimal sensitivity. Recently, WHO recommends GeneXpert to be used as the initial diagnostic test in patients suspected of having extra-pulmonary tuberculosis (EPTB). However, this was a conditional recommendation due to very low-quality evidence available and more studies are needed. In this study we evaluated the performance of Xpert for the diagnosis of TBL on concentrated fine needle aspirates (FNA) in Southwest Ethiopia.

METHODS

FNA was collected from presumptive TBL cases. Two smears were prepared from each aspirate and processed for cytology and conventional microscopy. The remaining aspirate was treated with N-acetyl-L-cysteine-NaOH and centrifuged for 15minutes at 3000g. The concentrated sediment was used for culture and Xpert test. Capilia TB-Neo test was used to differentiate M. tuberculosis complex (MTBC) from non-tuberculous mycobacteria (NTM). Composite bacteriological methods (culture and/or smear microscopy) were considered as a reference standard.

RESULT

Out of 143 enrolled suspects, 64.3% (92/143) were confirmed TBL cases by the composite reference standard (CRS). Xpert detected M. tuberculosis complex (MTBC) in 60.1% (86/143) of the presumptive TBL cases. The sensitivity of Xpert compared to CRS was 87.8% [95% CI: 81.0-94.5] and specificity 91.1% [95% CI: 82.8-99.4]. The sensitivity was 27.8% for smear microscopy and 80% for cytology compared to CRS. Cytology showed the lowest specificity (57.8%). Xpert was positive in 4 out of 45 culture- and smear-negative cases. Among 47 cytomorphologically non-TBL cases, 15 were positive on Xpert. More than half of Xpert-positive cases were in the range of very low cut-off threshold values (28

CONCLUSION

Xpert test showed a high sensitivity and specificity for the diagnosis of TBL on concentrated FNA samples. In addition, Xpert offered rapid detection of rifampicin-resistant M. tuberculosis strains from lymph node aspirates.

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MESH Headings

• Adolescent
• Adult
• Bacteriological Techniques/methods
• Biopsy, Fine-Needle
• Ethiopia
• Female
• Humans
• Lymph Nodes/microbiology
• Lymph Nodes/pathology
• Male
• Middle Aged
• Mycobacterium tuberculosis/chemistry
• Mycobacterium tuberculosis/cytology
• Prognosis
• Rifampin/chemistry
• Sputum/microbiology
• Tuberculosis, Lymph Node/diagnosis
• Young Adult

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Affiliation(s)

Mulualem Tadesse Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia Mycobacteriology Research Center, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
Gemeda Abebe Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia Mycobacteriology Research Center, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia
Ketema Abdissa Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia
Dossegnaw Aragaw Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia Mycobacteriology Research Center, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia
Kedir Abdella Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia Mycobacteriology Research Center, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia
Alemayehu Bekele Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia
Mesele Bezabih Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia
Ludwig Apers Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
Bouke C. de Jong Mycobacteriology Unit, Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium
Leen Rigouts Mycobacteriology Unit, Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium

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