Epidemiology of tuberculous lymphadenitis in Denmark: A nationwide register-based study

Performance of fine needle aspiration cytology and Ziehl-Neelsen staining technique in the diagnosis of tuberculosis lymphadenitis

INTRODUCTION

Proper diagnosis of tuberculosis (TB) lymphadenitis is critical for its treatment and prevention. Fine needle aspirate cytology (FNAC) is the mainstay method for the diagnosis of TB lymphadenitis in Ethiopia; however, the performance of FNAC has not been evaluated in the Eastern Region of Ethiopia. This study aimed to evaluate the performance of FNAC and Ziehl-Neelsen (ZN) staining compared with that of GeneXpert for the diagnosis of TB lymphadenitis.

METHODS

Fine needle aspiration (FNA) specimens collected from 291 patients suspected of having TB lymphadenitis were examined using FNAC, ZN, and GeneXpert to diagnose TB lymphadenitis. Gene-Xpert was considered the reference standard method for comparison. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa coefficient were determined using SPSS version 25.

RESULTS

The sensitivity, specificity, PPV, and NPV of ZN for diagnosing TB lymphadenitis were 73.2%, 97.4%, 96.2%, and 80.1% respectively. There was poor agreement between ZN and GeneXpert (Kappa=-0.253). The sensitivity, specificity, PPV, and NPV of FNAC were 83.3%, 94.8%, 93.5%, and 86.3% respectively. There was moderate agreement between the FNAC and GeneXpert (Kappa = 0.785).

CONCLUSION

The fine needle aspiration cytology (FNAC) is a more sensitive test for the diagnosis of TB lymphadenitis than ZN. The FNAC showed a moderate agreement with the GeneXpert assay. This study recommends the FNA GeneXpert MTB/RIF test in preference to FNAC for the diagnosis of TB lymphadenitis to avoid a missed diagnosis of smear-negative TB lymphadenitis.

Clinical Course of Patients With Mediastinal Lymph Node Tuberculosis and Risk Factors for Paradoxical Responses

BACKGROUND

Paradoxical responses (PR) occur more frequently in lymph node tuberculosis (LNTB) than in pulmonary tuberculosis and present difficulties in differential diagnosis of drug resistance, new infection, poor patient compliance, and adverse drug reactions. Although diagnosis of mediastinal LNTB has become much easier with the development of endosonography, limited information is available. The aim of this study was to investigate the clinical course of mediastinal LNTB and the risk factors associated with PR.

METHODS

Patients diagnosed with mediastinal LNTB via endosonography were evaluated retrospectively between October 2009 and December 2019. Multivariable logistic regression was applied to evaluate the risk factors associated with PR.

RESULTS

Of 9,052 patients who underwent endosonography during the study period, 158 were diagnosed with mediastinal LNTB. Of these, 55 (35%) and 41 (26%) concurrently had pulmonary tuberculosis and extrapulmonary tuberculosis other than mediastinal LNTB, respectively. Of 125 patients who completed anti-tuberculosis treatment, 21 (17%) developed PR at a median of 4.4 months after initiation of anti-tuberculosis treatment. The median duration of anti-tuberculosis treatment was 6.3 and 10.4 months in patients without and with PR, respectively. Development of PR was independently associated with age < 55 years (adjusted odds ratio [aOR], 5.72; 95% confidence interval [CI], 1.81-18.14; P = 0.003), lymphocyte count < 800/μL (aOR, 8.59; 95% CI, 1.60-46.20; P = 0.012), and short axis diameter of the largest lymph node (LN) ≥ 16 mm (aOR, 5.22; 95% CI, 1.70-16.00; P = 0.004) at the time of diagnosis of mediastinal LNTB.

CONCLUSION

As PR occurred in one of six patients with mediastinal LNTB during anti-tuberculosis treatment, physicians should pay attention to patients with risk factors (younger age, lymphocytopenia, and larger LN) at the time of diagnosis.

Revisiting Scrofula: An Entity Not to Forget in Migrants' Health

Tuberculous lymphadenitis (TBL) is one of the most common presentations of extrapulmonary tuberculosis (EPTB). The particularity of this presentation is the difficulty in establishing a definitive diagnosis, as clinical manifestations and imaging may be unspecific. We describe a case of tuberculous cervical lymphadenitis in a young male from Pakistan, a high-burden tuberculosis country. We intend to raise awareness of this entity, given the high index of suspicion required to diagnose it, which can lead to delays in appropriate treatment, potentially increasing the morbidity and mortality of affected patients. Increased awareness is especially important in immigrants, in whom tuberculosis cases continue to increase, exposing the need for easy and equitable access to healthcare. A brief review of the subject is also presented.

Clinico-epidemiologic Considerations in the Diagnosis of Tuberculous Lymphadenitis: Evidence from a high burden country

Tuberculosis is the biggest global health issue, tuberculous lymphadenopathy (TBL) being its commonest extra-pulmonary manifestation. Clinical diagnoses of TBL often pose challenges,thus this study aimed to analyze the clinical, epidemiologic and laboratory aspects of TBL in Debre Markos Specialized Comprehensive Hospital (DMSCH), North-west Ethiopia.

METHODS

The study was conducted at DMSCH, from October 2019 to March 2021. Patients with lymphadenopathy displaying cytomorphologic features of TB were enrolled. Checklist was used to collect clinico-demographic data.

RESULTS

Among a total of 294 TBL patients, majority 237 (80.61%) were adults aged 15-45 years. A fluctuant consistency 177 (60.20%; n=294) with predominant involvement of cervical lymph nodes 229 (77.8%) was the most frequent presentation. Most patients did not have either HIV infection 235 (94.37%; n=261) or known chronic medical illnesses 250(95.8%). Constitutional symptoms 113 (41.85%; n=270) and chronic cough 56 (20.74%; n=270) were infrequent. Erythrocyte Sedimentation Rate (ESR) raised in majority 133 (80%; n=165), of whom, extreme elevation (≥ 100mm/hr) seen in 63 (38.18 %).

CONCLUSION

TBL typically present as a fluctuant neck mass, predominantly in adults. Majority patients have no constitutional symptoms or cough. HIV infection or chronic medical illnesses are uncommon. Raised ESR is a fairly consistent finding.

Tuberculosis: An Overview of the Immunogenic Response, Disease Progression, and Medicinal Chemistry Efforts in the Last Decade toward the Development of Potential Drugs for Extensively Drug-Resistant Tuberculosis Strains

Tuberculosis (TB) is a slow growing, potentially debilitating disease that has plagued humanity for centuries and has claimed numerous lives across the globe. Concerted efforts by researchers have culminated in the development of various strategies to combat this malady. This review aims to raise awareness of the rapidly increasing incidences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, highlighting the significant modifications that were introduced in the TB treatment regimen over the past decade. A description of the role of pathogen-host immune mechanisms together with strategies for prevention of the disease is discussed. The struggle to develop novel drug therapies has continued in an effort to reduce the treatment duration, improve patient compliance and outcomes, and circumvent TB resistance mechanisms. Herein, we give an overview of the extensive medicinal chemistry efforts made during the past decade toward the discovery of new chemotypes, which are potentially active against TB-resistant strains.

Long-term risk of tuberculosis among migrants according to migrant status: a cohort study

BACKGROUND

The majority of tuberculosis (TB) cases in low-incidence countries occur in migrants. Only few studies have assessed the long-term TB risk in migrants after immigration, and datasets have not considered this across a range of diverse migrant groups. This nationwide study aimed to investigate long-term TB risk among migrants according to migrant status and region of origin.

METHODS

This cohort study included all migrants aged  ≥ 18 years who obtained residence in Denmark from 1993 to 2015, with a mean follow-up of 10.8 years [standard deviation (SD) 7.3]. Migrants were categorized based on legal status of residence and region of origin. Incidence rates (IR) and rate ratios (IRR) were estimated by Poisson regression.

RESULTS

A total of 142 314 migrants were included. Across all migrants, the TB risk was highest during year 1 of residence (IR 275/100 000 person-years; 95% CI 249-305) followed by a gradual decline, though TB risk remained high for over a decade. Compared with the Danish-born population, the IRRs after 7-8 years were particularly higher among former asylum seekers (IRR 31; 95% CI 20-46), quota refugees (IRR 31; 95% CI 16-71), and family-reunified with refugees (IRR 22; 95% CI 12-44). Sub-Saharan African migrants also experienced elevated risk (IRR 75; 95% CI 51-109). The proportion of migrants with pulmonary TB was 52.4%.

CONCLUSION

All migrant groups experienced an initial high TB risk, but long-term risk remained high in key migrant groups. Most European countries focus TB screening on or soon after arrival. Our study suggests that approaches to TB screening should be adapted, with migrant populations benefiting from long-term access to preventive health services.

What pulmonologists need to know about extrapulmonary tuberculosis

Extrapulmonary tuberculosis (EPT) can affect all organs. Its diagnosis is often challenging, especially when the lung is not involved. Some EPT locations, such as when the central nervous system is involved, are a medical emergency, and some have implications for treatment options and length. This review describes clinical features of EPT, diagnostic tests and treatment regimens.

Extrapulmonary tuberculosis can affect any organ, can be potentially life threatening or disabling, poses diagnostic difficulties and may change the type and length of treatment. Looking for concomitant pulmonary tuberculosis is essential.https://bit.ly/2YEaRVb

TB or not TB: A comprehensive review of imaging manifestations of abdominal tuberculosis and its mimics

The ever-growing prevalence of tuberculosis is a cause for concern among both developing and developed countries. Abdominal tuberculosis is the most common site of extrapulmonary tuberculosis and involves almost all of the visceral organs. Clinical presentation of abdominal tuberculosis is often non-specific. Thus, having a high index of clinical suspicion is necessary to aide early diagnosis and guide prompt initiation of appropriate treatment. In this review, we focus on the entire spectrum of abdominal tuberculosis and other diseases mimicking it with an emphasis on their imaging findings.

Clinical features of tuberculous lymphadenitis in a low-incidence country

BACKGROUND

Tuberculous lymphadenitis (TBLA) is the most common extrapulmonary manifestation of tuberculosis (TB) in Denmark. However, the clinical features of patients with TBLA have never been systematically studied in this setting.

METHODS

Patients treated for TBLA in Central Region Denmark from 2007 to 2016 were identified using the national TB surveillance register and The Danish Hospital Patient Registry. Data of clinical characteristics and treatment were extracted from hospital records.

RESULTS

Eighty-three TBLA patients were identified. The median age was 32 years (IQR 23-42); 71 (85.5%) were migrants; 58 (69.9%) presented with cervical lymphadenopathy; and 45 (54.2%) had one or more systemic TB symptom such as fever, chills, night sweats, fatigue, and weight loss. Sixty-five patients had no comorbidities (78.3%). HIV co-infection was seen in five (7.2%) of the 69 who were tested for HIV. Abscesses and/or draining sinuses were noted in 13 (15.7%) patients and 15 (18.1%) had concurrent pulmonary infection. The median time from first hospital contact to treatment initiation was 42 days (IQR 16-82) and admitted patients were hospitalised for a median of 7 days (IQR 3-13.5). For 24 patients (28.9%), lymph node material was not sent for mycobacterial culture and 52 (62.7%) had microbiologically confirmed TB. Treatment outcome was successful for 70 patients (84.3%).

CONCLUSION

In Denmark, TBLA is mainly seen among young and previously healthy migrants presenting with cervical lymphadenopathy and sparse systemic symptoms. The diagnosis is often considerably delayed and not microbiologically verified, implying diagnostic difficulties. Treatment outcome needs to be improved.

Extrapulmonary tuberculosis

Extrapulmonary tuberculosis can be confused with other pathologies because of the variety of symptoms it generates according to the affected organ. So, extrapulmonary tuberculosis must always be taken into account by medical staff within the differential diagnosis. In this paper, a review of the literature on extrapulmonary tuberculosis is carried out with emphasis on the most frequently affected organs.