Diagnosis of cervical tuberculous lymphadenitis with fine needle aspiration biopsy and cytologic examination under ultrasonographic guides

[Extrapulmonary tuberculosis]

Each year, there are more than eight million new cases of tuberculosis and 1.3 million deaths. There is a renewed interest in extrapulmonary forms of tuberculosis as its relative frequency increases. Among extrapulmonary organs, pleura and lymph nodes are the most common. Their diagnosis is often difficult and is based on clinical, radiological, bacteriological and histological findings. Extrapulmonary lesions are paucibacillary and samplings, in most cases, difficult to obtain, so diagnosis is often simply presumptive. Nucleic acid amplification tests, which are fast and specific, have greatly facilitated the diagnosis of some forms of extrapulmonary tuberculosis. However, their sensitivity is poor and a negative test does not eliminate the diagnosis. Treatment is the same as for pulmonary forms, but its duration is nine to 12 months for central nervous system and for bone tuberculosis. Corticosteroids are indicated in meningeal and pericardial localizations. Complementary surgery is used for certain complicated forms.

Immunocytochemical detection of Mycobacterium Tuberculosis complex specific antigen, MPT64, improves diagnosis of tuberculous lymphadenitis and tuberculous pleuritis

BACKGROUND

A rapid, sensitive and accurate laboratory diagnosis is of prime importance in suspected extrapulmonary tuberculosis (EPTB) cases. However, traditional techniques for the detection of acid-fast bacilli have limitations. The aim of the study was to evaluate the diagnostic value of immunocytochemical staining for detection of Mycobacterium tuberculosis complex specific antigen, MPT64, in aspirates from pleural effusions and lymph nodes, the most common presentations of EPTB.

METHOD

A cross-sectional study was conducted by including patients at Tikur Anbessa Specialized Hospital and the United Vision Medical Services from December 2011 to June 2012. Lymph node aspirates and pleural fluid samples were collected and analyzed from a total of 51 cases (26 tuberculous (TB) pleuritis and 25 TB lymphadenitis) and 67 non-TB controls. Each specimen was subjected to Ziehl-Neelsen (ZN) staining, culture on Lowenstein- Jensen (LJ) medium, cytological examination, Polymerase Chain Reaction (PCR) using IS1081gene sequence as a primer and immunocytochemistry (ICC) with polyclonal anti-MPT64 antibody. All patients were screened for HIV.

RESULT

ICC was positive in 38 of 51 cases and in the 7 of 67 controls giving an overall sensitivity and specificity of 74.5% and 89.5%, respectively. Using IS1081-PCR as a reference method, the sensitivity and specificity, positive and negative predictive value of ICC was 88.1%, 89.5%, 82.2% and 93.2%, respectively. The case detection rate increased from 13.7% by ZN stain to 19.6% by LJ culture, to 66.7% by cytology and 74.5% by ICC.

CONCLUSION

Immunocytochemistry with anti-MPT64 antigen improved detection of TB in pleural effusion and lymph node aspirates. Further studies using monoclonal antibodies on samples from other sites of EPTB is recommended to validate this relatively simple diagnostic method for EPTB.

Sonographically guided core needle biopsy of cervical lymphadenopathy in patients without known malignancy

OBJECTIVE

The purpose of this study was to retrospectively evaluate the efficacy of sonographically guided core needle biopsy (core biopsy) for diagnosing the causes of cervical lymphadenopathy in patients without known malignancy.

METHODS

One hundred fifty-five sonographically guided core biopsies performed in 155 patients with cervical lymphadenopathy were retrospectively evaluated. None of the 155 patients had any known primary malignancy. Final diagnoses were determined by the histologic examination from excision biopsy when performed or by the clinical and sonographic follow-up for more than 12 months. When a lymph node diagnosed as benign by sonographically guided core biopsy regressed spontaneously or by subsequent management, the diagnosis made by the sonographically guided core biopsy was considered correct. When a lymph node diagnosed as benign by sonographically guided core biopsy was unchanged or increased in size with subsequent management, excision biopsy was performed. Diagnostic yield, sensitivity, specificity, accuracy, and complications of core biopsy were evaluated.

RESULTS

Histologic diagnosis could be made by sonographically guided core biopsy in 146 (94%) of the 155 patients. The histologic diagnoses were reactive hyperplasia in 44 patients, tuberculosis in 37, Kikuchi disease in 25, metastasis in 16, lymphoma in 16, normal in 7, and toxoplasmosis in 1. Sensitivity, specificity, and accuracy of sonographically guided core biopsy were 97.9%, 99.1%, and 97.9%, respectively. There were no procedure-related complications.

CONCLUSIONS

Sonographically guided core biopsy is a safe and efficient tool for diagnosing the cause of cervical lymphadenopathy in patients without known malignancy and may obviate unnecessary excisional biopsy.

Tuberculosis of the Lymph Glands of the Neck: A Limited Role for Surgery

BACKGROUND AND OBJECTIVE: The clinical problem of a neck mass in general and tuberculous lymph nodes in the neck in particular may present a diagnostic dilemma. This retrospective study was conducted to highlight clinical presentation, management, and outcome.

PATIENTS AND METHODS: All patients (n = 59) diagnosed with tuberculosis of the cervical lymph node in Irbid governorate during the period 1996 through 2000 were reviewed for standard criteria, in addition to diagnostic and therapeutic modalities.

RESULTS: Medical records were reviewed and relevant data were included; all age groups were equally involved with a female/male ratio of 2:1. Most of the patients presented with a neck mass to the outpatient surgical clinic. The diagnosis was made mainly based on the clinical picture and results of the Mantoux test, Ziehl-Neelsen staining, and culture of bacilli. Fine needle aspiration cytology and histologic examination of incisional or excisional specimens are the main objective diagnostic tools. All patients were treated with antituberculous drugs under directly observed therapy short-course regimen with 83% cure rate.

CONCLUSION: Tuberculosis of the cervical lymph nodes responds well to antituberculous drugs and the surgical role is limited to guidance in fine needle aspiration, incision and drainage, and incisional and limited excisional biopsy. Major excisional procedures are not without complications and should be avoided.

MRI of tuberculous cervical lymphadenopathy

PURPOSE

The purpose of the study was to document the range of appearances of tuberculous cervical lymphadenopathy (TCL) on MRI.

METHOD

The MR images of nine patients who were subsequently found to have TCL were retrospectively reviewed. All patients were scanned on a 1.5 T unit using a neck coil (nine patients) and a surface coil (five patients). Each abnormal region was assessed separately for maximum size, pattern of disease, necrosis, calcification, soft tissue edema, muscle involvement, and vascular compression.

RESULTS

There were 17 abnormal regions. The posterior triangle was most frequently involved (six patients) followed by the supraclavicular fossa (five patients). There were three patterns of disease, comprising discrete nodes, matted nodes, and confluent masses. Necrosis occurred in 10 of the 17 abnormal regions; necrotic areas were located peripherally in 7 of these 10. The percentage of necrotic to solid areas ranged from <25 to >75% and was not related to the pattern of disease. Edema was present in four patients and was seen with matted nodes and confluent masses. Muscle involvement and vascular compression occurred in three regions. Calcification was not identified.

CONCLUSION

MRI revealed three patterns of disease in TCL: discrete nodes, matted nodes, and confluent masses. Necrotic foci, when present, were more frequently peripheral rather than central, and this together with the soft tissue edema may be of value in differentiating TCL from metastatic nodes.