[Tuberculous lymphadenopathy. Diagnosis and treatment. Case report]

Tuberculosis is a common cause of morbimortality among children, especially in developing countries, where 95% of cases occur. Child tuberculosis is closely related to tuberculosis in the adult, since the diagnosis is an indicator of poor surveillance, treatment, and effort to eradicate it. Tuberculous lymphadenitis (tuberculosis of the lymph node) is the most common form of extrapulmonary tuberculosis. We describe the case of an infant diagnosed with disseminated tuberculous lymphadenitis, by axillary lymph node excisional biopsy. Medical treatment first line antituberculosis drugs with allowed complete healing of the patient.

Current concepts in the management of tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Management of peripheral lymph node tuberculosis in routine practice: an unselected 10-year cohort

BACKGROUND

The varied behaviour of tuberculous lymph nodes during TB chemotherapy can cause clinical uncertainty, resulting in prolonged courses of treatment.

OBJECTIVES

To investigate whether results in routine practice in Blackburn, a high-incidence tuberculosis (TB) area in England and Wales, replicated the results of the 6-month chemotherapy trial for lymph node TB conducted by the British Thoracic Society.

DESIGN

All TB cases managed at the Blackburn Chest Clinic are recorded prospectively. Patients with lymph node TB were identified over a 10-year period.

RESULTS

A total of 100 patients with lymph node TB were listed in the database. Fine-needle aspiration was performed in 49 patients, while 66 underwent incisional lymph node biopsy. Culture confirmation was achieved in 60 cases. Sinus and new lymph node development was comparable between our study and the BTS trial. After cessation of treatment, 10 patients developed new/enlarged lymph nodes, but further investigations revealed that only three patients had relapsed TB.

CONCLUSION

The varied behaviour of lymph node TB during and after treatment causes clinical uncertainty. Six months of chemotherapy is effective for fully susceptible TB in routine clinical practice in England. Investigation of new signs is important in differentiating patients with relapsed TB from normal varied behaviour.

Disseminated lupus vulgaris

A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement.

Mediastinal tuberculosis in Bradford, United Kingdom: the role of mediastinoscopy

OBJECTIVE

To evaluate patients with mediastinal tuberculosis (MT), their demographic profiles, symptoms, radiological features and the role of mediastinoscopy.

METHODS

This retrospective study conducted at Bradford Teaching Hospitals, Bradford, United Kingdom, looked at the case notes of 160 (13%) patients with MT out of a cohort of 1252 notifications of tuberculosis (TB) cases from 1995 to 2004, analysing the demographic data, diagnostic findings, computed tomography (CT) scans and outcomes. Interventions included bronchoscopy, lymph node biopsy and mediastinoscopy.

RESULTS

Patient age ranged from 1 to 75 years; the majority were females and from minority ethnic groups. Contact history was positive in 76% of cases. Cough was the most common symptom (50%); however, asymptomatic patients were also common (45%). Heaf test was positive in 99%. Right paratracheal lymphadenopathy was common on chest X-ray and chest CT scan. Mediastinoscopy was performed in only 37 patients with definitive diagnosis.

CONCLUSION

MT should be suspected in adult asymptomatic immigrants presenting with mediastinal adenopathy and a strongly positive Heaf test. Trial of anti-tuberculosis treatment should be initiated and response should guide further management. Mediastinoscopy is required in only a minority of patients.

Unusual complication of cervical tuberculous lymphadenopathy

Lymphadenopathy is the most common form of extrapulmonary tuberculosis; cervical region being the most frequent site. Yet, tuberculous cervical lymphadenopathy is rarely associated with Internal Jugular Vein (IJV) thrombosis. We report right IJV thrombosis with isolated cervical tuberculous lymphadenopathy in a 22-year-old woman. Anti-tuberculous treatment resulted in complete regression of lymphadenopathy but anticoagulation treatment failed to restore the caliber of thrombosed IJV to normal. Thrombosis of adjacent IJV is a potential complication of delay in diagnosis and treatment of cervical lymphnode tuberculosis.

The use of light-emitting diode fluorescence to diagnose mycobacterial lymphadenitis in fine-needle aspirates from children

BACKGROUND

Fine-needle aspiration biopsy (FNAB) is a simple, safe and effective method for investigating suspected mycobacterial lymphadenitis in children. Fluorescence microscopy can provide rapid mycobacterial confirmation. Light-emitting diodes (LEDs) provide a cheap and robust excitation light source, making fluorescence microscopy feasible in resource-limited settings.

OBJECTIVE

To compare the diagnostic performance of LED fluorescence microscopy on Papanicolaou (PAP) stained smears with the conventional mercury vapour lamp (MVL).

METHODS

FNAB smears routinely collected from palpable lymph nodes in children with suspected mycobacterial disease were PAP-stained and evaluated by two independent microscopists using different excitatory light sources (MVL and LED). Mycobacterial culture results provided the reference standard. A manually rechargeable battery-powered LED power source was evaluated in a random subset.

RESULTS

We evaluated 182 FNAB smears from 121 children (median age 31 months, interquartile range 10-67). Mycobacterial cultures were positive in 84 of 121 (69%) children. The mean sensitivity with LED (mains-powered), LED (rechargeable battery-powered) and MVL was respectively 48.2%, 50.0% and 51.8% (specificity 78.4%, 86.7% and 78.4%). Inter-observer variation was similar for LED and MVL (κ = 0.5).

CONCLUSION

LED fluorescence microscopy provides a reliable alternative to conventional methods and has many favourable attributes that would facilitate improved, decentralised diagnostic services.

Tuberculous lymphadenitis at Penang General Hospital, Malaysia

OBJECTIVE

To evaluate the incidence, treatment and clinical outcomes of tuberculous (TB) lymphadenitis at Penang General Hospital, Malaysia.

MATERIALS AND METHODS

Penang General Hospital is the referral center for all tuberculosis patients in the state of Penang. Patient records were reviewed to identify patients with confirmed diagnosis of TB lymphadenitis between January 2006 and December 2008. Data were analyzed using SPSS version 15.

RESULTS

Of 1,548 tuberculosis cases, 109 (7.0%) patients had TB lymphadenitis. The mean age was 36.4 ± 12.87 years and of the 109 patients with TB lymphadenitis, 35 (33.0%), 37 (34.0%) and 36 (33.0%) were observed for 2006, 2007 and 2008, respectively. Ethnically, 45 (41.3%) were Malay followed by 37 Chinese (33.9%). Among risk factors for TB lymphadenitis, HIV and diabetes mellitus were seen in 17 (15.6%) and 11 (10.0%) patients, respectively. Cough and fever were the most frequently reported symptoms. In a majority of cases (n = 90, 82.5%) positive results were obtained for fine-needle aspiration (FNA). Directly observed therapy was given to all patients. Sixty-two (56.9%) patients were successfully treated, and 5 (4.6%) patients died during the treatment.

CONCLUSION

There was no increase in the incidence of TB lymphadenitis over the 3-year study period. The incidence was slightly higher in male than female gender and in Malay (ethnic group). Diabetes mellitus and HIV were the most commonly reported risk factors. FNA is the most reliable diagnostic test.

Assessment of lymph node tuberculosis in two provinces in Turkey

The aim of this study was to evaluate lymph node tuberculosis (LNT) cases in two provinces in Turkey with different demographic and socioeconomic characteristics. A total of 109 LNT cases were reviewed retrospectively. The cases were analyzed and compared for symptoms, findings, age, vaccination status, and diagnostic procedures. Socioeconomic conditions were also assessed for the two provinces. A palpable cervical node was considered a significant predictor for all LNT. Mediastinal lymph node involvement was found to be common in cases of pulmonary manifestation of LNT. Female patients were predominantly from the Van Province, while older patients were found to be from Izmir Province. LNT should be suspected in lymphadenitis patients of all age-groups especially in young adolescents with cervical lymph node enlargements. In the presence of mediastinal lymphadenopathy, pulmonary tuberculosis should be investigated.

[Analysis of lethal outcomes in patients with newly-diagnosed tuberculosis of the respiratory organs in combination with HIV-infection]

AIM

To analyse lethal outcomes in patients with newly-diagnosed respiratory tuberculosis comorbid with HIV-infection depending on initial count of CD4+ lymphocytes.

MATERIAL AND METHODS

Of 304 HIV patients with newly-diagnosed tuberculosis treated in Moscow Tubercusis Hospital N 7 in 2006-2010, 40 (13.2%) patients died. Tuberculosis diagnosis was made after detection of M. tuberculosis (MT) by different tests, MT DNA in different biological material, histological verification or by effectiveness of specific antituberculous therapy. Postmortem examinations were made according to the protocol.

RESULTS

Significant differences were detected in patients with initial count of CD4+ lymphocytes less than 50 in 1 mcl. Specific CNS affection was found in patients with initial lymphocyte count CD4+ less than 100 in 1 mcl. Most of autopsy examinations registered generalized acutely progressive tuberculosis with multiple lesions of internal organs and lymph nodes (LN). Microscopy revealed obscure morphological picture of specific inflammation with prevalence of alternative-exudative tissue reactions in the absence of a productive inflammation component. Cases with submiliary dissemination which was invisible in macroscopic examination due to a bright picture of exudative tissue reaction (rare plethora of the lungs, alveolar and interstitial edema, perifocal inflammatory reaction of nonspecific reactive nature) and small size of the lesions. The comparison of clinical and autopsy diagnoses revealed that involvement of intrathoracic LN and miliary dissemination, according to autopsy, occurred much more frequently than shown by antemortem standard x-ray examination of the chest.

CONCLUSION

It is strongly recommended to perform computed tomography of the chest in all HIV-infected patients with long-term fever but without visible alterations on chest x-ray.

Spectrum of cytological findings in patients with neck lymphadenopathy--experience in a tertiary care hospital in Pakistan

INTRODUCTION

Lymph adenopathy is of great clinical significance as underlying diseases may range from a treatable infectious etiology to malignant neoplasms. In fact it is also essential to establish that the swelling in question is a lymph node. Fine needle aspiration cytology (FNAC) plays a vital role in solving these issues, nowadays being recognized as a rapid diagnostic technique because of its simplicity, cost effectiveness, early availability of results, accuracy and minimal invasion. FNAC is particularly helpful in the work-up of cervical masses and nodules because biopsy of cervical adenopathy should be avoided unless all other diagnostic modalities have failed to establish a diagnosis.

OBJECTIVE

To determine the epidemiological and cytomorphological patterns of enlarged neck nodes.

STUDY DESIGN

This retrospective observational study was performed at the Section of Histopathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan.

MATERIALS AND METHODS

Three Hundred and seventy seven (377) neck swelling specimens obtained over a period of two and a half years registered from different regions of Pakistan were selected. Data were analyzed using SPSS 17.

RESULTS

Of a total of 377 cases of FNAC performed on neck nodes, the most frequent cause of lymphadenopathy was found to be tuberculosis with 199 cases (52.7%), followed by reactive lymphoid hyperplasia with 61 cases (16.1%). Metastatic carcinoma was found to be the third most common cause with 33 cases (8.7%). A diagnosis of lymphoproliferative disorder was rendered in 21 cases (5.5%). Acute and chronic non-specific inflammation was seen in 16 cases (4.2%). In 47 cases (12%) FNAC was inconclusive.

CONCLUSION

In our study, the predominant cause of enlarged neck nodes was tuberculous lymphadenitis, followed by reactive lymphadenitis and malignant neoplasm, especially metastatic carcinoma and lymphoma. FNAC was helpful in establishing the diagnosis in approximately 98% of the cases.

[Ileus as a manifestation of intestinal tuberculosis]

BACKGROUND

'Intestinal tuberculosis' is sometimes difficult to diagnose. The symptoms are non-specific and there is an extensive differential diagnosis.

CASE DESCRIPTION

A 27-year-old man from Pakistan presented at the emergency department with a history of constipation, weight loss and abdominal pain. An abdominal CT scan revealed dilated small bowel loops, lymphadenopathy and a thickened intestinal wall of the terminal ileum. Cultures of a cervical lymph node biopsy tested positive for Mycobacterium tuberculosis: intestinal tuberculosis. The man eventually recovered after treatment with tuberculostatics.

CONCLUSION

The most sensitive methods for establishing the diagnosis 'intestinal tuberculosis' are an abdominal CT scan and a colonoscopy with ileal and colonic biopsies; establishing the diagnosis can be challenging as a result of non-specific test results.

An unusual cause of dysphagia: esophageal tuberculosis

A 25-year old Indian exchange-student presented to our department with a three week history of dysphagia. Diagnostic evaluation by upper gastrointestinal endoscopy, endosonography and chest-CT revealed a tumor-suspect ulcerative lesion at the middle esophagus, and a mediastinal lymph node enlargement. Initial histopathological evaluation of multiple esophageal tissue biopsies showed an unspecific esophagitis without signs for malignancy. A positive T-spot (R) TB assay result, together with the bronchoscopic detection of a small exophytic lesion at the right main bronchus depicting caseating epitheloid cell granulomas, provided evidence for a tuberculous etiology of the esophageal tumor. Multiple further deep submucosal biopsies were needed to finally detect epitheloid cell granulomas in the esophageal lesion. Microbacteriological or molecular tests were negative for M. tuberculosis. Tuberculostatic treatment resulted in a good response with complete remission of the esophageal lesion and the mediastinal lymph node enlargement. Esophageal tuberculosis is rare in developed countries, and its possible presence deserves consideration particularly in patients at risk.

[Tuberculous lymphadenitis]

OBJECTIVES

In this study, we evaluate tuberculosis (Tbc) lymphadenitis diagnosed patients age, gender, contact history, history of smoking, socioeconomic status, lymphadenitis localization, imaging techniques, fine needle aspiration biopsy (FNAB) and excisional biopsy results.

PATIENTS AND METHODS

Between February 2006 and February 2008 104 patients were operated to determine the etiology of their neck masses. Twenty-six patients (16 females, 10 males; mean age 36.9 years; range 16 to 52 years) who were diagnosed as Tbc lymphadenitis according to pathology results were included in the study. Ear, nose and throat examinations were performed in all patients routinely. Hemogram, biochemical and serological tests were performed. The patients were evaluated with anterior-posterior chest radiographs and purified protein derivative (PPD) by chest diseases consultation imaging methods and FNAB was performed. All patients diagnosed with excisional biopsy of neck mass. During the operation, tissue culture and Ziehl-Neelsen method for staining was prepared.

RESULTS

Out of 26 patients eight had a history of contact with Tbc. One person had previously lung Tbc. Six patients had previously received treatment because of Tbc lymphadenitis, but didn't complete the treatment. Neck ultrasonography and neck computed tomography detected a solid mass in 16 patients and cystic mass in 10 patients. The 24 patients were evaluated as positive PPD (>10 mm). None of the patients had an association between active pulmonary Tbc and Tbc lymphadenitis.

CONCLUSION

Suspicion is the most important step in the diagnosis of Tbc lymphadenitis. In patients with low socioeconomic status, previous Tbc contact, tabacco usage, suppressed immune system, and particularly in those with drainage from neck masses, Tbc lymphadenitis should be considered in the differential diagnosis.

[Evaluation of 694 tuberculous lymphadenitis cases reported from Turkey between 1997-2009 period by pooled analysis method]

Tuberculosis which mainly involves the lungs, can also cause infection in almost all other organs and tissues in the body. One of the most common forms of extrapulmonary tuberculosis is tuberculous lymphadenitis. In this study, tuberculous lymphadenitis cases reported from Turkey in national and international journals in the last 12 years, were reviewed systematically with pooled-analysis method. Related articles were retrieved by search of three national (Ulakbim Turkish Medical literature databases, http://www.turkishmedline.com, http://medline.pleksus.com.tr) and two international databases [PubMed and Science Citation Index (SCI)]. Between the years 1997-2009, tuberculous lymphadenitis cases have been published in a total of 44 articles (13 international, 31 national data base). These articles included a total of 694 tuberculous lymphadenitis cases (62.4% women, 37.6% men; mean age 37.5 years). The distribution of the lymph nodes involved was determined in 528 cases and the most commonly involved areas were cervical (61.4%), mediastinal (20.5%) and axillary (6.4%) areas. The most common complaints of patients were fever (15.8%), weight loss (14.5%), malaise-fatigue (13.1%) and sweating (12.4%). Tuberculous lymphadenitis was identified in 10.6% (51/479) of the cases by direct microscopical examination, in 15.9% (65/408) by culture and in 648 cases from whom biopsies were taken, by histopathological examination. Tuberculin skin test positivity was detected in 78.9% (377/478) cases. History of contact with active tuberculosis patients was determined in 24.2% (88/364) of the patients. Coexisting lung tuberculosis was detected in 7.8% (54/694) of the cases. The total number of cases that had died was four; two cases due to malignancy, one due to sepsis and one due to central nervous system tuberculosis that have developed four years following the diagnosis of tuberculous lymphadenitis. Since microbiological diagnosis is difficult in tuberculous lymphadenitis and not available in all centers, evaluation of the patients' history and clinical findings are of great importance. This pooled analysis which enabled the evaluation of a large number of tuberculous lymphadenitis cases, indicated that in countries where tuberculosis is widespread, careful evaluation of clinical findings and a good microbiological and histopathological investigation will provide valuable support for diagnosis and treatment of tuberculous lymphadenitis.

Evaluation of polymerase chain reaction (PCR) using hupB gene in diagnosis of tuberculous lymphadenitis in fine needle aspirates

BACKGROUND

Although pulmonary tuberculosis (PTB) is the most common manifestation of tuberculosis, extra pulmonary tuberculosis(EPTB) has equal significance. Among the extra pulmonary manifestations, tubercular lymphadenitis (TBL) is the most common form.

OBJECTIVES

To perform PCR on fine needle aspirates of lymphnode by using hupB gene as target. To compare the sensitivity and specificity of PCR with culture, cytology, serology and clinical response to therapy.

MATERIAL & METHODS

After processing the samples by Universal Sample Processing(USP) method,two step nested PCR was performed using two sets of primers (N1S1 & CTFR) of hupB gene. All patients were put on ATT and were followed up for two months. The response to therapy was considered as the gold standard in our study.

RESULTS

The PCR assay for hupB gene was positive in 85 patients. Of these, 82% patients showed infection with M. tuberculosis, 1% was positive for M. bovis and 2% showed coinfection with both M. tuberculosis and M. bovis. The PCR assay of hupB gene in our study showed a sensitivity of 87.4% and specificity of 66.7%.

CONCLUSION

PCR assay for hup B gene is a rapid means of diagnosis of tubercular lymphadenitis.

Oropharyngeal tularemia--a differential diagnosis of tonsillopharyngitis and cervical lymphadenitis

Francisella tularensis, the causative agent of tularemia, has been recognized as a human and zoonotic pathogen for almost 100 years. The increasing number of tularemia outbreaks in regions of Europe outside the classic endemic areas in recent years has prompted renewed interest in this rare infectious disease. We report on a case of oropharyngeal tularemia in an 18-year-old girl from Bavaria (Germany) who presented with tonsillopharyngitis and cervical lymphadenitis. Strongly positive serological tests and PCR detection of F. tularensis subsp. holarctica in lymph node tissue led to the diagnosis of tularemia. After long-term treatment with doxycycline, partly in combination with ciprofloxacin, the patient recovered completely. Clinical presentation, diagnostics, treatment and recent epidemiological aspects of tularemia in Europe are discussed in this case report and review of the literature.

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of extra-pulmonary tuberculosis

SETTING

The incidence of extra-pulmonary tuberculosis (EPTB) is surprisingly high among certain subgroups of patients in industrialized countries. Diagnosis is often difficult and can require costly invasive workup. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe, minimally invasive, accurate, out-patient diagnostic modality for assessing mediastinal and abdominal lymphadenopathy and masses.

OBJECTIVE

To evaluate the usefulness of EUS-FNA for diagnosing EPTB.

DESIGN

Retrospective 6-year review, including all patients who had evidence of lymphadenopathy or mass on computed tomography scan accessible by EUS and consideration of tuberculosis (TB) in the differential diagnosis.

RESULTS

Of 81 potential patients, a total of 20 cases with EPTB diagnosed by EUS-FNA were identified. Necrotizing granulomas had a 58% likelihood of TB vs. 14% for other cytologic findings (P < 0.0001); necrosis was also predictive, with a 44% likelihood of TB vs. 19% (P < 0.0225). EUS-FNA cytology was diagnostic for TB when an African-born patient had necrotizing granulomas (P < 0.0001), and was highly suggestive with necrosis alone (P < 0.0514). Non-necrotizing granulomas were not predictive of TB and an alternative diagnosis was more likely, including sarcoidosis and cancer.

CONCLUSION

EUS-FNA is a useful diagnostic modality that should be used early in the diagnostic workup of suspected EPTB.

Scenario of extrapulmonary tuberculosis in a tertiary care center

BACKGROUND

Tuberculosis is a worldwide disease and one of the major health problems of Nepal. Extrapulmonary tuberculosis is increasing all over the world. The main aim of this study was to assess the frequency of extrapulmonary tuberculosis in various organ systems of the body and to assess the pattern of disease in different age groups and gender.

METHODS

This observational retrospective study was carried out from December 2003 to October 2009 at the Department of Pathology, Kathmandu University Hospital, Kavre, Nepal. A total of 259 extrapulmonary tuberculosis cases diagnosed by fine needle aspiration cytology and biopsy were included. Frequency of extrapulmonary tuberculosis in the lymph nodes in relation to age and sex were studied.

RESULTS

Lymph nodes tuberculosis was present in 179 (69.11%) cases. Among all extrapulmonary tuberculosis, 132 (50.56%) cases were in males and 127 (49.04%) were in females. Out of total 179 tuberculosis of lymph nodes, 116 (74.35%) were seen in age group of 25 years and above (p=0.018) and 86 (48.04%) in males and 93 (51.95%) in females (p=0.18).

CONCLUSIONS

Extrapulmonary tuberculosis is common in lymph nodes, equally in both sexes and more in age group of 25 and above. Therefore, this age group should be focused upon more for investigation and management of extrapulmonary tuberculosis.

[Lesions of tuberculosis in the head and neck region: a retrospective analysis of 48 cases]

OBJECTIVES

We evaluated patients who had been treated for head and neck tuberculosis.

PATIENTS AND METHODS

This retrospective study included 40 patients (28 males, 20 females; mean age 32.6 years; range 11 to 65 years) who had received treatment for tuberculosis of the head and neck region between January 2000 and June 2009. Clinical findings, treatment modalities, and the results of treatment were evaluated.

RESULTS

Forty-one patients had cervical lymphadenopathy, two patients had parotid gland tuberculosis, two patients had nasopharyngeal tuberculosis, and three patient were diagnosed as tongue, tonsil and larynx tuberculosis respectively. Lymph nodes in the posterior triangle were found to be the most common region afflicted by tuberculosis lymphadenitis. Diagnosis was confirmed by excisional biopsy in all patients and lesions were resolved after antituberculosis chemotherapy.

CONCLUSION

Although different clinical presentations were seen, tuberculosis cervical lymphadenitis is the most common presentation of tuberculosis in the head and neck region. Tuberculosis should be considered in the differential diagnosis of the neck mass and other head and neck lesions.

[A CASE OF ESOPHAGOGASTRIC FISTULA CURE IN A PATIENT WITH COMPLICATED TUBERCULOSIS OF INTRATHORACIC LYMPH NODES]

The authors describe a successful case of esophageal fistula being cured in a patient with complicated tuberculosis of intrathoracic lymph nodes. They show it possible to medically cure the fistula via temporary esophageal stenting, which in combination with therapeutic bronchoscopies enables prompt fistula healing, without resorting to surgical treatment.

[EVALUATION OF THE EFFICIENCY OF TREATMENT AND THE CHOICE OF CONTROL COMPUTED TOMOGRAPHY TIME IN CHILDREN WITH MINOR FORMS OF INTRATHORACIC TUBERCULOSIS]

Three chemotherapy regimens (Group 1: 2HRZ/4HR, n = 31; Group 2: 2HRZ/4HZ, n = 33; Group 3: 6HR, n = 33) were comparatively assessed in children with minor forms of intrathoracic tuberculosis diagnosed by the computed tomography (CT). The leading criteria for therapeutic effectiveness were regression of intoxication symptoms and changes in the CT pattern. The results of treatment were equal in all the groups. With the 6HR regimen, varying unavoidable adverse reactions were 4.3-fold less frequently (3.0 ± 3.0% and 12.5 ± 4.1%, respectively; p = 0.25). CT pattern changes by months 2-3 and 6 of therapy were compared. Single control CT investigation by 6 months of therapy was optimal. Additional CT study at 2-3 months of therapy reflected positive changes in most cases, but failed to affect treatment policy.

[THE CURRENT ASPECTS OF DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF COMPLICATIONS AFTER BCG VACCINATION]

Whether the diagnosis of BCG complications might be verified by molecular genetic methods, such as polymerase chain reaction (PCR) and sequencing, was studied. PCR could identify Mycobacterium tuberculosis as M. bovis strain BCG and increase the detection rate of M. tuberculosis by 38% as compared with traditional microbiological assays, which provides a means of recommending the method to verify the diagnosis of BCG complications.

[CAUSES OF CHRONIC TUBERCULOSIS OF INTRATHORACIC LYMPH NODES IN CHILDREN, THE SPECIFIC FEATURES OF CLINICAL MANIFESTATIONS AND THERAPY]

Studying the results of examination in 59 children with tuberculosis of intrathoracic lymph nodes over time could establish the main causes of the chronic course of the disease, reveal the specific features of clinical manifestations, and define the optimal regimens of specific therapy. The chronic primary tuberculosis is characterized by a multiple intrathoracic lymph node lesion that corresponds to different phases of specific inflammation and is accompanied by complications in a third of cases. The signs of process activity are observed in 79.7%. Complex therapy lasted more than 10 months in 32.3% of cases and achieved recovery with insignificant residual changes in 69.5% of children. The basic causes of chronic tuberculosis are untimely and inadequate prophylactic measures in risk groups and failures in early tuberculosis detection in children.

The diagnostic efficacy of fine-needle aspiration using cytology and culture in tuberculous lymphadenitis

OBJECTIVE

To retrospectively assess the diagnostic efficacy of fine-needle aspiration (FNA) using cytological and microbiological examinations in tuberculous lymphadenitis.

METHODS

Patients with tuberculous lymphadenitis treated at St Mary's Hospital, London, between January 2001 and June 2007 were identified. The cytological and microbiological reports of 97 patients were found. The criteria for a definite diagnosis of tuberculous lymphadenitis were based on a compatible clinical history, tuberculin positivity and either an indicative cytological result or positive culture.

RESULTS

In 77 of the 97 (79%) cases, FNA cytology showed evidence of a tuberculous process. In 65 cases, Mycobacterium tuberculosis was cultured from the aspirates, and 54 of these 65 cases showed corresponding cytological evidence of a tuberculous process; 23 cases were diagnosed by cytology but not microbiology, while 11 cases were diagnosed by microbiology but not cytology.

CONCLUSION

Cytological and microbiological results appeared to correlate well, but each also gives an exclusive diagnosis. When combining both modalities, the diagnostic efficacy of FNA rises to 91%. A definitive microbiological diagnosis was achieved in 67% of cases and provided information on drug susceptibility. We conclude that samples should be provided for both cytological and microbiological examination when using FNA to diagnose possible tuberculous lymphadenitis.

Clinical profile and treatment outcome of tuberculous lymphadenitis in children using DOTS strategy

BACKGROUND

Extra pulmonary TB (EPTB) including tuberculous lymphadenitis is becoming more common probably due to human immuno deficiency virus (HIV) co-infection. While children do experience a high TB related morbidity and mortality, management of TB in children is challenging. The present study was designed to study the treatment outcome of DOTS strategy for pediatric tuberculous lymphadenitis.

OBJECTIVE

To study the efficacy of DOTS strategy for pediatric lymphhnode tuberculosis.

METHODS

Retrospective analysis of 669 children of lymphnode tuberculosis treated with DOTS strategy over 9 1/2 years.

RESULTS

Mean age was 9.8 years with significantly more girls (61.3%) than boys (38.7%) {chi2=34.08, P<0.001 (S)}. Most of the patients were in the age group of 11-14 years (48.0%) followed by 6-10 years (34.5%) and 0-5 years (17.5%) respectively. Cervical tuberculous lymphadenitis (88.2%) was the commonest form for all ages followed by axillary lymphadenitis in 3.3%. TB of other sites was seen in only 57 (8.5%) cases. Out of total 622 (93%) cases of lymphnode TB where fine needle aspiration and/or excisional biopsy was done, it was positive (84.2%) and negative (15.6%) respectively for AFB/cytology, while it could not be done in 47 patients due to inaccessible sites. Category I, II and III was started on 15.4%, 7.5% and 77.1% patients respectively. Overall, treatment completion rate was 94.9% and the default rate was 2.2% with a failure rate of 2.5%. Death rate was 0.3%.

CONCLUSION

The study confirms the efficacy of DOTS strategy for pediatric TB lymphadenitis.

[Diagnosis of abdominal tuberculosis in general and specialized healthcare facilities]

The aim of this work was to study clinical manifestations of abdominal tuberculosis (AT) and its diagnosis. It included 142 patients examined in Ulyanovsk region in 1990-2006. 88.7% of them first applied to general practitioners who diagnosed AT in 69.7% of the cases (half of them postmortem). AT was found in one third (30.3%) of the patients attending tuberculosis dispensaries (86.1% during urgent laparatomy). AT manifests itself as clinical conditions requiring therapeutic, surgical, anti-infectious, and anti-tumour treatment. The most informative diagnostic tool is histological study of tissue biopsies obtained during endoscopic and videolaparoscopic procedures. Medical histories also provide materials for early diagnosis and treatment of AT by evidence-based methods; they include data on refractory gastrointestinal ulcers and infiltrates, calcinates located in mesenteric lymph nodes, liver and spleen by X-ray, hypersensitivity to tuberculin.

Ten-year experience of children with tuberculosis in southern Taiwan

BACKGROUND AND PURPOSE

Data on the clinical characteristics of pediatric tuberculosis (TB) are limited. This retrospective study was performed to evaluate the demographic characteristics and clinical features of pediatric TB.

METHODS

The medical records of children with TB at Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, between 1992 and 2002 were analyzed for demographic and clinical characteristics, and treatment regimens.

RESULTS

103 children aged 0 to 14 years with probable or confirmed TB were enrolled. Ninety patients (87.4%) had pulmonary tuberculosis (PTB) and 13 (12.6%) had extrapulmonary tuberculosis (EPTB). The mean +/- standard deviation age of children with PTB and with EPTB was 6.0 +/- 4.2 years and 4.5 +/- 5.4 years, respectively. Household contact was the route of infection for 44.4% of patients with PTB and 7.7% of patients with EPTB. TB in children aged 0 to 4 years most commonly involved the lung (53.3%) or the extrapulmonary region (69.2%). Common symptoms of PTB were cough (81.1%) and fever (33.3%). The most frequent sites of pediatric EPTB were bone (n = 4) and cervical lymph nodes (n = 4). Tuberculin skin test (TST; >or=10 mm) was positive in 69.6% of children with PTB (55/79) and 37.5% of children with EPTB (3/8). Children with PTB had a lower positive acidfast bacilli rate (40.0%) and Mycobacterium tuberculosis culture (27.8%). Eighty percent of patients infected through household contact had a positive TST.

CONCLUSIONS

Prolonged cough, household TB contact, and positive TST were characteristic factors for children with PTB in southern Taiwan. Young age was associated with high morbidity.

Mesenteric lymphangioma in adult: a case series with a review of the literature

Mesenteric lymphangioma is a rare benign tumor with nonspecific clinical features. A case series of three adult patients who had mesenteric lymphangioma is reported along with a review of literature. Two patients presented with painless abdominal swelling who were being managed as a case of abdominal tuberculosis and a third one had features of intestinal obstruction. In our cases, preoperative diagnosis of mesenteric lymphangioma was not suspected and all the patients had laparotomy. Peroperative findings revealed mesenteric masses, which were simulating cavitatory form of mesenteric node tuberculosis. It is stressed that mimicking of mesenteric lymphangioma with a cavitatory form of tuberculosis of mesenteric nodes in areas of high prevalence may lead to its misdiagnosis. Histopathology confirmed diagnosis of mesenteric lymphangioma in each case. Although rare and difficult to diagnose preoperatively, surgical resection is to be considered gold standard treatment for mesenteric lymphangioma.

Fine needle aspiration biopsy: an undervalued diagnostic modality in paediatric mycobacterial disease

Mycobacterial disease, and particularly tuberculosis (TB), is an escalating problem in developing countries, fuelled by the parallel human immunodeficiency virus (HIV) pandemic. In TB endemic countries children carry a very high burden of disease, which may be unrecognised due to the difficulty in making a diagnosis based on clinical, radiological or laboratory methods. One of the main hurdles is the difficulty of obtaining adequate specimens for bacteriological confirmation of disease in children. TB lymphadenitis is the most common extra-pulmonary manifestation of TB, and up to 22% of children with persistent cervical lymphadenopathy and no local cause may have tuberculous adenitis. Fine needle aspiration biopsy (FNAB), a simple and safe out-patient procedure that can be performed by nurses in resource-limited settings, and that provides material for direct microscopy as well as culture and susceptibility testing, provides an excellent opportunity to obtain bacteriological confirmation. However, it remains a greatly underutilised specimen collection modality. This review provides a comprehensive overview of the difficulties faced in the diagnosis of paediatric TB in resource-limited settings, and suggests ways to utilise FNAB as a practical modality for the rapid and effective diagnosis of mycobacterial disease in the significant subset of patients who present with peripheral lymphadenopathy. It also provides detail on how best to perform the technique, and suggests ways of making it more widely available in resource-limited settings, which carry the brunt of the paediatric TB disease burden.

Fine-needle aspiration biopsy: a first-line diagnostic procedure in paediatric tuberculosis suspects with peripheral lymphadenopathy?

OBJECTIVE

To evaluate the diagnostic yield and time to diagnosis of fine-needle aspiration biopsy (FNAB) vs. routine respiratory specimens collected from children with a palpable peripheral lymph node mass and symptoms suspicious of tuberculosis (TB).

DESIGN

We performed a retrospective review of laboratory records at Tygerberg Hospital over a 4-year period from January 2003 to December 2006. All children (aged <13 years) in whom an FNAB and other mycobacterial specimens were collected as part of their diagnostic workup were included.

RESULTS

In 95 children, the following specimens were collected: FNAB (n = 95), gastric aspirates (n = 142), other respiratory specimens (n = 36), non-respiratory specimens (n = 26). Mycobacterial disease was diagnosed in 70 (73.7%) patients. Children without respiratory specimens (n = 6) and/or with Mycobacterium bovis bacille Calmette-Guérin disease (n = 15) were excluded from comparative analysis. In the remainder, FNAB was positive in 45/74 (60.8%) vs. any respiratory specimen in 29/74 (39.2%, P < 0.001). The mean time to bacteriological diagnosis with FNAB was 7.1 days (95%CI 4.2-10.1) compared to 22.5 days (95%CI 15.8-29.1) for any respiratory specimen.

CONCLUSION

FNAB is a simple, rapid and effective modality for achieving confirmation of mycobacterial disease in paediatric TB suspects with a palpable peripheral lymph node mass.

[Diagnosis and treatment of 11 patients with acquired immune deficiency syndrome complicated with tuberculosis of mesenteric lymph nodes.]

OBJECTIVE

To study the clinical features of acquired immune deficiency syndrome (AIDS) complicated with tuberculosis of mesenteric lymph nodes.

METHODS

Cases (n = 153) with AIDS complicated with tuberculosis hospitalized in this hospital from September 1999 to December 2008 were retrospectively analyzed. Mesenteric lymph node tuberculosis was found in 11 cases, including 7 males and 4 females. One patient was 8 years old, and the other 10 were over 22 years (ranging from 8 to 55 years).

RESULTS

In patients with AIDS complicated with tuberculosis, 7% (11/158) had tuberculosis of the mesenteric lymph nodes. The CD(4)(+) cell count was less than 50 x 10(6) cells/L in 8 cases, and (50 - 100) x 10(6) cells/L in 3 cases. The symptoms included fever (11/11), abdominal pain (11/11), abdominal distension (11/11), night sweat (7/11), weight loss (10/11), diarrhea (7/11), anemia (5/11), abdominal mass (3/11), and ascites (1/11). Abdominal ultrasound showed multiple enlarged mesenteric lymph nodes in all of the 11 cases, and abdominal CT scanning presented typical enhanced ring shadows. Biopsy of mesenteric lymph nodes was obtained from 2 cases, and both revealed tuberculoma, caseous necrosis. Longerhan cell infiltration, and positive stain for fast anti-acid bacilli. Enlarged mesenteric lymph nodes became smaller and disappeared after treatment with antituberculous drugs for 6 months and highly active antiretroviral therapy (HAART) for 5 months in all the 11 patients.

CONCLUSIONS

There were no specific clinical manifestations in AIDS patients with tuberculosis of mesenteric lymph nodes. However, AIDS patients with CD(4)(+) cell count less than 50 x 10(6) cells/L might be more prone to developing tuberculosis of the mesenteric lymph nodes. Abdominal CT scanning with typical strengthened ring shadow is suggestive of the diagnosis. Anti-tuberculous therapy combined with HAART is recommended for the treatment of patients with suspected tuberculosis.

Tubercular cervical adenitis: clinicopathologic analysis of 180 cases

OBJECTIVE

To analyze the clinical presentations, laboratory investigation results, and histopathologic evaluation of tubercular cervical adenitis (TCA) in our population.

DESIGN

Prospective study.

SETTING

Tertiary health care centre.

PATIENTS AND METHODS

We studied 180 patients with TCA who were managed in the Department of Otolaryngology between December 2004 and June 2007.

RESULTS

There were 76 male patients (42%) and 104 females (58%), with ages ranging from 5 to 58 years. All patients presented with single or multiple neck swellings. Constitutional symptoms such as fever were present in 52 patients (29%), whereas cough, weight loss, and reduced appetite were seen in 40 patients (22%). Forty-seven patients (26%) had bilateral lymph node involvement. Only 23 patients (13%) had chest radiographs suggestive of pulmonary tuberculosis. Fine-needle aspirates from 168 patients (93%) showed granulomas with caseating necrosis. However, acid-fast bacilli were seen in only 45 (25%) aspirate smears. Twelve patents (7%) required a lymph node biopsy to confirm the diagnosis.

CONCLUSION

TCA usually presents with multiple lymph node involvement without the constitutional signs and symptoms of tuberculosis. The diagnosis is based on a high index of clinical suspicion coupled with laboratory and pathologic investigations.

[A case of tuberculosis with multiple lung nodules, abdominal lymphadenopathy, and splenomegaly]

Abdominal tuberculous lymphadenitis is very rare. We report a case of pulmonary tuberculosis showing marked abdominal lymphadenopathy and splenomegaly. A 95-year-old man was admitted to our hospital because of abnormal chest X-ray and body weight loss in last 6 months. He had low grade fever with no abdominal pain. He did not have past history of tuberculosis. Laboratory examination showed mild renal dysfunction and mild glucose intolerance. Soluble interleukin 2 recepter was highly elevated (3800 U/ml). Tumor markers, such as carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA), and progastrin-releasing peptide (Pro GRP) were all within normal limit. Chest X-ray showed multiple nodules in bilateral lung fields. Chest computed tomography showed multiple nodules in bilateral lungs, especially in upper part of lungs, right hilar lymphadenopathy and upper mediastinal lymphadenopathy. Abdominal and pelvic enhanced computed tomography showed marked abdominal lymphadenopathy and splenomegaly (67 x 49 mm). Abdominal lymph nodes were hepatoduodenal (50 x 50 mm), splenic hilar (40 x 25 mm), upper paraaortic (30 x 60 mm), and small superior mesenteric (10 x 10 mm) lymph nodes. FDG-PET showed accumulation in the nodules of right lung field, right hilar lymph nodes, upper mediastinal lymph nodes, and abdominal lymph nodes. Bronchial lavage fluid (BAL) smear for acid-fast bacilli was positive, polymerase chain reaction for Mycobacterium tuberculosis was positive and acid-fast bacilli was cultured. Transbronchial lung biopsy specimen demonstrated non-specific intraalveolar organization and alveolitis. The patient was diagnosed as pulmonary tuberculosis, but about abdominal lymphadenopathy and splenomegaly we had to differentiate malignant lymphoma, and for definite diagnosis, laparotomy was necessary. But considering his age and general condition, we followed up carefully with anti-tuberculosis therapy. Pulmonary tuberculosis, abdominal lymphadenopathy and splenomegaly all showed marked improvement 4 months after starting anti-tuberculosis therapy with isoniazid, rifampicin, and ethambutol, so we clinically diagnosed abdominal tuberculous lymphadenitis and splenic tuberculosis.

Abdominal tuberculosis in southeastern Taiwan: 20 years of experience

BACKGROUND/PURPOSE

Abdominal tuberculosis (TB) is a rare manifestation of extrapulmonary TB. This disease entity can be overlooked, and its early diagnosis is difficult because of its variable manifestations and lack of specific symptoms.

METHODS

The clinical and diagnostic features, treatment, and outcome of patients with abdominal TB at a major hospital in southeastern Taiwan from January 1987 to December 2006 were investigated.

RESULTS

Twenty-one patients with abdominal TB identified during the 20-year period were included. A predominance of male (13/21, 61.9%) and Taiwanese aborigine (15/21, 71.4%) patients was noted. Middle-aged (30-50 years) patients with alcoholic liver cirrhosis had the highest risk. Common presenting features included abdominal pain (18/21, 85.7%), fever (16/21, 76.2%), ascites (13/21, 61.9%), and weight loss (12/21, 57.3%). The mean time to reach a diagnosis was 48 +/- 10 days. Tuberculous peritonitis was noted in 11 patients, with a high correlation with liver cirrhosis (p = 0.0237, Fisher's exact test). The other patients were diagnosed with TB of the gastrointestinal tract (n = 6), urinary tract (n = 2), and pelvis (n = 2). Abdominal sonography and abdominal computed tomography were helpful for diagnosis, by revealing ascites and thickening of the peritoneum. Pulmonary involvement was noted in 11 patients. Most of the patients (16/21, 76.2%) improved with anti-tuberculosis therapy, and five patients died from sepsis and respiratory failure.

CONCLUSION

Abdominal TB is a rare manifestation of extrapulmonary TB, even in southeastern Taiwan where TB is prevalent. Delay in diagnosis is common and abdominal TB should be included in the differential diagnosis of middle-aged aborigine men with alcoholic liver cirrhosis and peritonitis.

Tuberculous lymphadenitis

Lymphadenitis is the most common extrapulmonary manifestation of tuberculosis. It remains both diagnostic and therapeutic challenge because it mimics other pathologic processes and yields inconsistent physical and laboratory findings. Diagnosis is difficult often requiring biopsy. A thorough history and physical examination, staining for acid-fast bacilli, fine-needle aspiration and PCR are helpful in obtaining an early diagnosis. It is also important to differentiate tuberculous from nontuberculous mycobacterial cervical lymphadenitis because their treatment protocols vary. Treatment monitoring is more complex due to peculiar behavior of TB lymph nodes. Situation has become worse due to sharp increase in the incidence of atypical mycobacteria, poorly controlled HIV epidemic and rise of drug-resistant TB lymphadenitis. Tuberculous adenitis is best treated as a systemic disease with antituberculosis medication. Surgical therapy along with antituberculosis medication can be beneficial in selected patients.

Tuberculosis Presenting as Epitrochlear Lymphadenitis

Epitrochlear lymphadenitis is an uncommon presentation of extrapulmonary tuberculosis in an immunocompetent host. This case report describes the third case in the literature and provides a review of the literature.

Diagnosis of tubercular lymphadenopathy by fine needle aspiration cytology, acid-fast staining and mantoux test

INTRODUCTION

This study was undertaken to evaluate the role of Ziehl-Neelsen stain (for acid-fas bacilli), and Mantoux test in diagnosing tubercular lymphadenopathy on FNAC.

METHODS

FNAC was performed on patient with superficial lymphadenopathy. Ziehl-Neelsen stain for acid fast bacilli was done in all cases where cheesy or purulent material was aspirated and smear showed granulomatous lymphadenitis. A Mantoux test was also done in these patients. A Mantoux test was further done in patients of reactive lymphadenopathy where the lymph node size was more than 1 cm. If the result was positive, a repeat FNAC was performed. When the repeat FNAC showed ill-defined granulomas, excision biopsy was done.

RESULTS

Tubercular lymphadenopathy was seen in 122 (48.2%) cases. Acid- fast bacilli were found in 71 (58.1%) cases. Mantoux test was positive in 112 (91.8%) cases. A repeat FNAC was done in seven of 11 patients where the cytologic features of tuberculosis were not seen but the lymph node size was more than 1 cm and Mantoux test was positive. The repeat FNAC showed ill-defined granulomas without necrosis. Excision biopsy done in these patients diagnosed them as tubercular lymphadenitis in five of the seven cases, the remaining two cases being diagnosed as reactive lymphadenitis.

CONCLUSIONS

FNAC coupled with Ziehl - Neelsen staining for AFB and Mantoux test improves the diagnostic efficiency for tubercular lymphadenopathy.

Comparing three-dimensional volume-rendered CT images with fibreoptic tracheobronchoscopy in the evaluation of airway compression caused by tuberculous lymphadenopathy in children

BACKGROUND

Lymphobronchial tuberculosis (TB) causes airway compression in 38% of patients. The airway obstruction is conventionally assessed with fibreoptic tracheobronchoscopy (FTB). Multidetector-row spiral computed tomography (MDCT) with three-dimensional volume rendering (3-D VR) has significantly improved the imaging of the airways. No previous studies have assessed the accuracy of 3-D VR in determining the degree of airway compression in children due to TB lymphadenopathy.

OBJECTIVE

To compare 3-D VR CT to FTB for the assessment of airway compression due to TB lymphadenopathy in children.

MATERIALS AND METHODS

Included in the study were 26 children presenting with symptoms of airway compression caused by pulmonary TB. MDCT of the chest and FTB were performed in all patients. Retrospective 3-D VR reconstruction of the major airways was performed from the original CT raw data and used to evaluate the tracheobronchial tree for site and degree of airway compression and then compared to the FTB findings. FTB was used as the reference standard

RESULTS

By FTB 87 sites of airway compression were identified. Using the 3-D VR technique, 138 sites of airway compression were identified, of which 78 (90%) matched with the sites identified by FTB. The sensitivity and specificity of 3-D VR when compared with that of FTB was 92% and 85%, respectively. In four patients (15%), severe narrowing of the bronchus intermedius made FTB evaluation of the right middle and right lower lobe bronchi impossible. VR demonstrated significant distal obstruction in three of these four patients

CONCLUSION

3-D VR demonstrates a very good correlation with FTB in determining airway compression caused by TB lymphadenopathy in children. In combination with FTB, 3-D VR adds confidence to the bronchoscopy findings and complements FTB by adding additional information on the status of the airway distal to severe obstructions unreachable by FTB.

A novel mutation of the IL12RB1 gene in a child with nocardiosis, recurrent salmonellosis and neurofibromatosis type I: first case report from Thailand

Genetic defects of interleukin (IL)-12/23-and interferon (IFN)-gamma-mediated immunity can cause increased susceptibility to intracellular microbes. Among these defects, a mutation of the gene encoding the IL-12 receptor beta1 (IL-12Rbeta1) is the most common worldwide. A 12-year old Thai boy with pre-existing neurofibromatosis type 1 (NF1) was evaluated for primary immunodeficiency after a history of tuberculous lymphadenitis, recurrent Salmonella infections and nocardiosis. Flow cytometry of phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMCs) revealed a defect in the IL-12Rbeta1 surface expression. A genetic study showed a novel nonsense homozygous mutation of the IL12RB1 gene in exon 4 (402C > A), confirming the diagnosis of IL-12Rbeta1 deficiency. This is the first case report of a primary IL-12Rbeta1 deficiency in Thailand with the interesting finding of a coexisting NF1.

[Diagnosis of mycobacterial lymphadenitis by fine needle aspiration cytology and fluorescence quantization-polymerase chain reaction]

OBJECTIVE

To evaluate the application of fine needle aspiration cytology and fluorescence quantization-polymerase chain reaction (FQ-PCR) in the diagnosis of mycobacterial lymphadenitis.

METHODS

Samples obtained by fine needle aspiration cytology (FNAC), which showed granulomatous lesions, from patients with lymph node tuberculosis also confirmed by response to antituberculosis therapy, was subjected to FQ-PCR to test M. tuberculosis DNA (TB-DNA), and the acid-fast bacillus stain. The positivity of TB-DNA and the acid-fast bacillus stain results were analyzed in different types of cases classified by cytology. Wilcoxon test was used to compare different cytology results, the positive rates of acid fast stain and the copy numbers of TB-DNA.

RESULTS

Among the 72 cases, 46 were TB-DNA positive (46/72, 64%). By cytology examination, 7 cases were classified as type I, while 34 as type II and 31 as type III, in which the TB-DNA positive rates were 0% (0/7), 21/34 (61%) and 25/31 (81%) respectively. Sixty-four cases were subjected to the acid-fast bacillus stain and 14 were positive 14/ 64(22%). These 14 cases were all TB-DNA positive. The copy number of TB-DNA was significantly different between type II and type III cases (z = -2. 514,P < 0.05), and between acid fast stain positive and negative cases (z = -4.778, P < 0.05).

CONCLUSIONS

FQ-PCR is a useful method for the diagnosis of mycobacterial lymphadenitis and could be used with FNAC, with a higher sensitivity than acid-fast bacillus stain.

[Immunological changes in old-age group children with primary and secondary tuberculous infection]

In modern society, there is a rise in the incidence of tuberculosis in all age groups, including children and adolescents. In old age group, a specific inflammation is detectable from Mantoux test results only in every four children. Tuberculous infection is diagnosed in half of cases when they turn to physicians for complains. Disseminated and complicated forms of tuberculosis are more frequently identified in these situations. The immune system has a particular emphasis on the course and outcome of the disease. The authors have established that caseous masses actively form, followed by the stimulation of the adequate cell pathway promoting the limitation of specific inflammation in old-age group children with primary tuberculosis. In secondary forms of tuberculous infection, there is an increase in the level of monocytes where the persistence and multiplication of the causative microorganism, as well as the activation of the humoral pathway inadequate for tuberculous infection are likely to occur, i.e. the infectious agent may be inhibited until activation of the Th-2 pathway of an immune response takes place.