Diagnosis Of Lymph Node Tuberculosis Research Articles

The Performance of GeneXpert in the Diagnosis of Lymph Node Tuberculosis: A Prospective Study Comparing GeneXpert and Culture Findings.

Background and objective Lymph node tuberculosis (LNTB) is a common manifestation of extrapulmonary tuberculosis (EPTB). GeneXpert is a rapid diagnostic molecular test that simultaneously detects tuberculosis and rifampicin (RIF) resistance. In this study, we aimed to assess the epidemiology of LNTB and diagnostic performance parameters of the GeneXpert in routineENT practice. Methods We conducted a cross-sectional prospective study from January to July 2019,in the Department of Otorhinolaryngology and Head Neck Surgery at the Hassan II University Hospital Center of Fez, Morocco. The samples were collected using lymph node biopsy and subjected to GeneXpert assay, culture, and histopathology. Diagnostic performance parameters of the GeneXpert were calculated and compared with culture. Results All patients with cervical adenopathy were included. Lymph node biopsies were performed for all patients. The performance of the GeneXpert was assessed according to culture findings. Among the 75 cases, the mean age was 21.6 ± 12.7 years with a female predominance (60%). GeneXpert was positive in 66.7% of specimens. The sensitivity and specificity of the GeneXpert assay were 78.6% and 40.4% respectively. GeneXpert accuracy was 54.6%. The positive predictive value (PPV) and negative predictive value (NPV) were found to be 44% (95% CI: 30.2-57.8) and 76% (95% CI: 59.3-92.7) respectively. Mycobacterium bovis was isolated in all samples, with no case of resistance to RIF found. Conclusions The performance of GeneXpert was found to be superior in terms of establishing the diagnosis of LNTB. It offers speedy and prompt results and clinicians should adopt it in routine clinical practice.

A comparative study of ultrasound-guided puncture biopsy combined with histopathology and Xpert MTB/RIF in the diagnosis of lymph node tuberculosis.

Cervical tuberculous lymphadenitis (CTBL) is a disease often ignored in clinical work, and pathology and Xpert MTB/RIF (Xpert) are the commonly used methods for tuberculosis diagnosis. This study aimed to compare ultrasound-guided puncture biopsy combined with histopathology and Xpert in the diagnosis of lymph node tuberculosis. A total of 217 patients highly suspected for CTBL were retrospectively enrolled. All patients underwent ultrasound-guided puncture sampling. All samples were subjected to pathological examination and Xpert test. The sensitivity and specificity of the two methods were compared for all samples. The kappa value was calculated to assess the consistency of the pathological examination and Xpert test using comprehensive diagnosis as the gold standard. Receiver operating characteristic curves of the pathological examination, Xpert test, and their combination were generated, and the areas under the curve (AUCs) were calculated to compare the diagnostic value of the three methods. The sensitivity and specificity of the pathological diagnosis of CTBL were 70.1 and 100%, respectively. The sensitivity and specificity of Xpert for CTBL diagnosis were 82.5 and 97.5%, respectively. The results of the pathological examination and Xpert test showed poor consistency in the diagnosis of CTBL, with a kappa value of 0.388. The AUC of the pathological diagnosis of CTBL was 0.850 (95% CI: 0.796-0.895), whereas that of Xpert was 0.900 (95% CI: 0.852-0.936), and the difference was statistically significant (P = 0.0483). The AUC of pathological examination combined with Xpert for the diagnosis of CTBL was 0.956 (95% CI: 0.920-0.979), and the difference between pathological examination combined with Xpert for the diagnosis of CTBL was statistically significant compared with pathological examination and Xpert alone, respectively (both P < 0.001). The diagnostic efficiency of Xpert test is higher than that of pathological examination, but its sensitivity is still not ideal for clinical diagnosis. According to this study, the consistency of Xpert test and pathological diagnosis is poor, and the combination of Xpert test and pathological diagnosis can significantly increase the diagnostic efficiency.

Is nucleic acid amplification test sufficient enough for reducing the diagnostic dilemma of cervical lymph node tuberculosis? A descriptive study in a tertiary care hospital

Background: Pulmonary tuberculosis (TB) is common clinical presentation in India, but, nowadays, extrapulmonary TB (EPTB) is also a clinical problem. At present, no single test is available for diagnosing EPTB which is rapid, cost-effective, and confirmatory. Many studies were done to diagnose and treat the pulmonary TB, though more efforts are needed for diagnosis of EPTB. Aims and Objectives: The aim of this study is to find out any test or a series of tests that reduce the diagnostic dilemma of cervical lymph node TB. Materials and Methods: A total of 170 patients with cervical lymphadenopathy were enrolled in the pathology department between July 1, 2021, and December 31, 2021. It was a descriptive study and of cross-sectional design. The Institutional Ethics Committee approval was received (No. BSMC/IEC/101 dt. January 15, 2021). Suspected malignancy cases were excluded from the study. Fine-needle aspiration (FNA) was done for all these patients and stained with Leishman-Geimsa, Papaniculaou, and Zeihl-Neelsen (ZN) stain. After FNA, all samples were sent for cartridge based nucleic acid amplification test. Results: After FNA cytology, ZN stain was done and only 9.2% of acid–fast bacilli (AFB) positive cases were found. Granuloma was found in 27.6% of cases. After nucleic acid amplification test (NAAT) study, it was found that 36.8% patients were positive. Total number of lymph node considered to be positive for TB (NAAT positive and/or ZN stain positive and/or presence of granuloma) is 85 (52.1%). As per conventional method for diagnosis of lymph node TB (presence of granuloma and/or AFB positive in ZN stain), number of cases were 50 (30.7%). NAAT test was significantly more positive in respect of ZN staining but not significantly positive in respect of presence of granuloma. Conclusion: For diagnosis of cervical lymph node TB, all three methods (NAAT, ZN stain, and Leishman-Giemsa stain) should be used simultaneously.

Application of Mycobacterium tuberculosis RNA for the Rapid Diagnosis of Lymph Node Tuberculosis Using Different Specimens.

To evaluate the accuracy of Mycobacterium tuberculosis (MTB)-RNA in the rapid diagnosis of lymph node tuberculosis (LNTB). Moreover, the difference in the diagnostic accuracy of MTB-RNA using different specimens was determined. We included patients with suspected LNTB who met the inclusion criteria and retrospectively analyzed their clinical data. The sensitivity, specificity, positive-predictive value (PPV), negative-predictive value (NPV), and area under the curve (AUC) of MTB-RNA and culture were calculated and its diagnostic accuracy for LNTB was evaluated in comparison with the final clinical diagnosis. Overall, 285 patients were included in the study. The overall sensitivity, specificity, PPV, NPV, and AUC of MTB-RNA were 40.6%, 100.0%, 100.0%, 17.0%, and 0.70, respectively. These values were 30.8%, 100.0%, 100.0%, 16.0%, and 0.65, respectively, for tissue specimens; 34.2%, 100.0%, 100.0%, 24.6%, and 0.67, respectively, for puncture specimens; and 57.14%, 100.0%, 100.0%, 5.3%, and 0.79, respectively, for pus specimens. These values of culture were 24.4%, 100.0%, 100.0%, 13.9%, and 0.62, respectively, for all specimens; 17.6%, 100.0%, 100.0%, 13.8%, and 0.59, respectively, for tissue specimens; 25.3%, 100.0%, 100.0%, 22.4%, and 0.63, respectively, for puncture specimens; and 31.0%, 100.0%, 100.0%, 3.3%, and 0.65, respectively, for pus specimens. The diagnostic efficacy of MTB-RNA for the rapid diagnosis of LNTB was moderate, but its sensitivity was low. The lymph node pus specimens were the most sensitive for MTB-RNA testing, followed by puncture specimens; tissues were the least sensitive. Pus specimens should be preferably obtained in case only this test is to be used for diagnosis.

Combination method for the diagnosis of Tuberculous lymphadenitis in high burden settings

BackgroundIndia reports the highest number of extrapulmonary tuberculosis (EPTB) cases globally, most of which are lymph node TB (LNTB). In high tuberculosis (TB) burden countries rapid diagnosis is very important. Fine needle aspirate cytology (FNAC) diagnosis can be made with features of caseous necrosis with/without epithelioid granulomas. However, bacteriological confirmation is essential. This study was performed to evaluate the performance of the diagnostic tests available namely FNAC, GeneXpert (GX) and Ziehl Neelsen stain (ZN) stain at resource restricted settings, for LNTB.MethodsFNAC samples from affected lymph nodes were collected from 100 consenting patients with clinically suspected LNTB. FNA material was analyzed by cytomorphology, ZN and GX. If no Mycobacterium tuberculosis (MTB) was detected, repeat aspirate was cultured on Lowenstein Jensen medium. Descriptive statistical analysis was performed.ResultsOut of 100 cases, 73% showed cytological features consistent with TB. The most common cytomorphological pattern was epithelioid cell granulomas with caseous necrosis (59%). Caseous necrosis only pattern was seen in 14%. MTB was detected in 34% by ZN and 60% by GX. Overall, the combination of FNAC, ZN, GX detected 85% of LNTB.ConclusionsA combination of FNAC, ZN and GX is a practical tool that can improve and quicken the diagnosis of LNTB in resource restricted high-burden settings.

The Role of Core Needle Biopsy Pathology Combined with Molecular Tests in the Diagnosis of Lymph Node Tuberculosis

BackgroundEarly lymph node tuberculosis (LNTB) diagnosis is still difficult. The majority of LN specimens require the undertaking of invasive and unpleasant procedures.PurposeTo evaluate the diagnostic efficacy of pathology when combined with molecular tests for the diagnosis of LNTB in core needle biopsy (CNB) specimens and to compare that diagnostic efficacy with that deriving from tissue specimens’ examination alone.MethodsWe retrospectively analyzed the medical records of LNTB patients who met the inclusion criteria. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of pathology, molecular tests, and parallel test (positive result for either of these two assays) were calculated to evaluate their diagnostic efficacy compared with a composite reference standard.ResultsA total of 289 patients were included in the study. The overall sensitivity, specificity, PPV, NPV, and AUC of pathology, molecular tests, and parallel test were 94.5%, 97.2%, 99.6%, 71.4%, 0.96; 73.1%, 100.0%, 100.0%, 34.6%, 0.87; and 98.4%, 97.2%, 99.6%, 89.7%, 0.98, respectively. For CNB specimens, these values for pathology, molecular tests, and parallel test were 93.3%, 96.2%, 99.4%, 69.4%, 0.95; 76.4%, 100.0%, 100.0%, 40.0%, 0.88; and 99.4%, 96.2%, 99.4%,96.2%,0.98, while those same values for the tissue were 96.6%, 100.0%, 100.0%, 76.9%, 0.98; 67.1%, 100.0%, 100.0%, 25.6%, 0.84; and 96.6%, 100.0%, 100.0%, 76.9%,0.98, respectively.ConclusionThe validity of pathology and molecular testing when using CNB specimens was similar to that of tissue specimens for relevant assessment approaches. For the LNTB diagnosis, CNB specimens were preferred for the simultaneous undertaking of pathological examination and molecular testing.

Utility of CBNAAT, Cytology and Histology in diagnosis of suspected tubercular solid lymph node

Cytology, Ziehl Neelsen staining and Mantoux test are conventionally used to test and treat lymph node tuberculosis. Cartridge Based Nucleic Acid Amplification Test (CBNAAT) is being now recommended for diagnosis of all extrapulmonary tuberculosis including tubercular lymphadenitis.To asses efficacy of various diagnostic tools for diagnosis of lymph node tuberculosis in solid state (non-caseating stage).It was a prospective study conducted by including all consecutive patients with lymph node swelling suggestive of tuberculosis. Fine needle aspirate was subjected for cytology and CBNAAT. If both turned negative, excision biopsy was performed and subjected for histology. Results were tabulated.Sixty patients were included after excluding certain patients with caseous aspiration. Thirty-one (51.67%) had mycobacterium detected in CBNAAT. Remaining patients after histology had following diagnosis; Tuberculosis in eight, nonspecific reactive hyperplasia in 11, metastasis and lymphoma in four and Non Tubercular Mycobacteria and actinomycosis in one each patient. CBNAAT is an effective tool for diagnosing lymph node tuberculosis even in early stages of pathology. Relying solely on cytology to diagnose tuberculosis should be discouraged.

Left-sided portal hypertension caused by peripancreatic lymph node tuberculosis misdiagnosed as pancreatic cancer: a case report and literature review

BackgroundLeft-sided portal hypertension (LSPH) is an extremely rare clinical syndrome, and it is the only form of curable portal hypertension. It is primarily caused by pancreatic disease, and is associated with complications that cause spleen vein compression. Specific symptoms are often lacking, rendering it difficult to diagnose. Splenectomy is the main treatment for cases complicated by variceal bleeding, and the effects of treatment primarily depend on the condition of the primary disease.Case presentationThe patient was a 29-year-old woman who was admitted to the hospital for repeated hematemesis and black stool. She had been misdiagnosed with pancreatic cancer 7 years prior. Combined imaging and endoscopic examination indicated varicose gastric fundus veins, a pancreatic mass, and enlarged peripancreatic lymph nodes. Laboratory investigations revealed reduced erythrocyte, platelet, and leukocyte counts, the interferon gamma release assay was positive, and liver function was normal. Abdominal exploration, splenectomy, varicose vein dissection, and lesion resection were performed via laparotomy. Postoperative biopsy analysis confirmed the diagnosis of lymph node tuberculosis. Based on the above-described factors, LSPH caused by peripancreatic lymph node tuberculosis was a diagnosed.ConclusionsHerein we describe the first reported case of LSPH caused by peripancreatic lymph node tuberculosis. When left portal hypertension occurs simultaneously, peripancreatic lymph node tuberculosis is often misdiagnosed as pancreatic cancer. Further studies are necessary to develop a more favorable diagnostic method for pancreas masses and more advantageous therapy for LSPH, especially in cases caused by mechanical compression.

The use of Gene-Xpert MTB RIF in the diagnosis of extrapulmonary tuberculosis in childhood and adolescence.

INTRODUCTION: Gene-Xpert MTB RIF (Xpert) is based on nucleic acid amplification by real-time polymerase chain reaction, which allows for the identification of Mycobacterium tuberculosis and rifampin resistance. We describe the use of Xpert for extrapulmonary tuberculosis (EPTB) in children and adolescents. METHODS: A case series of two reference centers in Rio de Janeiro from 2014-2019. RESULTS: The final diagnosis of EPTB was established in 11/36 (31%) patients, with five cases detectable by Xpert. For lymph node evaluation (9/11), diagnosis by Xpert occurred in 5/9 patients, all with caseous aspects. CONCLUSIONS: Xpert can facilitate the rapid diagnosis of lymph node tuberculosis.

Evaluation of the Yield of Histopathology in the Diagnosis of Lymph Node Tuberculosis in Morocco, 2017: Cross-Sectional Study.

BackgroundThe frequency of occurrence of extrapulmonary tuberculosis (EPTB) has been increasing globally over the last two decades. In Morocco, EPTB cases account for 46% of the patients reported with a new episode of tuberculosis (TB). Lymph node TB (LNTB) is the most common form of EPTB. In line with the guidelines of the National TB Program, the diagnosis is mainly based on clinical evidence, including histopathology.ObjectiveThis study aimed to evaluate the yield of histopathology testing in the diagnosis of LNTB.MethodsThis cross-sectional, prospective study was conducted among patients with cervical lymph node who were enrolled in the study from November 2016 to May 2017 in three regions of Morocco. We compared the outcomes of histopathological testing with those of bacteriology. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of histopathology testing were calculated. Culture and Xpert tests were used as the gold standard Laboratoty Testing.ResultsA total of 262 patients were enrolled in this study. The Se, Sp, PPV, and NPV of histopathology testing were 95.6% (129/135), 64.6% (82/127), 74.1% (129/174), and 93.2% (82/88), respectively, in the presence of granuloma with or without caseous necrosis and were 84.4% (114/135), 74.8% (95/127), 78.1% (114/146), and 81.9% (95/116), respectively, in the presence of granuloma with caseous necrosis. The granuloma with caseous necrosis was associated with increased PPV and Sp of histopathology testing (P<.05).ConclusionsThe presence of the granuloma with caseous necrosis in the histopathological examination had significantly improved the yield of histopathology testing for the diagnosis of LNTB. The findings recommend to maintain histopathology testing in establishing the LNTB diagnosis and to explore other techniques to improve it.

Unexpected Association of HIV, Hepatitis C Virus Infection, Lymph Node Tuberculosis, and Sickle Cell Disease: A Case Report in a 35-Year-Old Woman from Cameroon

Introduction: HIV infection is a public health issue. Developing countries are facing the challenge of patient populations that remain undiagnosed and under-served in combined antiretroviral treatment (cART) leading to opportunistic infections. Lymph node tuberculosis is one of the most common. His firm diagnosis is not always easy in resources limited country. Case Presentation: We report a case of a 35-year-old woman known HIV for the past 10 years but not on treatment. She presented with a four-month history of fatigue, weight loss and pain in the right flank. The diagnosis of lymph node tuberculosis, hepatitis c virus infection and sickle cell disease was done. After 6 months of treatment, there was a favourable clinical evolution. Conclusion: This case report highlights the necessity to screen for opportunistic and non-opportunistic co-infection in HIV infected patient.

Lymph node tuberculosis – The ENT surgeon approach in four cases

Abstract BACKGROUND. Lymph node tuberculosis is a pathology with an increasing incidence and prevalence in middle income countries. MATERIAL AND METHODS. We present a series of 4 cases with cervical lymph node tuberculosis. We review current principles of diagnosis and treatment from the perspective of the ENT surgeon in a tertiary university clinic. RESULTS. In each case we underline diagnosis difficulties and treatment options. These cases presented management difficulties due to associated morbidities. All cases underwent surgical excision of the afflicted lymph nodes with subsequent microscopic confirmation of tuberculosis. We illustrate key concepts leading to the microscopy diagnosis of lymph node tuberculosis. CONCLUSION. There are various surgical incidents and accidents that the young surgeon must be aware of when approaching neck tuberculous lymph nodes. Further referral of the patient for long-term tuberculosis treatment is mandatory. All patients were supervised for a minimum of 1 year after the initial diagnosis and treatment with no sign of recurrence. A close cooperation between the ENT surgeon, the infectious disease specialist and the pathologist is the key to an optimum approach to lymph node tuberculosis at the head and neck level.

Comparative Studies of Xpert MTB/RIF and Pathologic and Bacteriologic Methods in the Diagnosis of Lymph Node Tuberculosis

Comparative Studies of Xpert MTB/RIF and Pathologic and Bacteriologic Methods in the Diagnosis of Lymph Node Tuberculosis

Diagnostic performance of interferon-γ release assay for lymph node tuberculosis

The aim of the study was to evaluate the performance of interferon-γ (IFN-γ) release assay (IGRA) (T-SPOT.TB) for patients with suspected lymph node tuberculosis (TB). Of the 405 patients with suspected lymph node TB, enrolled from Beijing Chest Hospital between July 2011 and April 2015, 83 (20.5%) were microbiologically/histopathologically confirmed lymph node TB, and 282 (69.6%) did not have active TB. The remaining 21 inconclusive TB and 19 clinical TB were excluded from the final analysis (9.9%). T-SPOT.TB using peripheral blood mononuclear cells was performed to examine the IFN-γ response to the Mycobacterium tuberculosis–specific antigens early secretory antigenic target 6 and culture filtrate protein 10. The overall sensitivity and specificity for T-SPOT.TB were 90.4% and 70.5%, respectively. Spot-forming cells in the lymph node TB group (184 [48–596/106 peripheral blood mononuclear cells {PBMCs}]) were significantly higher than that in the nonactive TB group (0 [0–41]/106 PBMCs) (P<0.001). These results suggest that the IGRA assay could be a useful aid in the diagnosis of lymph node TB.

Diagnosis of lymph node tuberculosis using the GeneXpert MTB/RIF in Tunisia

IntroductionGeneXpert MTB/RIF is a fully-automated diagnostic molecular test which simultaneously detects tuberculosis (TB) and rifampicin (RIF) drug resistance. The purpose of this study is to evaluate the performance of the GeneXpert MTB/RIF test for the detection of Mycobacterium tuberculosis complex (MTBC) in lymph node specimens and to show the place of Mycobacterium bovis as a major cause of TB lymphadenitis. Material and methodsThis study was conducted simultaneously in the National Reference Laboratory for Mycobacteria of Ariana and the Central Laboratory of Sfax, from January to December 2013. In total, 174 lymph node specimens were processed simultaneously for Ziehl–Neelsen, auramine and immuno-histochemical staining. Conventional culture on both Lowenstein–Jensen and liquid medium (Bactec MGIT 960 BD system) and the new molecular-based GeneXpert MTB/RIF assay system were performed. Positive cultures were confirmed using molecular identification (Genotype MTBC Hain Lifescience). ResultsAmong the 174 samples tested, the GeneXpert detected the DNA of MTBC in 134 samples (77%). Standard bacteriological assays, including AFB microscopy and culture, were positive, respectively, in 41 (23.6%) and 79 (45.4%) specimens. M. bovis was isolated in 76% of positive cultures. GeneXpert sensitivity and specificity results were assessed according to smear and culture results, clinical and histological findings. The sensitivity and specificity of the Xpert assay were 87.5% (126/144) and 73.3%, respectively. ConclusionThe implementation of the GeneXpert MTB/RIF assay may dramatically improve the rapid diagnosis of lymph node TB.

Delayed diagnosis of lymph node tuberculosis: time-honored importance of a thorough clinical examination, Cameroon

History taking and physical examination is the cornerstone of medical diagnosis as will lead to correct diagnosis 90% of the time. We report a case of a 30-year-old black African man with lymph node tuberculosis diagnosed one year and six months later after onset of symptoms and signs. Clinicians especially those in resource-limited settings should go in for thorough history taking and complete physical examination which is the basis for correct clinical diagnosis, will provide valuable guide in deciding which tests to order and thus laboratory tests done for confirmatory purposes and also, has a cost-effective benefit for the patient.

Mediastinal and peripheral lymphadenopathy

A 32-year-old man, with no history of cigarette smoking, had four weeks history of non productive cough, chest pain and myalgias. Physical examination revealed a painless bilateral cervical lymphadenopathy, the respiratory examination was normal. Chest radiography showed an enlarged upper and middle mediastinum (A). Computed tomography (CT) of the thorax showed a large and non homogeneous mass in the anterior and middle mediastinum and a small pericardial effusion, with displacement of vascular structures (B). Laboratory analysis revealed an elevated lactate dehydrogenase level of 690 IU per liter. The exicional biopsy of the left cervical lymph node revealed a caseating and necrotizing granulomatous lesions and confirmed a diagnosis of lymph node tuberculosis. The biopsy of the right cervical lymph node established a B-cell non-Hodgkin lymphoma, and so a rare association with tuberculosis. The patient received anti-tuberculosis therapy. The regimen was based on two months of ethambutol, rifampicin, pyrazinamide and isoniazid, followed by four months of rifampicin and isoniazid. He received also chemotherapy with cyclophosphamide, adriamycin, vincristine and prednisolone. The patient presented, two months later with clinical and radiographic improvement.

Diagnosis of lymph node tuberculosis using the GeneXpert MTB/RIF in Tunisia

IntroductionGeneXpert MTB/RIF is a fully-automated diagnostic molecular test which simultaneously detects tuberculosis (TB) and Rifampicin (RIF) drug resistance.The purpose of this study is to evaluate the accuracy of the GeneXpert MTB/RIF test for the detection of Mycobacterium tuberculosis complex (MTBC) in lymph node specimens. Materials and methodsThis study was conducted simultaneously in Abderrahmen Mami hospital, the National Reference Laboratory for Mycobacteria in Tunisia and Hedi Chaker Bacteriological Laboratory of Sfax, from January to December 2013. In total, 160 lymph node specimens (tissues and aspirates) were split and processed simultaneously for auramine fluorescent staining and immunohistochemical staining. In addition, conventional culture on both Lowenstein–Jensen and liquid medium (Bactec MGIT 960 BD system) and the new molecular-based GeneXpert MTB/RIF assay system were performed. Positive cultures were confirmed after the detection of the MPT64 antigen (SD BiolineTBAg MPT64 Rapid) and molecular identification (Genotype MTBC Hain Lifescience). ResultsAmong the 160 samples tested, the GeneXpert detected the DNA of MTC in 120 samples (75%). Standard bacteriological assays including AFB microscopy and culture were positive, respectively, in 37 (23.13%) and 74 (46.25%) specimens. Mycobacterium bovis was isolated in 67.4% of positive cultures. No Rifampicin resistance was detected.GeneXpert sensitivity and specificity results were assessed according to smear and culture results, clinical and histological findings.The sensitivity and specificity of the Xpert assay was 91.5% (118/129) and 70.4% (19/27), respectively.When compared with bacteriological findings, the concordance between the GeneXpert and bacteriological results was 69.4%. ConclusionThe implementation of the GeneXpert MTB/RIF assay may dramatically improve the rapid diagnosis of lymph node TB. This rapid TB test may complete usual methods (conventional microscopy, culture and histopathology).

Latero-cervical lymph node tuberculosis and brachial herpes zoster in a patient diagnosed with HIV infection

Tuberculosis and Herpes Zoster are known as common opportunistic infections in patients diagnosed with HIV infection. This is the presentation of a clinical case with right latero-cervical lymph node tuberculosis associated with brachial Herpes Zoster and oral candidiasis in a patient recently diagnosed with HIV infection, stage C3. The authors present the case of a 23 years old student, admitted in the Clinic of Infectious Diseases Timisoara for a latero-cervical lymphadenopathy in the right side, that appeared simultaneously with a progressively asthenic syndrome associated with weight loss in the past three months, night sweats and loss of appetite. We mention that she also presented a maculo-papular and vesicular rash in the upper limb, accompanied by burning pain. In order to establish the diagnosis, multiple biological samples were collected (blood cell identification, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lingual swabs, throat swabs, blood culture, ELISA test for HIV Ab, Western blot test, CD4 lymphocyte, viral load, etc.) and paraclinical investigations (lymph node biopsy, histological examination and cultures for Koch bacilli; cultures for Koch bacilli in the secretions from the bronchial lavage; chest radiography). From the biological samples we highlight: WBC=3,240/µL, ESR=125 mm/1h, CRP=32.83 mg/L, fibrinogen=3.77 mg%, HIV Ag-Ab=positive, HIV test positive, CD4=13 cells/µL, viral load=320,169 copies/mL; there were no radiological changes in the lungs. The histopathological exam of the lymph node biopsy pleaded for lymph node tuberculosis. The cultures for Koch bacilli in the secretions from the bronchial lavage were positive. The culture for Koch bacilli in the lymph node biopsy was also positive. The lingual swab, using Sabouraud medium culture revealed Candida albicans. Putting together the clinical data and the biological samples and the test results, we have established the diagnosis of lymph node tuberculosis, brachial herpes zoster, oral candidiasis, HIV infection stage C3. Under treatment with antituberculous and antiretroviral drugs the evolution of the patient was favorable. The early diagnosis of the opportunistic infections allows the detection of the patients with HIV infection and the establishment of a specific and efficient therapy.

Papulonecrotic tuberculid on the scalp

A 39-year-old woman was referred with a 1-year history of a 4-cm mass of the left axilla, compatible with a lymph node. Itchy red papules that evolved to crusty lesions and subsequently showed varioliform atrophic scarring appeared over the face, extensor surface of the arms, back, thighs, and scalp (1, 2). Her history included weight loss of 8 kg, but no other associated symptoms or contact with tuberculosis patients. The blood count showed a normochromic–normocytic anemia with an erythrocyte sedimentation rate (ESR) slightly elevated at 28 mm in the first hour (normal, < 20 mm). Tuberculin skin test was positive (13 mm with necrotic reaction) and anti-human immunodeficiency virus serology was negative. Four lesional skin biopsies and one lymph node biopsy were performed and sent for histopathology and culture. The skin biopsy showed small-vessel lumen occlusion by tiny thrombi, endothelial hyperplasia, and intense perivascular inflammatory reaction throughout the dermis, together with partial degeneration of collagen, compatible with tuberculid. Lymph node biopsy showed chronic, necrotizing, granulomatous lymphadenitis, consistent with a diagnosis of lymph node tuberculosis. Mycobacteria were absent on Ziehl–Neelsen staining and culture in all specimens. Figure 1Open in figure viewerPowerPoint Varioliform atrophic scarring over the extensor surface of the arms, typical of papulonecrotic tuberculid (PNT) Figure 2Open in figure viewerPowerPoint Varioliform atrophic scarring over the back, typical of papulonecrotic tuberculid (PNT) On the basis of the clinical features, positive tuberculin skin test, and histopathologic findings, a diagnosis of papulonecrotic tuberculid associated with tuberculous lymphadenitis was made. A triple therapeutic regimen with rifampicin, isoniazid, and pyrazinamide was started and the patient evolved with progressive clinical improvement. At the end of treatment at 6 months, there was clinical remission and improvement of anemia and ESR. Four months later, however, there was a clinical relapse of the lesions on the scalp, ultimately resulting in cicatricial alopecia with varioliform atrophic scarring (3, 4). A biopsy of these new lesions was performed and showed focal necrosis (V-shaped) in the epidermis and dermis with follicular involvement and thrombotic occlusion of vessels, confirming the diagnosis of tuberculid. The patient was retreated with rifampicin, isoniazid, pyrazinamide, and ethambutol for 9 months. A new investigation of another internal focus of tuberculosis was negative. Figure 3Open in figure viewerPowerPoint Cicatricial alopecia with varioliform atrophic scarring appearing after 6 months of treatment for tuberculosis Figure 4Open in figure viewerPowerPoint Cicatricial alopecia with varioliform atrophic scarring appearing after 6 months of treatment for tuberculosis In the last 2 years, the patient has had several recurring crops of lesions on the scalp. Further biopsies were taken, with histopathology showing nonspecific inflammatory changes. Cultures for Mycobacterium spp. were negative (five media: Lowenstein–Jensen, Lowenstein–Jensen supplemented with ferric ammonium citrate or pyruvate, Stonebrink and 7H9 supplemented with hemin) under different temperatures and light conditions. In addition, nucleic acid amplification for mycobacterial hsp65 using polymerase chain reaction restriction enzyme analysis methodology (Telenti A, Marchesi F, Balz M, et al. Rapid identification of mycobacteria to the species level by polymerase chain reaction and restriction enzyme analysis. J Clin Microbiol 1993; 31: 175–178; da Silva RA, Werneck Barreto AM, Dias Campos CE, et al. Novel allelic variants of mycobacteria isolated in Brazil as determined by PCR-restriction enzyme analysis of hsp65. J Clin Microbiol 2002; 40: 4191–4196) was negative. The patient is still being followed up in our clinic.