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Praba V and Sharmila G: Tuberculosis is still the leading cause of cervical lymphadenopathy-results of a fnac analysis in a tertiary care hospital


Introduction

Cervical lymphadenopathy is a common clinical presentation. Enlarged cervical lymphnodes could be due to variety of causes ranging from simple infectious process to malignant neoplastic conditions. Enlarged salivary glands, thyromegaly are also mimickers for enlarged cervical lymphnodes, hence posing diagnostic challenges clinically.3, 2, 1In those cases, FNAC can be used as first line diagnostic test in adults lymphnodes ranging in size from 2cm onwards(significant lymphadenopathy) persistent or progressively enlarging are of immediate clinical concern especially when associated with other clinical symptoms such as fever, chronic cough, weight loss, anorexia etc.

FNAC of lymphnode has high sensitivity and specificity in distinction between benign and malignant lesions. Advantages of lymphnode aspirate is of low cost, rapid turnaround time, could be done as outpatient procedure itself, less morbidity and easily provides cells for other special studies and molecular diagnostic tests.5, 4Care in preparation of smear is necessary because lymphocytes are fragile and easily crushed if too much pressure is applied.7, 6FNAC is accepted as a minimally invasive method for evaluating lymphadenopathy. It has added advantage of preserving lymphnode architecture when excision biopsy is needed.10, 9, 8

Aims and Objective

Purpose of this study is to utilize the usefulness of FNAC in diagnosis of both pediatric and adult cervical lymphadenopathy and to determine the spectrum of disease distribution among various age group patients in a tertiary care hospital.

Materials and Methods

This is a retrospective study carried out at IRT Perundurai medical college,pathology department for a period of two years from January 2018 to December 2019. 318 patients with enlarged significant neck lymphnodes of more than 6-week duration were registered with clinical history and aspirated.12, 11, 10FNAC was carried down by cytopathologist with 10ml syringe and 23 gauge needle, both isopropyl alcohol fixed and air dried are made for each case. Aspirated material was used for cytology analysis using Haematoxylin and eosin staining, MGG staining. Special stains such as modified ziehlneelson staining for AFB was also done. All slides are carefully screened with primary attention to overall low power pattern. All those slides with hypocellularity were excluded.15, 14, 13Datas were statistically analyzed.

Results

Table 1
S. No Age wise category Number of Patients
1 < 15 years 50
2 16 – 30 114
3 31 – 45 58
4 46 – 60 44
5 >60 years 52

Age Distribution of Cases

Out of 318 cases aspirated,50(15.7%) cases belongs to pediatric age group(<15yrs) and 268(84.3%)cases belongs to adult age group

Table 2
S. No Diagnosis distribution Number of Patients
1 Caseating Granulomatous Lymphadenitis 102
2 Granulomatous Lymphadenitis Without Necrosis 78
3 Reactive Lymphoid Hyperplasia 72
4 Metastatic Carcinomatous Deposit 52
5 Lymphoma 4
6 Non-Specific Lymphadenitis 10

Spectrum of disease distribution

Out of total 318 cases, 102(32%) cases were diagnosed as caseating granulomatous lymphadenitis, 78(24.5%) cases diagnosed as granulomatous lymphadenitis without necrosis, 52(16.3%) cases as metastatic carcinomatous deposit where squamous cell carcinomatous deposit is the leading cause,72(22.6%) as reactive lymphoid hyperplasia, 4(1.25%) cases as lymphoproliferative disorder, 10(3.14%) cases as nonspecific lymphadenitis. In cases with granulomatous lymphadenitis without necrosis diagnosis of tuberculosis was established by AFB positivity. 38(48.7%) out of 78 patients does not show AFB positivity, diagnosis in these cases was based on rapid response to empirical ATT started after FNAC report along with clinical correlation such as imaging studies, positive clinical history and positive mantoux test.

Table 3
Male patients Female patients
130 188

Sex wise disease distribution

In our study, 130(40.88%) cases are found to be male patients and 188(59.12%) female patients. Out of the male patients 30 cases (23.07%) and 116(61.7%) cases of female patientswere diagnosed as tuberculous lymphadenitis

Table 4
Tuberculosis Lymphadenitis Reactive Hyperplasia
30 100

Male patients analysis

Table 5
Tuberculosis Lymphadenitis Reactive Hyperplasia
116 72

Female patients analysis

Table 6
Tuberculosis Lymphadenitis 166
Reactive Lymphoid Hyperplasia 36
Metastatic Carcinomatous Deposit 52
Others 14

Adultpatients analysis

Table 7
Tuberculosis Lymphadenitis 14
Reactive Lymphoid Hyperplasia 36

Pediatricpatients analysis

Figure 1

Granulomatous Lymphadenitis, MGG Stain, 40X (High Power)

https://s3-us-west-2.amazonaws.com/typeset-media-server/4636a124-d10c-43eb-9a6b-27906ae5daa7image1.png

Figure 2

Reactive Lymphadenitis, H&E Stain, 40X (High Power)

https://s3-us-west-2.amazonaws.com/typeset-media-server/4636a124-d10c-43eb-9a6b-27906ae5daa7image2.png

Figure 3

Metastatic carcinomatous deposit in Lymphnode, H&E Stain, 10X (Low Power)

https://s3-us-west-2.amazonaws.com/typeset-media-server/4636a124-d10c-43eb-9a6b-27906ae5daa7image3.png

Figure 4

Smear showing AFB Positivity, 40X (High Power)

https://s3-us-west-2.amazonaws.com/typeset-media-server/4636a124-d10c-43eb-9a6b-27906ae5daa7image4.png

Discussion

Out of 318 cases of FNAC performed in patients with enlarged cervical nodes,50(15.7%) cases belongs to pediatric age group (<15yrs) and 268(84.3%)cases belongs to adult age group. The youngest patient involved in our study is one year four months old and most elderly patient in our study is 83 years old.18, 17, 16

Out of total 318 cases,102(32%) cases were diagnosed as caseating granulomatous lymphadenitis, 78(24.5%) cases diagnosed as granulomatous lymphadenitis without necrosis, 52(16.3%) cases as metastatic carcinomatous deposit where squamous cell carcinomatous deposit is the leading cause,72(22.6%) as reactive lymphoid hyperplasia, 4(1.25%) cases as lymphoproliferative disorder, 10(3.14%) cases as nonspecific lymphadenitis. Majority of our studied cases were found to be tuberculous lymphadenitis, which correlates well with study conducted by Shahid et al. 2010 which shows 69% incidence of tuberculous lymphadenitis.21, 20, 19

Gupta et al., 2003 in their study shows 59% as granulomatous lymphadenitis. Much higher incidence must be attributed to two factor such as1.this study was carried out in a tertiary care referral hospital2. Our institute is attached to Perundurai TB sanatorium, one of the largest regional referral centers for defaultersrelapse and multidrug resistant cases.

In our study,130(40.88%) cases are found to be male patients and 188(59.12%) female patients. Out of the male patients 30 cases(23.07%) and 116(61.7%) cases of female patients were diagnosed as tuberculous lymphadenitis. This correlates well with study done by Saira et al., 2011 which shows tuberculous lymphadenitis were more common in female patients(75%) as compared to male patients(25%).

The most frequent cause in adults was found to be tuberculous lymphadenitis (166 cases) followed by metastatic carcinomatous deposits (52 cases), whereas in pediatric patients the most common cause was found to be reactive lymphoid hyperplasia(36 cases) followed by tuberculous lymphadenitis (14 cases). Agarwal et al., 2010 in their study showed reactive lymphoid hyperplasia (70.9%) as predominant cause of pediatric lymphadenopathy.23, 22

In our study incidence of malignant lymphoma is 1.25%. Ahamed et al., also reported 4.5% cases as malignant lymphoma in their study. They consider the lower incidence of lymphoma is due to the fact that their study included mainly children.

Tuberculosis is a serious chronic pulmonary and systemic disease caused most often by M -Tuberculosis. Enlarged cervical lymphnodes is one of the most common extrapulmonary manifestation in tuberculosis. Every year millions of new cases are reported worldwide and India ranks first in the incidence of new cases in tuberculosis. In 2018,an estimated 10 million people fell ill with TB worldwide, India has the highest burden with estimated incidence of 2.2 million cases. Ending TB epidemic by 2030 is among the health target. Hence early diagnosis and prompt treatment is essential for control of mortality rate among tuberculosis patients, thus FNAC seems to have central role in both screening, evaluation and follow-up of patients with enlarged cervical lymphnodes. Hafez NH et al concluded the same in their study.

Conclusion

In our study was conducted in a tertiary care hospital, the most common cause of cervical lymphadenopathy in adults was found to be tuberculous lymphadenitis followed by reactive lymphoid hyperplasia whereas in case of pediatric cases the most common cause of cervical lymphadenopathy is reactive lymphoid hyperplasia closely followed by tuberculous lymphadenitis. As per WHO –Sustainable development goals-to end TB epidemic in 2030-this study alarms the increasing burden on health sector in fighting against mycobacterium. FNAC is particularly efficacious in our country where mycobacterial infection is endemic, thereby reducing the time for other surgical procedures and delay in starting treatment. Hence early intervention is mandatory.

Source of funding

None.

Conflict of interest

None.

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