Background: The diagnosis of tubercular lymphadenitis (TBLN) is challenging. This study assesses the role of diagnostic intervention with real-time PCR in clinically suspected tubercular lymphadenopathy in relation to cytology and microbiological methods. Methods: The cross-sectional study involved 214 patients, and PCR, cytology, and Ziehl-Neelsen (ZN) staining was performed on aspirates. The findings were compared with culture on Lowenstein-Jensen medium. The overall concordance of cytology and PCR, both individually and combined, was calculated. χ2 and Phi values were assessed between cytology, PCR, and culture. Results: A cytological diagnosis of tuberculosis (TB), reactive lymphoid hyperplasia, and suppurative lymphadenitis was made in 71, 112, and 6 patients, respectively. PCR and culture were positive in 40% of the cases. Among the TBLN patients, PCR showed higher positivity in necrosis and culture showed higher positivity in necrotizing granuloma. Positive ZN staining was observed in 29.6% of the TBLN cases, with an overall positivity of 11%. PCR could additionally detect 82 cases missed by ZN staining. The overall concordance rate for either diagnostic modality, i.e., PCR or cytology, was highest (75%), and for PCR alone was 74%. Phi values were observed to be 0.47 between PCR and culture. Conclusion: Real-time PCR for Mycobacterium tuberculosis complex on aspirates offers a definitive and comparable diagnosis of TBLN. Including this approach as the primary investigation in the work-up of TBLN could reduce the burden of TB.

Keywords:
Tubercular lymphadenopathy, Real-time PCR, Non-molecular methods, Lymph node aspirates, Clinical cytology
1.
World Health Organization: Global tuberculosis report, 2016. Geneva, WHO, 2016. http://www.who.int/mediacentre/factsheets/fs104/en/ (accessed August 15, 2016).
2.
Ravilone M: Global Tuberculosis Report 2015. Report No. 20. Geneva, WHO, 2016, p 204.
3.
Sharma SK, Mohan A: Extra pulmonary tuberculosis. Indian J Med Res 2004;120:4316-4353.
4.
Gupta PR: Difficulties in managing lymph node tuberculosis. Lung India 2004;21:50-53.
5.
Mittal P, Handa U, Mohan H, Gupta V: Comparative evaluation of fine needle aspiration cytology, culture and PCR in diagnosis of tuberculous lymphadenitis. Diagn Cytopathol 2011;39:822-826.
6.
Gupta V, Bhake A: Clinical and cytological features in diagnosis of peripheral tubercular lymphadenitis - a hospital based study from central India. Indian J Tuberc 2017, Epub ahead of print.
7.
Waard JH, Robledo J: Conventional diagnostic methods, Chapter 12; in Palomino JC, Leao SC, Ritacco V (eds): Tuberculosis 2007: from basic science to patient care, ed 1. Antwerp, Kamps and Broucillier, 2007, chapt 12, pp 401-424.
8.
Gopinath K, Singh S: Multiplex PCR assay for simultaneous detection and differentiation of Mycobacterium tuberculosis, Mycobacterium avium complexes and other mycobacterial species directly from clinical specimens. J Applied Microbiol 2009;107:425-435.
9.
Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare: TB India 2007, revised national tuberculosis control programme, annual status report. New Delhi, Government of India, 2007, vol 13, pp 10-14.
10.
Central Tuberculosis Division Directorate General of Health Services: TB India, 2015. New Delhi, Government of India, 2015. http://tbcindia.nic.in/WriteReadData/l892s/8838543515TB%20India%202007.pdf (accessed August 15, 2016).
11.
Gupta V, Bhake A: Molecular diagnosis of tubercular lymphadenopathy from fine needle aspirates in pediatric patients. Acta Cytol 2017, Epub ahead of print.
12.
Bales CE: Laboratory techniques; in Koss LG, Melamed MR (eds): Koss Diagnostic Cytology and Its Histological Bases, ed 5. New York. Lippincott, Williams & Wilkins, 2006, pp 1570-1634.
13.
Churukian CJ: Pigments and minerals; in Bancroft JD, Gamble M (eds): Theory and Practice of Histological Techniques, ed 6. Philadelphia, Churchill Livingstone, 2008, p 247.
14.
Chien HP, Yu MC, Wu MH, Lin TP, Luh KT: Comparison of the BACTEC 960 with Löwenstein-Jensen medium for recovery of mycobacteria from clinical specimens. Int J Tuberc Lung Dis 2000;4:866-870.
15.
Green MR, Sambrook J: Isolation and quantification of DNA; in Green MR, Sambrook J (eds): Molecular Cloning: A Laboratory Manual, ed 4. New York. Cold Spring Harbor Laboratory Press, 2012, pp 64-65.
16.
Van Soolingen D, Hermans PW, de Haas PE, Soll DR, van Embden JD: Occurrence and stability of insertion sequences in Mycobacterium tuberculosis complex strains: evaluation of an insertion sequence-dependent DNA polymorphism as a tool in the epidemiology of tuberculosis. J Clin Microbiol 1991;29:2578-2586.
17.
Alonso H, Samper S, Martín C, Otal I: Mapping IS6110 in high copy number Mycobacterium tuberculosis strains shows specific insertion points in the Beijing genotype. BMC Genomics 2013;14:422.
18.
Herrera EC, Sperhacke RD, Becker D, Kritski A, Zaha A, Rossetti MLR: Internal control in PCR for Mycobacterium tuberculosis: usefulness and improvement of the diagnosis. Braz Arch Biol Technol 2008;51:685-691.
19.
Pahwa R, Hedau S, Jain S, Jain N, Arora VM, Kumar N, et al: Assessment of possible tuberculous lymphadenopathy by PCR compared to non-molecular methods. J Med Microbiol 2005;54:873-878.
20.
Kartikranjan M: A clincopathological study of cervical lymphadenopathy. Int J Mod Res Rev 2014;2:354-357.
21.
Ramanathan VD, Jawahar MS, Paramasivan CN, Rajaram K, Chandrasekar K, Kumar V, et al: A histological spectrum of host responses in tuberculous lymphadenitis. Indian J Med Res 1999;109:212-220.
22.
Purohit MR, Mustafa T, Morkve O, Sviland L: Gender difference in clinical diagnosis of tuberculous lymphadenitis - a hospital based study from central India. Int J Infect Dis 2009;13:600-605.
23.
Aljafari AS, Khalil EAG, Elsiddig KE, Hag AE, Ibrahim ME, Elsaif MEMO, et al: Diagnosis of tuberculous lymphadenitis by FNAC, microbiological methods and PCR: a comparative study. Cytopathology 2004;15:44-48.
24.
Lashiram RS, Devi RKB, Konjengbam R, Devi RKT, Sharma LDC: Aspiration cytology for the diagnosis of tuberculous lymphadenopathies: a five-year study. JIACM 2010;11:31-35.
25.
Tiwari RP, Hattikudar NS, Bharmal RN, Kartikeyan S, Deshmukh NM, Bisen PS: Modern approaches to a rapid diagnosis of tuberculosis: promises and challenges ahead. Tuberculosis 2007;87:193-201.
26.
Raoot A, Geeta D: Detection of mycobacterial DNA directly from FNAC samples of tuberculous lymphadenopathy using real time PCR: a preliminary study. Indian J Tuberc 2013;124-127.
27.
Derese Y, Hailu E, Assefa T, Bekele Y, Mihret A, Aseffa A, et al: Comparison of PCR with standard culture of fine needle aspiration samples in the diagnosis of tubercular lymphadenitis. J Infect Dev Ctries 2012;6:53-57.
28.
Pravez M, Mohiuddin M, Hassan MZ, Ahamad F, Haz JA: Diagnosis of tubercular lymphadenitis by PCR of fine needle aspirates. Ibrahim Med Coll J 2012;6:46-49.
29.
Ishaq S, Mir RM, Musgtaq S, Kaur H, Rasool S: Real time polymerase chain reaction (Q-PCR): Its comparison with conventional techniques for the diagnosis of tubercular lymphadenopathy. Eur J Biomed Pharm Sci 2015;2:336-340.
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2017
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