From Microcytosis to Macrodiagnosis.

A 12-year-old Hispanic girl presented with fatigue, lightheadedness, and intermittent headaches. She was depressed and appeared pale to her mother. Her examination was unremarkable except for palpebral conjunctival pallor and was otherwise noncontributory. She had a profound hypoproliferative microcytic anemia with low iron level, low transferrin saturation, and a normal ferritin level. The patient experienced improvement in clinical symptoms following transfusion of packed red blood cells and oral iron therapy. At follow-up 2 months later, she presented with similar symptoms and persistent microcytic anemia with low iron levels. Her ferritin level was increased along with markedly elevated C-reactive protein and erythrocyte sedimentation rate. An oral iron challenge demonstrated lack of absorption, and hepcidin level was also significantly elevated. Thorough gastrointestinal and rheumatologic evaluations were performed to search for a source of inflammation. Key components of the patient's social history supplemented by serology, radiographic, and pathologic findings ultimately cinched an unexpected diagnosis.

Role of contrast-enhanced ultrasound guidance in core-needle biopsy for diagnosis of cervical tuberculous lymphadenitis.

OBJECTIVE: To investigate the diagnostic value of core-needle biopsy (CNB) guided by contrast-enhanced ultrasound (CEUS) in cervical tuberculous lymphadenitis (CTL). METHODS: 178 patients with pathological confirmation of CTL were retrospectively enrolled. All of them had undergone CNB prior to the final surgery. According to the different ways of puncture guidance, they were divided into two groups: conventional ultrasound (US) group (n = 81) and CEUS group (n = 97). The comparison of diagnostic efficacy between two groups was compared and analyzed. RESULTS: Among the 178 patients, 146 were directly diagnosed as CTL by CNB, including 59 patients in CEUS group and 87 patients in US group. The diagnostic accuracy were 89.7% (87/97) and 72.8% (59/81), respectively (P < 0.01). For subgroup analyses, differences among diagnostic efficacy ascribed to the different guiding methods were significant in medium size group (>2.0 cm and ≤3.0 cm) and large size group (>3.0 cm), 91.7% for CEUS group vs. 69.0% for US group (P < 0.05) and 84.4% for CEUS group vs. 57.7% for US group (P < 0.05), respectively. CONCLUSIONS: In the diagnosis of CTL, compared with the US-guided CNB, CEUS-guided CNB have certain advantages, especially for larger lymph nodes.

Percutaneous ultrasound-guided laser ablation for the treatment of cervical tuberculous lymphadenitis: a pilot study.

OBJECTIVE: This study was performed to assess the feasibility, effectiveness, and safety of percutaneous ultrasound (US)-guided laser ablation (LA) for the treatment of cervical tuberculous lymphadenitis (CTBL). METHODS: We retrospectively reviewed 11 patients with CTBL (mean age, 32.0 ± 8.6 years; range, 18-47 years) who underwent percutaneous US-guided LA from June 2014 to December 2016 with a subsequent 12-month follow-up. We assessed the mean volume reduction and contrast-enhanced US (CEUS) changes of the target lymph nodes as well as the tolerability and adverse effects of LA. RESULTS: The mean ablation energy was 522 ± 312 J (range, 204-1317 J). All 17 enrolled target lymph nodes were completely non-enhanced after LA treatment as detected by CEUS, indicating complete ablation of all lymph nodes (100%). The target lymph nodes significantly decreased in volume by a mean of 74.0% ± 15.6% from baseline to 12 months after LA. The LA procedure was well tolerated, and none of the 11 patients developed severe complications during the 12-month follow-up. CONCLUSION: Percutaneous US-guided LA for the treatment of CTBL exhibits good tolerability, minimal invasiveness, and few adverse effects. Further investigations with larger sample sizes and longer follow-up periods are warranted to confirm these findings.

High IL-6 and VEGF-A levels correlate with delayed wound healing in cervical lymph node tuberculosis patients.

SETTING: A high proportion of tuberculosis (TB) patients experience delayed wound healing after surgery, and the specific reasons for this phenomenon are not yet clear. OBJECTIVE: To analyse cytokine and growth factors at surgical sites to determine their contribution to delayed wound healing in patients with cervical lymph node TB (CLNT). DESIGN: We measured levels of interleukin (IL) 1ß, IL-6, IL-10, IL-22, epidermal growth factor, fibroblast growth factor-2, interferon-gamma, tumour necrosis factor alpha and vascular endothelial growth factor A (VEGF-A) in cervical wound drainage fluid from 36 CLNT patients who underwent lymphadenectomy and in 24 thyroidectomy patients. RESULTS: Wound drainage fluid from CLNT patients showed higher IL-6 (P = 0.007) and VEGF-A (P < 0.001) levels than control thyroidectomy patients (P < 0.05). CLNT patients with a delayed healing time (>5 days; n = 18) showed higher IL-6 (P = 0.002) and VEGF-A (P < 0.001) levels in wound drainage fluid than CLNT patients with normal healing times (5 days; n = 18). IL-6 (OR 11.280, 95%CI 1.413-90.028; P = 0.022) and VEGF-A (OR 13.510, 95%CI 2.168-84.182; P = 0.005) can independently and significantly predict wound healing time in CLNT patients. CONCLUSION: These findings demonstrate that high IL-6 and VEGF-A levels in the post-operative wound fluid of CLNT patients correlate with delayed wound healing.

Video-assisted thoracoscopic surgery for the treatment of mediastinal lymph node tuberculous abscesses.

The mediastinal lymph node tuberculous abscesses (MLNTAs) are secondary to mediastinal tuberculous lymphadenitis. Surgical excision is often required when cold abscesses form. This study was aimed to examine video-assisted thoracoscopic surgery (VATS) for the treatment of MLNTA. Clinical data of 16 MLNTA patients who were treated in our hospital between December 1, 2013 and December 1, 2015 were retrospectively analyzed. All of the patients underwent the radical debridement and drainage of abscesses, and intrathoracic lesions were removed by VATS. They were also administered the intensified anti-tuberculosis treatment (ATT), and engaged in normal physical activity and follow-up for 3 to 6 months. The results showed that VATS was successfully attempted in all of the 16 MLNTA patients and they all had good recovery. Two patients developed complications after surgery, with one patient developing recurrent laryngeal nerve injury, and the other reporting poor wound healing. It was concluded that VATS is easy to perform, and safe, and has high rates of success and relatively few side-effects when used to treat MLNTA.

Tuberculosis como causa de adenopatías cervicales / Tuberculosis as a cervical lymphadenopathy cause

La tuberculosis (TBC) es una enfermedad infecto-contagiosa de distribución mundial causada por Mycobacterium tuberculosis, y otras micobacterias atípicas. La afectación ganglionar es tardía y sus manifestaciones clínicas asociadas suelen ser inespecíficas, por eso, el diagnóstico de tuberculosis ganglionar a menudo se retrasa y es un hallazgo inesperado en numerosas ocasiones. Este artículo pretende realizar una revisión bibliográfica sobre la tuberculosis ganglionar y hacer hincapié en que la TBC ha de ser tenida en cuenta como diagnóstico diferencial en las masas cervicales, que muchas veces se presentan con escasa sintomatología acompañante. En este artículo presentamos dos casos de TBC ganglionar diagnosticados en nuestro servicio en los últimos meses, ambos casos se manifestaron exclusivamente como masa cervical de crecimiento lento, sin síntomas pulmonares acompañante y fueron diagnosticados de TBC tras el estudio anatomopatológico resultante de la exéresis quirúrgica de la lesión.

The tuberculosis (TB) is an infect-contagious worldwide distribution disease caused by Mycobacterium Tuberculosis and other atypical Mycobacteria. Lymph node involvement is late, and its associated clinical manifestations are usually unspecifics, therefore the diagnosis of tuberculosis lymph node is often delayed and is an unexpected finding in numerous occasions. This article aims to carry out a literature review of lymph node tuberculosis and to emphasize that TB must be taken into account as differential diagnosis in cervical masses, which often occur with few associated symptoms. In this article we present two cases of lymph node TB diagnosed in our department in last months, both cases presented exclusively as cervical mass of slow growth, without any accompanying pulmonary symptoms and were diagnosed as TB after the surgical removal of the lesion and its histopathological study.

What remains to surgeons in the management of abdominal tuberculosis? A 10 years experience in an endemic area.

BACKGROUND: Tuberculosis (TB) is a common endemic disease in Tunisia. Abdominal location is rare. Early diagnosis of abdominal TB remains difficult due to its non-specific clinical presentations. The aim of our study is to highlight the characteristics of the different presentations, to characterize tools contributing to a positive preoperative diagnosis, and finally to assess the role of surgery in the management of this entity. MATERIALS AND METHODS: A retrospective review from 2005 to 2015 identified 90 cases of confirmed abdominal TB managed in the Department of General Surgery of the Habib Thameur Hospital. The diagnosis was established by histopathology examination for all cases. This study was approved by the ethical committee. RESULTS: The mean age of the patient was 44.13 years with a sex ratio (M/F) of 0.34. We collected 56 cases of peritoneal TB, 12 cases of abdominal lymph node TB, 10 cases of intestinal TB, four cases of hepatic TB, and two cases of gallbladder's TB. For six patients, an association of many localizations was noted. The diagnosis was suspected on clinical, biological, and morphological arguments, but the confirmation was always made by surgical exploration and pathological examination of removed specimens. Surgical management was urgent in complicated cases (13.3%). Laparoscopy was performed in 71 cases (78.9%). Laparoscopic features of peritoneal TB were specific and always confirmed by histological examination. CONCLUSION: Despite the wide range of examination available for the preoperative exploration of abdominal TB, diagnosis is usually late and difficult. TB is a medical condition. However, surgical exploration is frequently needed in the management.

[Lymphadenectomy using dissection and protection of carotid sheath and main nerves in surgery for benign diseases in the neck].

Objective: To investigate the significance of lymphadenectomy using dissection and protection of carotid sheath and main nerves in treating complex benign disease of neck. Methods: A total of 54 cases with benign diseases in neck who received the protective surgical treatments were reviewed. There were 25 cases of recurrent branchial fistula, 15 cases of lymphoid tuberculosis, 5 cases of cystic hygroma, 5 cases of racemose angioma, and 4 cases of Madelung's disease. According to the location and extent of disease, all cases received operation with dissection and protection of carotid sheath and main nerves to removal lesions with lymphoid tissue and fat-connective tissue. Results: All cases recovered well, and no recurrence occurred with follow-up of 3 to 65 months. There was no other complication except for occurring of Horner syndrome in 1 patient. Conclusion: The protective surgical method has certain application value in the treatment of benign neck diseases that have no indefinite boundary and widely distribute.

Human Immunodeficiency Virus Lymphadenitis Patterns on Fine-Needle Aspiration Cytology.

OBJECTIVE: The aim of this work was to study the microscopic patterns of human immunodeficiency virus (HIV) lymphadenitis on fine-needle aspiration cytology (FNAC) and correlate them with cluster of differentiation 4 (CD4) counts. STUDY DESIGN: A retrospective study of known HIV-positive patients who underwent lymph node FNAC over a period of 5 years (2009-2013) was undertaken. The cytology slides were retrieved and reviewed. Out of 317 cases, 38 (11.7%) were diagnosed as HIV lymphadenitis. We analysed the cytomorphological patterns of HIV lymphadenitis and correlated them with the CD4 cell counts. RESULTS: Smears of HIV lymphadenitis were classified akin to histology patterns (A, B, and C) depending on cellularity, number of tingible body macrophages, mitosis, apoptotic bodies, plasma cells, Warthin-Finkeldey giant cells, and proliferating blood vessels. Thirty-one cases showed pattern A, 3 showed pattern B, and 4 were of pattern C. Pattern A had the highest CD4 cell count. CONCLUSION: Histologic patterns of HIV lymphadenitis are recognisable on FNAC smears. These can offer a clue to the diagnosis and guide further workup, even in the absence of history. The changes can mimic those of the infective lymphadenitis, Castleman disease, and lymphoma. Hence, the clinical history, serological correlation, and awareness of cytomorphology can aid the correct diagnosis.

Cytomorphological Analysis of Lymph Node Lesions in HIV-Positive Patients with CD4 Count Correlation: A Cross-Sectional Study.

OBJECTIVES: To study the cytomorphological spectrum of lymph node lesions in HIV-positive patients and correlate the cytological findings with the CD4 count. STUDY DESIGN: This was a cross-sectional study of 23 months' duration which included 110 HIV-positive cases proved according to the guidelines of the National AIDS Control Organisation. Fine-needle aspiration cytology (FNAC) was done on clinically palpable lymph nodes. Special stains and culture were done wherever necessary. CD4 count was done by flow cytometry and subsequently correlated with the cytological findings. RESULTS: Our study included 110 cases, ranging in age from 6 to 70 years, peaking in the 3rd to 4th decade (n = 46). The male-to-female ratio was 1.75:1 and the predominant site was the cervical group of lymph nodes (n = 71). Each lesion was correlated with CD4 count, laboratory and clinical findings, and was further segregated based on WHO and CDC staging. Cytological lesions were tubercular (53.6%), reactive (27.1%), suppurative (6.4%) lymphadenitis, lymphoma (4.5%), cystic lymphoid hyperplasia (2.8%), metastases (1.9%), cryptococcal lymphadenitis (0.9%). The mean CD4 count was 217.4, 434.4, 181.4, 149, 580, 225, and 207 cells/µL, respectively. There was a highly significant correlation of cytological findings with CD4 count (χ2 value = 44.57 and p < 0.001). CONCLUSION: FNAC is a primary, safe, and valuable tool for the identification of opportunistic infections, neoplastic and nonneoplastic lesions, as well as therapeutic modality in certain conditions. Correlation of lesions with CD4 count provides information about immune status, HIV stage and segregating cases, and also aids further evaluation and management.

Paradoxical reaction associated with cervical lymph node tuberculosis: predictive factors and therapeutic management.

OBJECTIVES: The aims of this study were to determine predictive factors of paradoxical reaction in patients with cervical lymph node tuberculosis (TB) and to discuss the therapeutic management of this condition. MATERIALS AND METHODS: A retrospective study was performed of 501 patients managed for cervical lymph node TB over a period of 12 years (from January 2000 to December 2011). Statistical data were analyzed using IBM SPSS Statistics version 20.0. RESULTS: Paradoxical reaction occurred in 67 patients (13.4%), with a median delay to onset after starting TB treatment of 7 months. Lymph node size ≥3cm and associated extra-lymph node TB were independently associated with paradoxical reaction. Treatment consisted of surgical excision (71.6%), restarting quadruple therapy (10.4%), reintroduction of ethambutol (23.8%), and addition of ciprofloxacin (20.8%); steroids were given in two cases . All patients recovered after an average treatment duration of 14.91±7.03 months. CONCLUSION: The occurrence of paradoxical reaction in cervical lymph node TB seems to be predicted by associated extra-lymph node TB and a swelling size ≥3cm. The treatment of paradoxical reaction remains unclear and more randomized trials are necessary to improve its management.

BCG-SSI(®) vaccine-associated lymphadenitis: Incidence and management.

BACKGROUND AND OBJECTIVE: There is a high incidence of childhood tuberculosis in Latvia, including children aged less than 1 year, while BCG-associated lymphadenitis is one of the most frequent adverse events requiring surgical treatment. The aim of this study was to analyze the incidence of purulent BCG adenitis through-out the population of Latvia after the introduction of BCG-SSI(®) vaccine and to evaluate the treatment results. MATERIAL AND METHODS: The study included 194 patients. All patients had received the BCG-SSI(®) vaccine during the first week of life routinely or at a later time according to the indications. The indications for surgical treatment were lymph node destruction also affecting the skin. All patients in this study received surgical treatment - the affected lymph node extirpation. RESULTS: The mean age of the patients was 5.12±0.96 months. A total of 172 patients had purulent axillar lymphadenitis, 14 had purulent supraclavicular lymphadenitis, 8 patients had lymphadenitis at both localizations. During the whole study period the incidence of BCG adenitis varied from 0.02% to 0.36%, while the mean rate was 0.11%±0.08% from 184,068 vaccinated children during the study period. We observed an increasing trend in the incidence of BCG lymphadenitis during the study period. The primary and complete healing rate at the end of period was 99.5% (n=193) following an affected lymph node extirpation. The mean hospitalization time after the operation was 3.71±0.18 days. CONCLUSIONS: The incidence of BCG-SSI(®) vaccine associated purulent lymphadenitis varied widely with an increasing trend, followed by the return to the product characteristic limits. Indications for the surgical treatment should not be changed. Extirpation of the purulent BCG adenitis is a safe treatment method and leads to the primary wound healing in the majority of cases.

A case of abdominal tuberculosis lymphadenitis extending into the gallbladder and duodenum in a human T-cell lymphotropic virus type 1 carrier.

A 69-year-old man with a history of pulmonary tuberculosis presented with fever. He tested positive for the QuantiFERON TB-2G and human T-cell lymphotropic virus type 1 antibodies. Imaging revealed a mass in the neck of the gallbladder, with periportal lymph node enlargement and penetration into the duodenum. A definite diagnosis could not be made, even with a subsequent detailed examination. Finally, cholecystectomy and a lymph node biopsy were performed. Histopathology revealed a caseating granuloma in the lymph nodes and in the serosa of the gallbladder, and polymerase chain reaction was positive for tuberculosis. Therefore, the patient was diagnosed with abdominal tuberculosis lymphadenitis extending into the gallbladder and duodenum.

[Tuberculous lesion of retropharyngeal lymph nodes responsible for labored nasal breathing]. / Tuberkuleznoe porazhenie zaglotochnykh limfaticheskikh uzlov, vyzvavshee zatrudnenie nosovogo dykhaniya.

A 62 year-old patient applied for the medical aid with complaints of labored nasal breathing. She was treated for tuberculosis in the childhood, underwent radical mastectomy in connection with left breast cancer in 2007 and adenotomy at the age of 60 years with the good functional outcome. One year after adenotomy, the enlargement of lymph nodes at the left-hand antero-lateral surface of the neck was detected. The histological changes in the lymph nodes corresponded to the picture of tuberculosis. Pharyngoscopy demonstrated an asymmetric protrusion at the posterior wall of the pharynx more prominent on the left side. Examination by spiral computed tomography revealed the presence of two enlarged lymph nodes with the signs of suppurative melting in the retropharyngeal space. These lymph nodes were opened through the posterior pharyngeal wall which resulted in the restoration of the normal pharynx configuration and the normalization of nasal breathing.

[Abdominal tuberculosis, a diagnostic dilemma: report of a series of cases]. / Tuberculosis abdominal, un dilema diagnóstico: reporte de una serie de casos.

INTRODUCTION: Abdominal tuberculosis is one of the most common non-pulmonary tuberculosis infection sites, and it relates to immunosuppression. The nonspecific features of this form of tuberculosis make an accurate diagnosis difficult. The aim of this study is to report seven (7) patients diagnosed with abdominal tuberculosis requiring surgery at the Clinical Hospital of Pontificia Universidad Católica de Chile. METHODS: A descriptive analysis of seven cases of abdominal tuberculosis treated in our center between August 2001 and June 2013 was performed to characterize its clinical presentation and diagnostic elements. RESULTS: Four men and three women (29-68 years old) were diagnosed and operated on for abdominal tuberculosis: three had the peritoneal form of tuberculosis, two had a lymph nodal form and two had the intestinal form. In three cases, abdominal tuberculosis was associated with immunosuppression (HIV and rheumatoid arthritis treatment) and six cases presented with wasting syndrome of at least one month duration. Three patients had an acute presentation with signs of intestinal obstruction. Diagnosis was made by surgical biopsy. Of the seven patients, who underwent surgery, three required bowel resection for intestinal obstruction. CONCLUSION: Abdominal tuberculosis requires a high index of suspicion for an early diagnosis, especially in populations at risk.

INTRODUCCIÓN : La tuberculosis abdominal es una de las variantes extrapulmonares más frecuentes. Se relaciona a estados de inmunodepresión y, dado su cuadro clínico inespecífico, su diagnóstico es difícil. Nuestro objetivo es presentar una serie de siete casos diagnosticados de tuberculosis abdominal que requirieron cirugía en el Hospital Clínico de la Pontificia Universidad Católica de Chile. MÉTODOS: Se realizó un análisis descriptivo de los siete casos de tuberculosis abdominal operados en nuestro centro entre agosto de 2001 y junio de 2013, caracterizando su presentación clínica y elementos diagnósticos requeridos. RESULTADOS: Cuatro hombres y tres mujeres (entre 29 y 68 años) fueron diagnosticados y operados de tuberculosis abdominal: tres en su forma peritoneal, dos ganglionar y dos intestinal. En tres casos la tuberculosis abdominal se asoció a inmunosupresión (VIH y artritis reumatoide en tratamiento) y en seis casos se presentó con síndrome consuntivo de al menos un mes de evolución. Tres pacientes tuvieron una presentación aguda con signos de obstrucción intestinal. El diagnóstico fue realizado mediante biopsia quirúrgica. Los siete pacientes fueron intervenidos quirúrgicamente, tres de ellos requirieron resección intestinal en el contexto de obstrucción intestinal. CONCLUSIÓN: La tuberculosis abdominal requiere de un alto índice de sospecha, principalmente en población de riesgo, para un diagnóstico oportuno.

[The surgical options of cervical tuberculous lymphadenitis].

OBJECTIVE: To analyze the clinical features & variation features of cervical tuberculous lymphadenitis and to discuss its effective surgical treatment. METHOD: Retrospective analysis of 27 cases of cervical tuberculous lymphadenitis patients admitted to the hospital from January 2008 to December 2013. The cervical tuberculous lymphadenitis is classified based on the enhanced CT scanning conducted before operation and the preoperative evaluation of clinical characters of patients. The lymphaden ncisional biopsy was conducted on the type I patients with cervical tuberculous lymphadenitis. The lesion resection was performed on the type II and mixed type I + II patients. The regional cervical lymph node dissection was carried on the type III, the type IV and other mixed type patients. The negative pressure drainage ball was placed after operation, and the cavity was flushed with 5% povidone iodine solution. The antituberculosis therapy was performed after wound healing. RESULT: The analysis of the clinical features for 27 patients: the incidence rate on the left side, right side, both sides and middle-line is 63.0%, 25.9%, 7.4% and 3.7% respectively. The majority of patients whose lesion involving more than one region account for 62.1%; the patients whose lesion involving one region account for 37.9%. The most common is level V involved lesion (69.0%), then level IV (62.1%), level III (51.7%), level II (34.5%), level I (10.3%) and level VI (3.4%) in order. The analysis of the CT imageology features for 27 patients: the simple type is the majority (65.5%), and the most common is type III (24.1%), then the type I (17.2%), type II (13.8%) and type IV (10.3%) in order. The mixed type is minority (34.5%), but the two mixed is often (31.0%). The three mixed is only located on one side (3.4%). The recurrence never happened on the patients with resection and standard antituberculosis therapy. CONCLUSION: For the cervical tuberculous lymphadenitis, the suitable surgical treatments shall be selected according to the lesion characteristics & location and CT imaging manifestations presurgical evaluation. The effective way to treat cervical tuberculous lymphadenitis is to conduct negative pressure drainage after operation, to flush the cavity with 5% povidone iodine solution and to perform antituberculosis therapy.

Mycobacterium bovis cervical lymphadenitis: A representative case and review.

Mycobacterium bovis is a tuberculosis causing bacterium that commonly presents with cervical lymphadenopathy. It is important to differentiate M. bovis from other Mycobacterial pathogens to ensure selection of correct anti-microbial therapy. This may decrease the number of treatment failures, the prevalence of anti-mycobacterial drug resistance patterns, and the need for surgical intervention. M. bovis has universal resistance to pyrazinamide and thus may not respond to typical first line mycobacterial drugs and may require surgical intervention. This case report and review of M. bovis cervical lymphadenitits demonstrates the need for accurate diagnosis as well as combined management with infectious disease and public health specialists.