Validación de la punción aspiración con aguja fina (PAAF) en el diagnóstico de linfadenitis tuberculosa en pacientes con infección por el virus de la inmunodeficiencia humana (VIH)

Susana G. Cabrera; Virginia Ortega; Julio C. Medina; Gabriela Gualco; Marcelo Viola; Graciela Pérez; María L. Musto; Justino Zeballos; Eduardo Savio

Authors

Susana G. Cabrera Universidad de la República, Facultad de Medicina, Hospital de Clínicas, Clínica Médica B, Prof. Adjunto. Colaborador Calificado de Cátedra de Enfermedades Infecciosas
Virginia Ortega Hospital Central de las Fuerzas Armadas, Patólogo asistente
Julio C. Medina Universidad de la República, Facultad de Medicina, Cátedra de Enfermedades Infecciosas, Prof. Adjunto
Gabriela Gualco Hospital Central de las Fuerzas Armadas, Expatólogo asistente. Laboratorio de Inmunohistoquímica, Encargada
Marcelo Viola Universidad de la República, Facultad de Medicina, Hospital de Clínicas, Clínica Quirúrgica B, Profesor Adjunto
Graciela Pérez Universidad de la República, Facultad de Medicina, Clínica Médica 2, Prof. Adjunto. Cátedra de Enfermedades Infecciosas, Ex Asistente
María L. Musto Hospital Central de las Fuerzas Armadas, Patólogo asistente
Justino Zeballos Universidad de la República, Facultad de Medicina, Hospital de Clínicas, Clínica Quirúrgica B, Ex Asistente
Eduardo Savio Universidad de la República, Facultad de Medicina, Cátedra de Enfermedades Infecciosas, Profesor Director

Keywords:

GANGLIONAR TUBERCULOSIS, BIOPSY WITH FINE NEEDLE

Abstract

Introduction: fine needle puncture aspiration (PAAF) of the lymph node is a simple, fast and low cost technique to obtain samples for diagnosis.
Objective: the objective of the study was to validate PAAF for the diagnosis of tuberculous lymphadenitis in patients with HIV, by using culture for Mycobacodeterium tuberculosis in node biopsy or histopathology as "gold standard", together to the response to the specific treatment.
Method: prospective clinical-pathological study. Patients included in our study: were infected with HIV, provided their informed consent, were older than 18 years of age, had superficial adenomagaly larger than 2 cm, and were seen at the Infectious Diseases Service from October 2004 through December 2006. Fine needle puncture aspiration (PAAF ) and biopsy of the same node were performed. Usual stain and Ziehl-Neelsen stain were used in cytological and histopatological samples, and microbacteria cultures were made.
We defined the following citology suggested TB lymphadenitis: 1) reactive lymphadenitis with necrosis; 2) reactive lymphadenitis with epithelial cells and/or macrophagos and/or multinuclear giant cells; with or without acid-alcohol resistant bacilli in the direct (sample?) with Ziehl-Neelsen stain.
Results: out of 30 patients included in the study, 23 corresponded to node TB. In the remaining seven patients, diagnosis was negative in six of them, according to PAAF, and thus unnecessary treatment was avoided, and histological study was determined for final diagnosis. Sensitivity, specificity, positive and negative predictive value of PAAF for the diagnosis of TB lymphadenitis was 95%, 86%, 95% and 86% respectively. Kappa concordance coefficient between both procedures was 90%.
Conclusions: lymph node PAAF in patients with HIV is a high performance diagnostic technique for the diagnosis of node TB. Likewise, it enables selecting patients to undergo node biopsy for final diagnose, avoiding its systematic conduction in all patients with adenomegaly.

References

(1) Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med 2003; 163(9): 1009-21.
(2) Meya DB, McAdam KP. The TB pandemic: an old problem seeking new solutions. J Intern Med 2007; 261(4): 309-29.
(3) Havlir DV, Barnes PF. Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 1999; 340(5): 367-73.
(4) Yang Z, Kong Y, Wilson F, Foxman B, Fowler AH, Marrs CF, et al. Identification of risk factors for extrapulmonary tuberculosis. Clin Infect Dis 2004; 38(2): 199-205.
(5) Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. Am Fam Physisian 2005; 72(9): 1761-8.
(6) Lazarus AA, Thilagar B. Tuberculous lymphadenitis. Dis Mon 2007; 53(1): 10-5.
(7) American Thoracic Society, Centers for Disease Control and Prevention. Diagnostic standards and classification of tuberculosis in adults and children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med 2000; 161(4 Pt 1): 1376-95.
(8) Artenstein AW, Kim JH, Williams WJ, Chung RC. Isolated peripheral tuberculous lymphadenitis in adults: current clinical and diagnostic issues. Clin Infect Dis 1995; 20(4): 876-82.
(9) Gupta N, Rajwanshi A, Srinivasan R, Nijhawan R. Pathology of supraclavicular lymphadenophaty in Chandigarh, north India: an audit of 200 cases diagnosed by needle aspiration. Cytopathology 2006; 17(2): 94-6.
(10) Gupta RK, Naran S, Lallu S, Fauck R. The diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes: a study of 218 cases. Cytopathology 2003; 14(4): 201-7.
(11) Rameshkumar K. Tuberculous lymphadenitis in children-role of fine needle aspiration cytology. J Assoc Physicians India 1999; 47(10): 976-9.
(12) Verma K, Kapila K. Aspiration cytology for diagnosis of tuberculosis-perspectives in India. Indian J Pediatr 2002; 69 (Suppl 1): S39-43.
(13) Saikia UN, Dey P, Jindal B, Saikia B. Fine needle aspiration cytology in lymphadenopathy of HIV-positive cases. Acta Cytol 2001; 45(4): 589-92.
(14) Shenoy R, Kapadi SN, Pai KP, Kini H, Mallya S, Khadilkar UN, et al. Fine needle aspiration diagnosis in HIV-related lymphadenopathy in Mangalore, India. Acta Cytol 2002; 46(1): 35-9.
(15) Jayaram G, Chew MT. Fine needle aspiration cytology of lymph nodes in HIV-infected individuals. Acta Cytol 2000; 44(6): 960-6.
(16) Polesky A, Grove W, Bhatia G. Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome. Medicine (Baltimore) 2005; 84(6): 350-62.
(17) Memish ZA, Mah MW, Mahmood SA, Bannatyne RM, Khan MY. Clinico-diagnostic experience with tuberculous lymphadenitis in Saudi Arabia. Clin Microbiol Infect 2000; 6(3): 137-41.
(18) Ellison E, Lapuerta P, Martin SE. Fine needle aspiration diagnosis of mycobacterial lymphadenitis. Sensitivity and predictive value in the United States. Acta Cytol 1999; 43(2): 153-7
(19) Yassin MA, Olobo JO, Kidane D, Negesse Y, Shimeles E, Tadesse A, et al. Diagnosis of tuberculous lymphadenitis in Butajira, rural Ethiopia. Scand J Infect Dis 2003; 35(4): 240-3.
(20) Nataraj G, Kurup S, Pandit A, Mehta P. Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a prospective study. J Postgrad Med 2002; 48(2): 113-6.
(21) Bezabih M, Mariam DW, Selassie SG. Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology 2002; 13(5): 284-90.
(22) Nayak S, Puranik SC, Deshmukh SD, Mani R, Bhore AV, Bollinger RC. Fine-needle aspiration cytology in tuberculous lymphadenitis of patients with and without HIV infection. Diagn Cytopathol 2004; 31(4): 204-6.
(23) Piaggio Blanco R, Paseyro P. La punción ganglionar. Su importancia en la clínica. An Fac Med Montevideo 1940; 15(1): 895-926.
(24) Das DK. Lymph nodes. In: Bibbo, M., ed. Comprenhensive Cytophatology. Philadelphia: WB Saunders, 1991: 671-702.
(25) Cabrera S, Medina J, Ortega V, Pérez G, Cappuccio P, Viola M, et al. Diagnóstico de la linfadenitis tuberculosa en pacientes VIH: validación de la punción-aspiración con aguja fina. XII Congreso de la Asociación Panamericana de Infectología. Caracas, Venezuela. 15-18 de mayo 2005.
(26) Cabrera SG, Medina JC, Salaberryborda AM, Librán MJ, González HM, Savio E. Dificultad en el diagnóstico de tuberculosis en pacientes infectados por el virus de la inmunodeficiencia humana (VIH) y variables que determinan el inicio de un tratamiento empírico antituberculoso. Rev Méd Urug 2007; 23(3): 164-72.