Original

102 Article

FNAC IN TUBERCULOUS LYMPHADENITIS: EXPERIENCE FROM A

TERTIARY LEVEL REFERRAL CENTRE

Paliwal Nidhi1, Thakur Sapna1, Mullick Shalini2 and Gupta Kumud3

(Received on 20.1.2011. Accepted after revision on 15.6.2011)

Summary
Background: In developing countries like India, tuberculous lymphadenitis is one of the most common causes of
lymphadenopathy. However, anti-tubercular treatment cannot be given only on clinical suspicion. Cytomorphology with acid
fast staining proves to be a valuable tool in diagnosing these cases.
Aims: To study the utility, limitations of fine needle aspiration cytology and various cytomorphological presentations in
reference to Ziehl-Neelsen staining in tuberculous lymphadenitis.
Material and Methods: In a study period of July to October 2010, three hundred and eighteen consecutive superficial lymph
nodes, clinically suspected to be tuberculous were subjected to cytological evaluation with Hematoxylin & Eosin, Giemsa
and Ziehl-Neelsen stained smears. In addition, demographic profile of these patients with clinical presentation was also
studied.
Results: Incidence of tuberculous lymphadenitis was 55%. Overall AFB positivity was 71.0%. Only Necrosis without
epithelioid cell granulomas was the most common cytological picture and that showed highest AFB positivity also. Three-
fourth of the patients presented in second to fourth decade of life. Cervical region was the most common site of involvement
with solitary lymphadenopathy as the most common presentation in contrast to matted lymph nodes as reported by others.
Conclusions: Fine needle aspiration cytology is a safe, cheap procedure requiring minimal instrumentation and is highly
sensitive to diagnose tuberculous lymphadenitis. The sensitivity can be further increased by complementing cytomorphology
with acid fast staining. In acid fast staining negative cases, yield of acid fast bacilli positivity can be increased by doing
Ziehl-Neelsen staining on second smear or decolourized smear revealing necrosis or by repeat aspiration. Microbiological
assessment should also be done in such cases. [Indian J Tuberc 2011; 58: 102-107]

Key words: Cytomorphological patterns, Tuberculous lymphadenitis, Ziehl-Neelsen staining

INTRODUCTION MATERIAL AND METHODS

Fine Needle Aspiration Cytology (FNAC) Three hundred and eighteen consecutive
is almost safe, cost effective and conclusive superficial lymph nodes, clinically suspected to be
procedure.1 It provides an alternative to excision tuberculous, were aspirated for cytological evaluation
biopsy for lymph nodes and is an easy procedure after thorough clinical examination in a study period
for collection of material for cytomorphological of July to October 2010. Aspirations were performed
and bacteriological examination. 2 Tuberculous using 22 G needle and disposable 10 ml plastic syringe
lymphadenitis is a very common cause of superficial with a detachable syringe holder. In all the cases,
lymphadenopathy in countries like India. The aim alcohol fixed smears were made and stained with
of this study was to describe various cytological Hematoxylin & Eosin, one air-dried smear was stained
pictures of tuberculous lymphadenitis with their with Giemsa stain, one smear was stained with Z-N
relative frequency and to assess correlation between technique (hot method) and an additional slide was
FNAC and Ziehl-Neelsen (Z-N) staining in kept unstained for any further required stain. The
diagnosing tuberculous lymphadenitis. cytology smears revealing features of tuberculous

1. Senior Resident 2. Specialist 3. Sr. Pathologist

Department of Pathology, LRS Institute of TB & Respiratory Diseases, New Delhi.
Correspondence: Dr. Paliwal Nidhi, Senior Resident, Department of Pathology, LRS Institute of TB & Respiratory Diseases, Sri Aurobindo Marg,
New Delhi – 110 030; Email: lrspathology@yahoo.in; Phone: 9278749894, 011-26854929.

Indian Journal of Tuberculosis

 PALIWAL NIDHI ET AL 103

lymphadenitis were grouped into four categories: patients came to the institute from DOTS non-area
epithelioid granulomas with caseous necrosis, (area in Delhi but not covered in DOTS area under our
epithelioid granulomas without necrosis, necrosis institute), 23% from DOTS area and 27% were from
only without epithelioid granulomas and polymorphs outside Delhi. Forty-eight patients had history of
with necrosis with or without epithelioid granulomas.3 tuberculosis in the past and 42 patients were already
In addition, demographic profile of tuberculous on ATT at the time of aspiration. The cervical region
patients with their present and past treatment history was the most common site; involved in 90% cases,
and clinical characteristics of lymphnodes were also followed by axillary (6.4%) and inguinal (1.6%). Only
studied. three cases presented with generalized
lymphadenopathy. In our study, most common
RESULTS presentation was single palpable cervical lymphnode
in 63.3% of cases followed by multiple unilateral
Out of three hundred and eighteen cervical lymphadenopathy in 19.2% of cases and
superficial lymphnodes aspirated,125 cases showed multiple bilateral cervical lymphadenopathy in 7.2%
AFB positivity (of which smears initially AFB negative of cases. Grossly purulent material was aspirated in
showed positivity by doing Z-N staining on 61.6%, caseous or cheesy material in 23.3% and blood
decolourized smears) while 51 cases were AFB mixed material in 15.1% of AFB positive cases while
negative with cytological picture of tuberculous blood mixed material was the most common aspirate
lymphadenitis, 58 cases revealed reactive lymphnode in 69.8% of AFB negative cases. Out of 176 cases
hyperplasia and 84 cases included inadequate samples, showing cytological picture of tuberculous
lymphomas, metastases, etc. Among tuberculous lymphadenitis, smears revealed epithelioid
cases, 77% of males and 75% of females were in the granulomas with caseous necrosis in 16.4% of cases ,
second to fourth decades of life with male to female epithelioid granulomas without necrosis in 14.3% of
ratio of 1:1.2 (Tables 1 and 2). Majority (50%) of the cases, necrosis only without epithelioid granulomas

Table 1: Incidence of reactive versus tuberculous lymphadenopathy in male and female

Diagnosis Male Female Total

Reactive lymph node 38 20 58
hyperplasia
Tuberculous 81 95 176
lymphadenopathy
Total 119 115 234

Table 2: Incidence of tuberculous lymphadenopathy in relation to age and sex

Age group Male Female Total %

1-10 yrs 5 9 14 7.9
11-20 yrs 16 18 34 19.4
21-30 yrs 25 32 57 32.3
31-40 yrs 22 21 43 24.5
41-50 yrs 9 9 18 10.3
50 yrs and above 4 6 10 5.6
Total 81 95 176 100

Indian Journal of Tuberculosis

104 FNAC IN TUBERCULOUS LYMPHADENITIS

in 39.2% of cases and polymorphs with necrosis granulomas without necrosis, 85.5% of cases with
with or without epithelioid granulomas in 30.1% of necrosis only without epithelioid granulomas and 79.2%
cases (Figs.1.A,B,C,D). AFB positivity was found of cases with polymorphs with necrosis with or without
in 69.5% of the cases showing epithelioid granulomas epithelioid granulomas (Table 3). Overall AFB positivity
with caseous necrosis, 3.2% of cases with epithelioid was seen in 71.0% cases.

Various cyto-morphological patterns in tuberculous lymphadenitis

Fig. 1.A: Epithelioid cell granuloma with necrosis. (H&E 100X)

Fig. 1.B: Epithelioid cell granuloma without necrosis. (H&E 100X)
Fig. 1.C: Only necrosis, no granulomas. (H&E 100X)
Fig. 1.D: Only neutrophils, no granulomas. (H&E 100X)

Table 3: Various cytomorphological pictures in tuberculous lymphadenopathy

Cytomorphological picture No. of cases % AFB positive cases AFB negative cases
Epithelioid granulomas with 29 16.4 20(69.5%) 9(30.5%)
caseous necrosis
Epithelioid granulomas 25 14.3 4(3.2%) 21(96.8%)
without necrosis
Necrosis only without 69 39.2 59(85.5%) 10(14.5%)
epithelioid granulomas
Polymorphs with necrosis 53 30.1 42(79.2%) 11(20.8%)
Total 176 100 125 51


Indian Journal of Tuberculosis

 PALIWAL NIDHI ET AL 105

DISCUSSION observed cervical involvement in 74.2% of cases.

A study conducted by Sharma et al10 in pediatric
Superficial lymphadenopathy is a very age group also showed similar results with female
common clinical finding, aetiology of which can be predominance and most common involvement of
suspected by clinical signs and symptoms. However, cervical region (88.2%). While matted lymph nodes
a morphological diagnosis is essential to start anti- were seen in majority of cases (60%) by Ahmad et
tuberculous treatment in cases of tuberculous al4, in our study 63.3% of cases presented with
lymphadenopathy. FNAC lymph node is a simple, non- solitary lymphadenopathy. Single lymph node
invasive, cheap tool with high sensitivity in enlargement was seen in 48.6% cases of tubercular
tuberculous cases and can replace excision biopsy for lymphadenopathy by Aggarwal et al.11 We noted a
diagnosing tuberculosis in developing countries like much higher incidence(55%) of tuberculous
India. Tuberculous lymphadenopathy can be seen in lymphadenopathy while Ahmad et al4 found 38% and
patients ranging from early to advanced age. In our Tilak et al 12 38.8% cases of tuberculous
study, the youngest patient was four-year-old and lymphadenopathy. The high incidence noted by us
the oldest was 63 years’ old. In a study by Ahmad et al, may be because our institute is a referral centre for
the youngest patient was two-year-old and the oldest tuberculosis cases.
being 95 years.4 Majority of the patients (75%) were
in the second to fourth decades of life. Similar age Most common cytological pattern seen was
distribution was seen in a study by Ergete and necrosis only without granulomas in 39.2% of cases
Bekele2, Purohit et al5 and Dandapat et al6. A slight and polymorphs with necrosis in 30.1% of cases.
female predominance with 1:1.2 sex ratio was seen While in a study by Gupta et al, epithelioid clusters
in our study. Similarly, female predominance was with or without Langhan’s giant cells with necrosis was
noted by Pamra et al7, Ergete and Bekele2 and Purohit most commonly observed cytological pattern in 50.35
et al 5 while male predominance was noted by cases.13 This is also the classic pattern, commonly
Rajsekaran et a l8, and Ahmad et al.4 Clinically, in seen in excision specimens of tuberculous
our study, cervical region was the most commonly lymphnodes (Fig. 2). Highest AFB positivity was seen
affected region, involved in 90% of cases. This in smears revealing necrosis only without epithelioid
was in concordance with Bezabih et al 9 who granulomas (85.5%) and polymorphs with necrosis

Fig. 2: Histological picture of tuberculous lymphadenitis showing necrotizing granulomatous

lymphadenitis (H&E 40X)

Indian Journal of Tuberculosis

106 FNAC IN TUBERCULOUS LYMPHADENITIS

with or without epithelioid granulomas (79.2%) 83.3% by Dandapat et al6 and 87% by Narang.17
while the lowest was seen in smears showing Therefore even in most remote areas, FNAC
epithelioid granulomas without necrosis(3.2%). can be used for diagnosing tuberculous
Bezabih et al9 found the highest AFB positivity in lymphadenopathy. Coupling FNAC with Z-N
cases showing necrosis only without epithelioid staining increases the diagnostic accuracy.
granulomas (69.7%) and the lowest in cases showing Diagnostic accuracy can be further increased by
epithelioid granulomas without necrosis (20.0%). submitting some material obtained by FNA for
Similarly, the highest AFB positivity (75.6%) was culture.
seen in smears revealing necrosis only without
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 PALIWAL NIDHI ET AL 107

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