CLINICOPATHOLOGICAL STUDY OF CORRELATION BETWEEN FNAC SMEAR , ZN STAINED SMEAR & HIV STATUS IN CLINICALLY SUSPECTED CASES OF LYMPH NODE TUBERCULOSIS IN URBAN EASTERN INDIA

BACKGROUND: Tuberculous lymphadenitis (TBL) is the commonest form of extra pulmonary tuberculosis. Fine Needle Aspiration Cytology (FNAC) is a simple outpatient diagnostic procedure used in the diagnosis of TBL and all stages of Human Immunodeficiency Virus (HIV) infection are associated with increased risk of tuberculosis (TB). AIM & OBJECTIVE: To correlate different cytomorphologies of FNAC smears and presence or absence of Acid fast bacilli (AFB) in the Ziehl Neelsen (ZN) stained smear prepared from the same aspirate. Association of HIV infection are also to be evaluated. METHOD: An observational cross-sectional study was conducted at department of pathology in collaboration with department of pulmonary medicine, Medical College & Hospital, Kolkata from January 2015 to June 2016.It included 305 cases with enlarged palpable lymph nodes. FNAC done; aspirated smears were stained with papanicolaou, Leishman-Giemsa and ZN stains. HIV status were also noted. RESULTS: 251 aspirates were reported on cytomorphology as suggestive of TBL with 117 (47.01 %) AFB positivity in ZN stained smears. Cervical lymph node were most commonly involved site (86.84 %) and females (63.75%) were affected more than males (36.25%).Most cases of AFB positive smears were associated with caseation necrosis only (71.8 %). 17 (6.77 %) out of 251 cases were co infected with HIV. CONCLUSION: Special stains should be done in all suspected cases of TB lymphadenitis and most common cytomorphology associated with AFB positivity is caseation necrosis without granuloma. Also it can be concluded that TB/HIV co infection is not predominant in India.

Lupus Miliaris Disseminatus Faciei: Enhanced cosmesis by Combination of Medications, Laser and Fillers (Preprint)

UNSTRUCTURED A rare granulomatous disease of unknown origin is lupus miliaris disseminatus faciei (LMDF). Associated pitted scars are major complication leads to psychological distress resulting in increased demand for dermatological consultation. Histopathologically, epithelioid granulomas with caseation necrosis are the typical presentation. Advanced research is still ongoing, yet its treatment remains challenging. Management should be individually structured and, the appropriate combination may have a beneficial effect. We report an LMDF case with facial and extra facial localization successfully treated with a combination of medications, the fractional CO2 laser and fillers. In conclusion, the attitude of the patient towards the scar has considerably improved after treatment. In the past era, most authors assumed that a relationship existed between tuberculosis, rosacea and sarcoidosis, however, many authors found it to be a distinct entity. Herein, we also discussed the distinction between listed the ambiguous entities.

Pathogenesis and Animal Models of Post-Primary (Bronchogenic) Tuberculosis, A Review

Primary and post-primary tuberculosis (TB) are different diseases caused by the same organism. Primary TB produces systemic immunity. Post-primary TB produces cavities to support massive proliferation of organisms for transmission of infection to new hosts from a person with sufficient immunity to prevent systemic infection. Post-primary, also known as bronchogenic, TB begins in humans as asymptomatic bronchial spread of obstructive lobular pneumonia, not as expanding granulomas. Most lesions regress spontaneously. However, some undergo caseation necrosis that is coughed out through the necrotic bronchi to form cavities. Caseous pneumonia that is not expelled through the bronchi is retained to become the focus of fibrocaseous disease. No animal reproduces this entire process. However, it appears that many mammals utilize similar mechanisms, but fail to coordinate them as do humans. Understanding this makes it possible to use human tuberculous lung sections to guide manipulation of animals to produce models of particular human lesions. For example, slowly progressive and reactivation TB in mice resemble developing human bronchogenic TB. Similarly, bronchogenic TB and cavities resembling those in humans can be induced by bronchial infection of sensitized rabbits. Granulomas in guinea pigs have characteristics of both primary and post primary TB. Mice can be induced to produce a spectrum of human like caseating granulomas. There is evidence that primates can develop bronchogenic TB. We are optimistic that such models developed by coordinated study of human and animal tissues can be used with modern technologies to finally address long-standing questions about host/parasite relationships in TB, and support development of targeted therapeutics and vaccines.

Erythema induratum: a rare case with unusual presentation

Tuberculosis, still one of the most common infectious diseases globally, manifests primarily as pulmonary tuberculosis. Extra-pulmonary tuberculosis can occur in other sites including skin. Cutaneous tuberculosis, comprising merely 1-2% of all forms of tuberculosis, has been classified into various morphological variants. One of the morphological variants of cutaneous tuberculosis is erythema induratum, a tuberculid, which is caused by hematogenous spread of tuberculosis, the pathogenesis of which is due to hypersensitive reaction against the mycobacterial antigens. The skin biopsy findings of erythema induratum are characterized by panniculitis with formation of non-caseating epithelioid granulomas with no mycobacteria detected in the lesions, though mycobacterial antigens or DNA could be detected by polymerase chain reaction (PCR). In this context, being presented here is a case of erythema induratum which is rare and unusual in its presentation inasmuch as caseating epithelioid granulomas were seen in the lesional skin biopsy along with detection of acid-fast bacilli. In our study a 57-year-old male presented to the Dermatology OPD with multiple erythematous lesions bilaterally over the groin and thigh regions. Clinically the lesions were considered to be equivocally suggestive of migratory erythema or erythema marginatum. The skin biopsy taken from the lesions revealed multiple epithelioid granulomas in the dermis with central areas of caseation necrosis. Sections stained with Ziehl-Neelsen stain showed the presence of occasional acid-fast bacilli. Erythema induratum, a rare tuberculid form of cutaneous tuberculosis, which is pathogenetically considered to be occurring as a result of hypersensitivity reaction against mycobacterial antigens with characteristic absence of tubercle bacilli. In the case presented here erythema induratum presents in a rare unusual manner as a caseating granulomatous lesion with presence of demonstrable acid-fast bacilli.

A Case of Tuberculous Granulomatous Panniculitis without Vasculitis

We report a case of tuberculous granulomatous panniculitis without vasculitis in an 87-year-old female patient with B-cell chronic lymphocytic leukaemia. One month after starting chemotherapy with chlorambucil and prednisone she presented superficial erythematous plaques on the anterior side of the left leg. Three weeks later erythematous painless deep nodules appeared on the left popliteal fossa and on the left thigh. Cutaneous biopsy revealed granulomatous panniculitis without caseation necrosis or vasculitis. Polymerase chain reaction for Mycobacterium tuberculosis revealed positivity in the skin. The final diagnosis was reactivation of latent tuberculosis (TB) induced by deep immunosuppression associated with chemotherapy and haematological disease. Tuberculous granulomatous panniculitis without vasculitis is a rare presentation of cutaneous TB and may be part of the heterogeneous histopathologic spectrum of erythema induratum of Bazin (nodular vasculitis). Our case shows that the diagnosis of cutaneous TB requires the correlation of clinical findings with histopathology and microbiological tests.

The Incidence of Tuberculous Cervical Lymphadenitis- Three Year Study of Sixty Cases

Tuberculous cervical lymphadenitis (TCL) is not very uncommon in our country. A series of 60 cases was studied from 204 non- thyroid neck swelling which were selected from 20,558 patients attending in ENT department in Central Police Hospital and Mitford Hospital, Dhaka in 3 years. The incidence of TCL was 29.41% among the non- thyroid neck swelling and 0.3% from total number of patients attending in ENT department. The most vulnerable ago group was the second decade 38.33% with female preponderance ( Female male ratio was 2: 1). The common presentaions were neck swelling (100%), fever (66.67%), night sweat (50%). 50% cases were associated with pulmonary tuberculosis. Tuberculin test was positive in 73.34%. Maximum number of patients were from low socioeconomic class and BCG vaccination had a significant protective role (31.67% were vaccinated and 68.33% were one- vaccinated). On histopathology of cervical lymph nodes caseation necrosis was found in 85% of cases.DOI: http://dx.doi.org/10.3329/bmj.v41i2.18793 Bangladesh Medical Journal 2012 Vol. 41 No. 2: 9-12

Cytomorphological Patterns in the Diagnosis of Tuberculous Lymphadenitis

The reliable diagnosis of tuberculous lymphadenitis by FNAC has important implications in a developing country like India. The aim is to study various cytomorphological patterns seen in tuberculous lymphadenitis and their correlation with AFB positivity. Fine needle aspiration cytology (FNAC) was performed on three hundred and twenty two patients with lymphadenopathy referred to the cytopathology section of pathology department, Sri Guru Ramdas Institute if Medical sciences and research Amritsar from August 2010 to July 2012. The patients with cytological diagnosis of tuberculous lymphadenitis were followed for their response to antitubercular treatment. A total of 322 FNACs were performed on patients with lymphnode lesions; out of which the most common (119) cytological diagnosis was tuberculous lymphadenitis. The most common pattern observed was (group II) presence of epitheloid granuloma with caseation necrosis which was seen in about half (50.5%) of the cases followed by smears with caseation necrosis only (group III) (27.7%) and smears with epitheloid granulomas only (group I) (21.8%).The overall AFB positivity was seen in 19.3% cases of tuberculous lymphadenitis. Maximum (30.3%) AFB positivity was seen in smears (group III) with only necrotic debris without granuloma and was least in group I (7.6%).While comparing Group I smears with that of group III using Fisher's exact test, the difference in AFB positivity between the smears was statistically significant as the two-tailed p value was 0.0496. Thus FNAC is safe, easy, quick reliable as well as conclusive for the diagnosis of tuberculous lymphadenitis when done along with Zeihl Neelsen stain for acid fast bacilli.

Multiple oral ulcers leading to diagnosis of pulmonary tuberculosis

ABSTRACTWe report a 47 year old man who presented with painful non-healing tongue ulcers of 3 months duration.Examination revealed an additional buccal ulcer that he was unaware of. Histopathology of the ulcers showed caseation necrosis. Following this report, chest radiography and sputum microscopy performed revealed pulmonary tuberculosis. From this case-study, one should be aware of coexisting pulmonary tuberculosis in patients with chronic non-healing oral ulcers, both for diagnosis as well as prevention of transmission through respiratory droplets.