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Prevalence of tuberculous lymphadenitis in Gondar University Hospital, Northwest Ethiopia

  • Dagnachew Muluye1Email author,
  • Belete Biadgo1,
  • Eden Woldegerima1 and
  • Andebet Ambachew1
BMC Public HealthBMC series ¿ open, inclusive and trusted201313:435

DOI: 10.1186/1471-2458-13-435

Received: 19 September 2012

Accepted: 30 April 2013

Published: 3 May 2013

Abstract

Background

Tuberculous is the leading cause of death worldwide with a large number ofdeaths occurring in developing countries. Tuberculous lymphadenitis is amongthe most common presentations of extra pulmonary tuberculous. This studyattempts to determine the magnitude of tuberculous lymphadenitis frompatients with lymph node aspirate in Gondar University Hospital, NorthwestEthiopia.

Methods

Retrospective study was conducted. Data were collected from registration bookof Gondar university Hospital pathology laboratory after checking thecompleteness of patient’s necessary information like age, sex and fineneedle aspiration cytology results. Data were entered and analyzed usingSPSS version 16 statistical package. Chi-square test was done to determineassociations.

Result

A total of 3,440 lymph node aspirates were examined using fine needleaspiration cytology. Of these, 2,392 (69.5%) cases were found to havetuberculous lymphadenitis. Male 1647(47.9%) to female 1793(52.1%) ratio ofall study subjects were 0.9:1. Females (54.1%) were more affected than males(45.9%). Age, sex and site of aspiration were found to be statisticallyassociated with tuberculous lymphadenitis (p-value < 0.001).The age group of 15–24 years had the highest prevalence of tuberculouslymphadenitis followed by those of 25–34 years old. The most affectedsites were cervical lymph nodes (47.5%) followed by auxiliary (19.4%) andsubmandibular (12.9%) lymph node regions. None of the records documented theHIV status of subjects.

Conclusion

The prevalence of tuberculous from lymph node aspirate was found to be higherinvolving the frequently affected site of cervical lymph node. The HIVstatus of patients with all forms of tuberculous should have to be checkedand documented. Further prospective and advanced studies are recommended todetermine the specific etiologic agents and contributing factors.

Keywords

Tuberculous lymphadenitis Fine needle aspiration cytology Ethiopia

Background

Tuberculous (TB) is a chronic bacterial disease caused by a slightly curved nonmotile, aerobic, non-capsulated and non-spore forming strains of mycobacteriausually Mycobacterium tuberculous[1]. It is a major public health problem in the world and 1/3 ofworld’s population is infected predominantly in developing countries [2]. The magnitude of TB is higher in the developing world due to variousfactors including malnutrition, different causes of immune suppression, dual HIV-TBepidemic and increasing causes of drug resistant TB (Multi drug resistant TB(MDRTB), Extreme drug resistant TB (X-DRTB)) [3]. Ethiopia ranks 7th in the list of 22 high burdens countries severelyaffected by tuberculous [4]. As per WHO global TB report of 2012, the estimated incidence of allforms of TB in Ethiopia was 220/100,000 population [5] and smear positive cases was 63/100,000 population [6].

Extra pulmonary tuberculous (EPTB) affects different organs of human body wheretuberculous lymphadenitis (TBLN) is the most common manifestations of all EPTB [710]. The most commonly involved lymph nodes were cervical, axilliary,inguinal, abdominal and supra clavicular sites. Cervical lymph nodes are the mostcommonly affected group of nodes [11]. Tuberculous that affects cervical lymph nodes represents about 50% ofEPTB even though it could vary in different areas [12]. A number of studies showed higher proportion of tuberculouslymphadenitis among patients in different areas [1316]. In a study conducted in the rural part of Ethiopia, 72.8% cases of TBLNwere found [17] and the cervical region was the most affected site (74.2%) followed bythe axillaries and inguinal lymph node regions, 20.3% and 4.3%, respectively [18].

In Ethiopia, there are only few reports concerning TBLN. Particularly in Gondar thereis no data that shows the magnitude of TBLN. This study attempts to assess themagnitude of TBLN and provide baseline information for health professionals andother concerned bodies. Therefore, the aim of the study was to assess magnitude ofTBLN from patients with lymph node aspirate in Gondar University Hospital.

Methods

A retrospective study of seven years period from January, 2003 to January, 2007 andJanuary, 2010 to January 2011 was carried out in Gondar University Hospitalpathology laboratory registration book. Gondar is found in North West part ofEthiopia, with in the Amhara regional state at about 748 and 175 kilometers awayfrom the capital Addis Ababa and Bahir Dar respectively. The population of the townis about 206,987 as stated in central statistical agency (CSA) of Ethiopia,2007.

The study populations were all patients with lymph node aspirate in Gondar UniversityHospital. The study subjects were all patients with lymph node aspirate betweenJanuary, 2003 and January, 2007 and January, 2010 to January, 2011. All patientswith lymph node aspirate between January, 2003 to January, 2007 and January, 2010 toJanuary, 2011 were included in the study by collecting data from the registrationbook. Records with incomplete data and demographic characteristics were excluded.TBLN diagnosis by cytology was made by examination of the presence of caseousnecrosis, epitheloid cell granulomas, multi nucleated giant cells, degeneratedepithelioid cell with neutrophil and hetrogeneous lymphoid population plusgranulomatous features.

Data were collected by investigators from registration book of Gondar universityHospital pathology laboratory after checking the completeness of patient’snecessary information like age, sex and fine needle aspiration cytology results.Data were analyzed using SPSS version 16 statistical package. Data were summarizedusing descriptive statistics. Association was done using Chi-square test and P-value<0.05 were considered statistically significant.

Ethical consideration

Data were collected after ethical clearance obtained from the School ofBiomedical and Laboratory Sciences, College of Medicine and Health Science,University of Gondar. After discussing the purpose and aim of the study,permission was obtained from the Head of Gondar University Hospital pathologylaboratory before the data collection.

Result

A seven year period retrospective study was carried out to determine the prevalenceof tuberculous lymphadenitis among patients examined by FNAC at Gondar UniversityHospital pathology laboratory. A total of 3,440 lymph node aspirates were examined.Out of these, 2,392 (69.5%) were found to have cytological findings suggestive ofTBLN and 1,048 (30.5%) cases were diagnosed as reactive lymphadenitis. Male 1,647(47.9%) to female 1,793 (52.1%) ratio of all study subjects were 0.9:1. Tuberculouslymphadenitis was found among 1,098 (45.9%) males and 1294 (54.1%) females with anoverall prevalence of 69.5% (Table 1). Females arerelatively more affected than males. Higher proportion of tuberculous lymphadenitiswere found among the age group of 15–24 years (28.5%) and 25–34 years(27.6%) (Table 1). The most affected sites were cervicallymph nodes 1135 (47.5%); axilliary 463 (19.4%) and submandibular 308 (12.9%). Theleast affected lymph node sites were the auricular, neck and other sites with 6%,4.2% and 0.5% respectively (Figure 1).
Table 1

Distribution of patients with tuberculous lymphadenitis by sex, age andsite of aspiration in Gondar University Hospital from January,2003– January, 2007 and January, 2010– January, 2011G.C.

Variables

Tuberculous lymphadenitis

X2

P value

 

Positive (%)

Negative (%)

  

Age

  

10.402

<0.001

<5

108(4.5)

113 (10.4)

  

5-14

296 (12.6)

221 (21.1)

  

15-24

682 (28.5)

255 (24.3)

  

25-34

660 (27.6)

246 (23.5)

  

35-44

347 (14.5)

119 (11.4)

  

≥45

299 (12.5)

94 (9.0)

  

Sex

  

12.271

<0.001

Male

1098 (45.9)

549 (52.4)

  

Female

1294 (54.1)

499 (47.6)

  

Site of aspiration

  

65.749

<0.001

Cervical

1135 (47.4)

423 (40.4)

  

Axillary

463 19.4)

272 (28.0)

  

Inguinal

150 (6.3)

60 (5.7)

  

Supraclavicular

208 (8.7)

43 (4.1)

  

Submandibular

308 (12.9)

182 (17.4)

  

Auricular

15 (0.6)

12 (1.1)

  

Neck

100 (4.2)

40 (3.8)

  

Others

13 (0.5)

16 (1.5)

  
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-435/MediaObjects/12889_2012_Article_5347_Fig1_HTML.jpg
Figure 1

Prevalence of tuberculous lymphadenitis by Site of aspiration amongpatients with lymph node aspirate in Gondar University Hospital fromJanuary, 2003– January, 2007 and January, 2010– January,2011 G.C.

The trend prevalence of TBLN over the years is fluctuating from 234 to 781 cases. Thetrend has continued with no great difference in 2003 and 2004 with a total of 623and 582 TBLN cases but lower in the year 2005 and 2006 that was 453 and 234 casesrespectively. In the year 2007, 2010 and 2011, the occurrence rises to 280, 487 and781 cases respectively (Figure 2).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-435/MediaObjects/12889_2012_Article_5347_Fig2_HTML.jpg
Figure 2

Trend prevalence of tuberculous lymphadenitis among patients with lymphnode aspirate in Gondar University Hospital from January, 2003–January, 2007 and January, 2010– January, 2011 G.C.

Age, sex and Site of aspiration were found to be significantly associated with TBLN.The age group of 15–24 years had the highest prevalence 682 (28.5%) followedby those of 25–34 years with 660 (27.6%) and 35–44 years with 347(14.5%) and >45 years with 299 (12.5%) (P-value < 0.001).Tuberculous lymphadenitis was higher in females than males with statisticallysignificant difference (p-value < 0.001). The most affected siteswere cervical lymph nodes, axillary and submandibular with statistically significantdifference (p-value < 0.001) (Table 1).None of the records documented the HIV status of patients.

Discussion

The prevalence of tuberculous lymphadenitis has been reported to be higher indeveloping countries like Ethiopia compared to developed countries [2]. In this study, the prevalence of TBLN was 69.5% which is identical withother study done in Tanzania with prevalence of 69.5% [14]. Other studies in Israel, Ethiopia and India showed similar figure withprevalence of 70%, 72.8% and 73.75% [17, 19, 20] but to some extent higher in another Indian study with prevalence of 83% [11]. The higher prevalence in this Indian study could be due to the samplesize and the time of study where awareness of TB was poor years ago. In contrast tothis study, the prevalence of TBLN was lower in Nigeria (24.45%), Pakistan (44%) andIndia (62%) [13, 15, 21]. This difference could be due to the different study methods used wheresmall sample size was used in Pakistan and in India. In addition, these studies wereonetime studies while our study is retrospective study.

The age profile of patients with TBLN showed involvement of younger patients with15–24 years old being affected accounting 28.5% followed by 25–34 yearsold accounting 27.6% of the cases. This finding is similar to other studies whereyounger than 30 years old are the commonest age group affected by this disease [18]. Similar study in Nigeria showed the age group of 10–19 years oldwith highest prevalence (28.1%) and 20–29 years with 21.8% which is consistentwith our study but the magnitude of the age group 0–9 years has prevalence of26.3% which is higher than our study [15]. Male to female ratio of our study is found to be 0.9:1 in which femalesbeing highly affected than males with no obvious preponderance in Israel, Pakistan,Nigeria, Ethiopia [11, 15, 18, 19]. Cervical lymph node was found to be the most commonly affected site(47.5%) compared to axillaries and other affected sites. This finding is inagreement with the previous study done in Ethiopia where cervical regions (74.2%)being mostly affected site followed by axillary (20.3%) and inguinal regions (4.3%) [18] and the study in India and Nigeria were also revealed similar manner [15, 21]. Historically, tuberculous cervical lymphadenitis has been more common inchildren and young adults [22].

The trend prevalence of TBLN cases in this study was variable over the yearsrevealing increment in the recent years. The variation in patterns of prevalence ofTBLN might be due to TB-HIV co-infection, other immune compromization (chronicdiseases) that causes immune suppression and increased risk of developingtuberculous, awareness of people about early diagnosis and treatment of TB patients.Especially in 2003 and 2004 before the era of anti retroviral therapy, the numbersof cases were higher compared to 2005 and 2006. The reason for decreased prevalencein the two consecutive years could be due to lack of service expansion in thehospital hence patients were appointed for more than a month and cannot come back tothe hospital. In 2007, 2010 and 2011, there was slight increment in number of cases.This might be due to the increased awareness of community about tuberculous and getdiagnosed than the previous years. Increased cases of malnutrition, chronic diseasesand MDR-TB could also exaggerate the rate of TBLN in these recent years. The otherreason could be increased patient health seeking behavior, service expansion wherepatients were not appointed not more than a week, well equipped laboratory serviceand increased number of pathologist by which the quality of the service increasedthe case detection rate as well as the number of patients compared to the previousyears. Previously there was no or one off and on type of pathologist but recentlythere are at least three actively working pathologists which might contribute forincreased case detection rate.

This study tried to assess yet untouched area in the study site. It is very valuableand informative which could give insights for health professionals and policy makersto address the problem. The HIV status of patients with TB (prior emphasis for EPTB)should have to be checked and documented. We couldn’t able to include othersocio demographic variables which has contribution for tuberculous because ofincomplete registration. Lack of the two years data in between due to fire accidenton pathology laboratory was also the dare for generalization to the overall trendprevalence.

Conclusion

The prevalence of TBLN in patients with lymph node aspirate in Gondar UniversityHospital is high. Among all lymph node sites, cervical region was the predominantlyaffected site compared to other sites. Female patients were more affected thanmales. It is important for pathologists to be conscious of tuberculous caseswhenever they encounter enlarged lymph node region. The HIV status of patients withTB (prior emphasis for EPTB) should have to be checked and documented. Furtherprospective and advanced studies are recommended to determine the specific etiologicagents and contributing factors of TBLN in the study area.

Declarations

Acknowledgement

We acknowledge the staff of Gondar University Hospital pathology laboratory fortheir cooperation during data collection.

Authors’ Affiliations

(1)
School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar

References

  1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C: Tuberculous. Lancet. 2003, 362 (9387): 887-899. 10.1016/S0140-6736(03)14333-4.View ArticlePubMed
  2. WHO | Tuberculous: WHO, cited 2012 Jun 8. Available from:[http://www.who.int/mediacentre/factsheets/fs104/en/],
  3. Ministry of Health, Ethiopia: Available from:[http://www.tbcta.org/Uploaded_files/Zelf/MinistryofHealthEthiopia1280040820.pdf],
  4. WHO: WHO | Global tuberculous control - epidemiology, strategy,financing. cited 2012 Jun 8. Available from:[http://www.who.int/tb/publications/global_report/2009/en/index.html],
  5. WHO: Global tuberculous report. 2012, Geneva
  6. Ethiopian Federal Ministry of Health: First Ethiopian National Population Based Tuberculous PrevalenceSurvey. 2011, Addis Ababa, Ethiopia,
  7. Ishikawa N: How to cope with the global tuberculous burden--experiences and perspectivesfor Japan’s international cooperation. Kekkaku. 2005, 80 (2): 89-94.PubMed
  8. Hasan Z, Tanveer M, Kanji A, Hasan Q, Ghebremichael S, Hasan R: Spoligotyping of Mycobacterium tuberculous isolates from Pakistan revealspredominance of Central Asian Strain 1 and Beijing isolates. J Clin Microbiol. 2006, 44 (5): 1763-1768. 10.1128/JCM.44.5.1763-1768.2006.PubMed CentralView ArticlePubMed
  9. Agarwal R, Srinivas R, Aggarwal AN: Parenchymal pseudotumoral tuberculous: Case series and systematic review ofliterature. Respir Med. 2008, 102 (3): 382-389. 10.1016/j.rmed.2007.10.017.View ArticlePubMed
  10. ibrt00i4p241.pdf [Internet]: cited 2012 Jun 8. Available from:[http://medind.nic.in/ibr/t00/i4/ibrt00i4p241.pdf],
  11. Dandapat MC, Mishra BM, Dash SP, Kar PK: Peripheral lymph node tuberculous: a review of 80 cases. Br J Surg. 1990, 77 (8): 911-912. 10.1002/bjs.1800770823.View ArticlePubMed
  12. Fain O, Lortholary O, Djouab M, Amoura I, Babinet P, Beaudreuil J: Lymph node tuberculous in the suburbs of Paris: 59 cases in adults notinfected by the human immunodeficiency virus. Int J Tuberc Lung Dis. 1999, 3 (2): 162-165.PubMed
  13. Majeed MM, Bukhari MH: Evaluation for granulomatous inflammation on fine needle aspiration cytologyusing special stains. Patholog Res Int. 2011, 2011: 851524-PubMed CentralPubMed
  14. Perenboom RM, Richter C, Swai AB, Kitinya J, Mtoni I, Chande H: Diagnosis of tuberculous lymphadenitis in an area of HIV infection andlimited diagnostic facilities. Trop Geogr Med. 1994, 46 (5): 288-292.PubMed
  15. Cadmus SIB, Oluwasola AO, Okolo CA, Bethrand AFN: Pattern of tuberculous lymphadenitis diagnosed by fine needle aspirationcytology at the University College Hospital, Ibadan, Nigeria. Afr J Med Med Sci. 2010, 39 (3): 193-197.
  16. Ahmed HGE, Nassar AS, Ginawi I: Screening for tuberculous and its histological pattern in patients withenlarged lymph node. Patholog Res Int. 2011, 2011: 417635-PubMed CentralPubMed
  17. Yassin MA, Olobo JO, Kidane D, Negesse Y, Shimeles E, Tadesse A: Diagnosis of tuberculous lymphadenitis in Butajira, rural Ethiopia. Scand J Infect Dis. 2003, 35 (4): 240-243. 10.1080/00365540310004027.View ArticlePubMed
  18. Bezabih M, Mariam D, Selassie S: Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology. 2002, 13 (5): 284-290. 10.1046/j.1365-2303.2002.00418.x.View ArticlePubMed
  19. Weiler Z, Nelly P, Baruchin AM, Oren S: Diagnosis and treatment of cervical tuberculous lymphadenitis. J Oral Maxillofac Surg. 2000, 58 (5): 477-481. 10.1016/S0278-2391(00)90004-1.View ArticlePubMed
  20. Kakkar S, Kapila K, Singh MK, Verma K: Tuberculous of the Breast. Acta Cytol. 2000, 44 (3): 292-296. 10.1159/000328467.View ArticlePubMed
  21. Arora B, Arora DR: Fine needle aspiration cytology in diagnosis of tuberculous lymphadenitis. Indian J Med Res. 1990, 91: 189-192.PubMed
  22. Perlman DC, D’Amico R, Salomon N: Mycobacterial infections of the head and neck. Curr Infect Dis Rep. 2001, 3 (3): 233-241. 10.1007/s11908-001-0025-4.View ArticlePubMed
  23. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/435/prepub

Copyright

© Muluye et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), whichpermits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.

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