Diagnosis of Lymph Node TB Simon Bailey Chest Physician Manchester Royal Infirmary Thur 6 th Nov 2014

Overview Epidemiology – local data Patients present Case presentation – What would you do? Approach peripheral and mediastinal LN TB Newer molecular techniques

Eurosurveillance, Volume 18, Issue 12, 21 March 2013

UNITED KINGDOM 2,360 49% % 130 3% 181 4% 320 7% 349 7% 150 3% 89 2% 61 1% %

5 Proportion of TB case reports by site of disease, UK, * With or without extra-pulmonary disease Tuberculosis in the UK: 2014 report Source: Enhance Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI) Data as at: May Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England

6 Tuberculosis case reports by site of disease, UK, 2013 Tuberculosis in the UK: 2014 report Source: Enhance Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI) Data as at: May Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England *With or without disease at another site **Percentage of cases with known site of disease (8751) ± For Scotland cases, this includes both cryptic and miliary site CNS-Central Nervous System Total percentage exceeds 100% due to infections at more than one site 2, % Cervical Axillary Inguinal Intramammary Mediastinal/ hilar

MRI Data Christine Bell

Scrofula – King’s Evil

Clinical Presentation Well. Only 44% symptoms Lee et al. Laryngoscope 102:Jan 1992 Painless Cold abscess Discharge Different teams – ENT(32%), Surgeons(3.7%), A+E(19%), Resp(33%), others(8%) - Haem M. Gilhooly, M Woodhead. Efficacy of diagnostic techniques used for the investigation of lymph node Tuberculosis Bacterial load low. Formalin doesn’t help!

5 Stages – Jones and Campbell Enlarged, firm, mobile, discrete nodes 2.Large rubbery nodes fixed to surrounding tissue 3.Central softening- abscess 4.Collar stud formation 5.Sinus tract formation Jones PG, Campbell PE. Br J Surg. 1962;50:

Lymph Node Stations

Diagnostic challenge NTM Bacterial Fungal Toxoplasmosis Sarcoidosis Cat scratch disease Cystic Hygoma Non specific hyperplasia Malignancy

Hierarchy of diagnosis 1.Clinical diagnosis – Hx and Exam 2.PathologicalCytological – FNA Histological – Surgical 3.AFB’s 4.Molecular – PCR and others. 5.Microbiological - SENSTIVITIES

39yr Nepalease man – R groin LN

‘Large groin LN. 2.7X3.7cm right paratracheal LN. 5mm R ML GGO’ Q. How do you proceed?

Q. What do you do next? 1.FNA to R groin? – cyto,micro,molecular and start Tx if granulomatous 2.FNA to R groin? – cyto,micro,molecular and start Tx only if PUS 3.Excisional biopsy R groin and await the results? 4.FNA to R groin, Bronchoscopy (wash R middle lobe) and EBUS (R paratracheal)

Q. What do you do next? 1.FNA to R groin? – cyto,micro,molecular and start Tx if pus 2.FNA to R groin? – cyto,micro,molecular and start Tx if granulomatous 3.Excisional biopsy R groin and await the results? 4.FNA to R groin, Bronchoscopy (wash R middle lobe) and EBUS (R paratracheal)

What we did 13/8 – FNA R groin in clinic. No PUS

What we did 13/8– FNA R groin in clinic. No PUS 13/8– Granulomatous lymphadenitis( ) WE HAD A GOOD THINK!! 18/8– FNA X2 – green needle. All for TB - Bronch – lavage R middle lobe - EBUS – R paratracheal node 18/8- Voractiv

R Groin FNA X2

Q. To FNA or to Biopsy? Peripheral nodes L P Ormerod et al. Int J Tuber Lung Dis 2011:15(3): patients 90%

Open biopsy gold standard TABLE IV. Comparison of results from diagnostic procedures Method used FNABOpen Biopsy (29 patients)(30 patients) Positive culture 18(62%)28(93%) Positive pathology 16(55%)23(77%) Positive AFB’s10(34%)11(37%) Non diagnostic5(17%) Lee et al, Cervical tuberculosis. Laryngoscope 102:Jan 1992

Or is it that Good? Table3. Diagnostic tests in tuberculous lymphadenitis ProcedureNo. PositiveTotal% positive Fine-needle aspirate Cytology AFB smear TB culture Excisional lymph node biopsy Histology AFB smear TB culture M. Y. Khan et al. Clinico-diagnostic experience with tuberculous lymphadenitis in Saudi Arabia ClinicalMicrobiologyandInfection,Volume6Number3,March2000

Location (Year)Culture (+)AFB (+)GI (+)Culture + GI (+)NAAT (+) California (‘92) Excisional Biopsy28/30 (93%)11/30 (37%)23/30 (77%)N/A FNA18/29 (62%)10/29 (35%)16/29 (55%)N/A France(‘99) Excisional Biopsy12/39 (31%)2/39 (5%)32/39 (82%)N/A FNA8/26 (31%)2/26 (8%)N/A California(‘99) FNA44/238 (18%)58/238 (24%)84/238 (35%)N/A India (‘00) Excisional Biopsy4/22 (18%)5/22(23%)13/22 (59%)17/22 (77%)15/22 (68%) FNA2/22 (10%)4/22 (18%)7/22 (32%)9/22 (41%)12/22 (55%) California (‘05) Excisional Biopsy24/34 (71%)15/39 (38%)36/31 (88%)N/A FNA48/77 (62%)5/19 (26%)47/76 (62%)N/A UK (‘10) FNA65/97 (67%)22/97 (23%)77/97 (79%)88/97 (91%)N/A TABLE 3,Primary Diagnostic Tests in Tuberculous Lymphadenitis Clinical Infectious Diseases 2011;53(6):555–562

Location (Year)Culture (+)AFB (+)GI (+)Culture + GI (+)NAAT (+) California (‘92) Excisional Biopsy28/30 (93%)11/30 (37%)23/30 (77%)N/A FNA18/29 (62%)10/29 (35%)16/29 (55%)N/A France(‘99) Excisional Biopsy12/39 (31%)2/39 (5%)32/39 (82%)N/A FNA8/26 (31%)2/26 (8%)N/A California(‘99) FNA44/238 (18%)58/238 (24%)84/238 (35%)N/A India (‘00) Excisional Biopsy4/22 (18%)5/22(23%)13/22 (59%)17/22 (77%)15/22 (68%) FNA2/22 (10%)4/22 (18%)7/22 (32%)9/22 (41%)12/22 (55%) California (‘05) Excisional Biopsy24/34 (71%)15/39 (38%)36/31 (88%)N/A FNA48/77 (62%)5/19 (26%)47/76 (62%)N/A UK (‘10) FNA65/97 (67%)22/97 (23%)77/97 (79%)88/97 (91%)N/A TABLE 3,Primary Diagnostic Tests in Tuberculous Lymphadenitis Clinical Infectious Diseases 2011;53(6):555–562 FNABIOPSY CULTURE+VE 10 – 67%18-93% GRANULOMA35-79%59-88%

Algorithm – P Ormerod 100 patients – 49 FNA 38(77.5%) PUS PUS – Culture +ve 71% PERIPHERAL LN - FNA PUS No PUS TB culture and treat BIOPSY L P Ormerod et al. Int J Tuber Lung Dis 2011:15(3):

Lymph Node Stations

Mediastinoscopy 9/14 patients with TB histology or culture +ve (64%) THORAX: 1978 EW Cameron 14/18 patients with TB histology orculture +ve (78%) THORAX: 1985 J B Cookson et al

EBUS – Endobronchial Ultrasound

Bronchoscope with small US at end. Direct visualisation and real time LN sampling Sedation Outpatient setting 1-1.5hr till discharge Lung cancer staging Used in benign mediastinal lymphadenitis

ENDOBRONCHIAL ULTRASOUND EBUS-TBFNA 20 patients. Diagnostic accuracy 79%. Cytology 83%. Culture +ve 63% J.Keane et al. AJRCCM 183; patients. 4 centres London 2 yr. Cytology 134(86%). Culture +ve 74(47%) Navani et al. Thorax. Oct2011;66(10):

Cmft lymph node data % 22 patients32 patients FNA/biopsy p=0.037 Mellisa Sherlock 4yr medical student

Hierarchy of diagnosis 1.Clinical diagnosis – Hx and Exam 2.PathologicalCytological – FNA Histological – Surgical 3.AFB’s 4.Molecular – PCR and others. 5.Microbiological - SENSTIVITIES

Molecular techniques - PCR

Nucleic acid amplification tests for the diagnosis of tuberculous lymphadenitis: a systematic review. The International journal of tuberculosis and lung disease2007, 11(11): papers. Sen 2-100%. Specificity %. False-ve/+ve 73 patients –Biopsy PCRSen 63.4% Spec 96.9% FNA PCRSen 17.1% Spec 100% ‘Did not increase the yield of rapid diagnosis’ Linasmita et al. Clin Infect Dis 2012

Molecular techniques – PCR/FISH 41 patients – biopsies 22 Histo +VE 19 Histo –ve PCR Sen 62.5% Spec 77.8% Modified DNA FISH Sen 71.1% Spec 84% ‘PCR and DNA FISH showed a signif increase in no cases detected and a higher sen/spec compared to traditional methods’ Mycobaterium tuberculosis complex detected by modified fluorescent in situ hybridization in lymph nodes of clinical samples. J Infect Dev Ctries 2012;6:58.

Molecular tests TB - cmft KitDirect samplesCulturesOrganism detectedResistance detectedResults within Hain DRplus (v2)Pulmonary: Smear + or - YesM.tb complexRIF/INH7 hours Hain DRsl (sl = second line) Pulmonary: Smear +YesM.tb complexFluoroquinolones, Aminoglycoside s, Cyclic peptides 7 hours Hain CM (CM = common mycobac.) NoYes13 most common Mycobacteria sp. None6 hours Cepheid GeneXpert TB/RIF Pulmonary: Smear + or - Not validatedM.tb complexRIF2 hours Hain Fluorotype MTBPulmonary and non- pulmonary (excl. blood) Not validatedM.tb complexNone3 hours Line probe assays Cepheid GeneXpert system Hain Fluorotype system

PCR-Cepheid/Xpert®MTB/RIF Steingart KR et al.(2014) "Xpert® MTB/RIF assay for pulmonary tuberculosis. COCHRANE DATABASE SYST REV Pulmonary TB Result within 2 hrs Limit detection 131 CFU/ml (AFB +ve – 10,000 CFU/ml) Rapid molecular detection of tuberculosis and rifampacin resistance NEngJMed 2010;363:

PCR-Cepheid/Xpert®MTB/RIF Steingart KR et al.(2014) "Xpert® MTB/RIF assay for pulmonary tuberculosis. COCHRANE DATABASE SYST REV Pulmonary TB Result within 2 hrs Limit detection 131 CFU/ml (AFB +ve – 10,000 CFU/ml) Rapid molecular detection of tuberculosis and rifampacin resistance NEngJMed 2010;363: Sputum SENSITIVITY 88% SPECIFICITY 99% ‘provides accurate results and allows rapid initiation of MDR-TB Tx pending culture + DST

Cepheid/Xpert®MTB/RIF – Extrapulm TB 18 studies4461 samples Accuracy of Xpert compared with culture Lymph node tissue or aspirates SEN 83.1% (95%CI %) V Cult. 81.2% (95%CI %) Eur Resp J 2014:Aug,44(2): Xpert MTB/RIF assay for the diagnosis of extra pulm TB: a systematic review and meta analysis

Cepheid/Xpert®MTB/RIF – Extrapulm TB 18 studies4461 samples Accuracy of Xpert compared with culture and a composite reference standard (CRS) Lymph node tissue or aspirates SEN 83.1% (95%CI %) V Cult. 81.2% (95%CI %) V CRS Eur Resp J 2014:Aug,44(2): Xpert MTB/RIF assay for the diagnosis of extra pulm TB: a systematic review and meta analysis WHO – recommends Xpert over conventional tests for the diagnosis of TB in lymph nodes and other tissues

Cepheid/Xpert®MTB/RIF - EBUS

Summary Lymph node TB is very common – cervical Culture/sensitivity gold standard Biopsy is better than FNA – caveats Mediastinum/hilar LN now easily accessible – reasonable results Molecular techniques – interesting/likely to become increasingly helpful

ANY QUESTIONS?