Search

Background This study evaluated the prevalence ofspreading pathways in nontuberculous mycobacteria(NTM) pulmonary infections according to nodulardistribution patterns seen on chest computed tomog-raphy (CT). Methods This study included 63 patients diagnosedwith NTM lung infections who underwent CT at ourinstitution. A retrospective analysis of CT images fo-cused on the presence and distribution of nodules, presence of intrathoracic lymphadenopathy and thepredominant side of infection in the lungs. The find-ings were classified into five groups ; centrilobular(bronchogenic spread), perilymphatic (lymphangiticspread), random (hematogenous spread), combinedpattern and no nodules present. The groups werethen compared according to other CT findings. Results Among 51 (81%) patients identified with anodular pattern on chest CT, 25 (39.8%) presentedwith centrilobular, 7 (11.1%) with perilymphatic, 6(9.5%) with random and 13 (20.6%) with combinednodular patterns but located in different areas of thelungs. The right side of the lungs was predominantin 38 cases (60.3%). Intrathoracic lymphadenopa-thy was evident in 20 patients (31.7%). Significantdifferences in distributions of nodular patterns wereseen in patients infected withMycoplasma aviumcomplex(MAC) associated with centrilobular pat-tern (p= 0.0019) andM. fortuitumassociated withrandom pattern (p= 0.0004). Some of the findingswere related to perilymphatic nodules between otherisolated species of NTM (p= 0.0379). Conclusion The results of this study showed a highproportion of perilymphatic nodules and right-sidedpredominance in the upper lobe, which, combinedwith intrathoracic lymphadenopathy is highly sugges-tive of the lymphangitic spread of lung NTM infec-tions.

Sarcoidosis is an inflammatory disease characterized by the formation of non-caseating granulomas in various organs and tissues. The clinical signs of sarcoidosis are determined by the number of affected organs, the degree of their structural and functional impairment, and the severity of inflammatory symptoms. The article presents a clinical observation of one of the forms of sarcoidosis — Lofgren’s syndrome, which is characterized by a triad of intrathoracic lymphadenopathy, acute arthritis and erythema nodosum. The diagnosis was confirmed histologically. Under the prescribed treatment, signs of acute inflammation reversed and the patient’s state improved. The authors emphasize that they do not recommend widespread use of systemic glucocorticosteroids in patients with this disease, since their use may be associated with a relapsing course.

Bu çalışma, 2019 yılında Bodrum[Türkiye]'da düzenlenen TRS Kongresi'nde bildiri olarak sunulmuştur. Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established diagnostic tool for lung cancer, sarcoidosis, and suspected metastatic extra-thoracic malignancy (ETM). Patients with primary ETM often have hypermetabolic mediastinal/hilar lymph node enlargement in the PET-scan done for initial staging or post treatment follow-up. We aimed to determine the diagnostic performance of EBUS-TBNA and the relationship between PET-SUV values and diagnosis of malignancy metastasis in patients with ETM. Materials and Methods: Results of EBUS-TBNA in ETM patients with suspected MLN metastasis were retrospectively analysed (May 2016 to July 2019). Non-malign results were confirmed for surgery or clinical/radiological follow-up. Lymph nodes with a high FDG-uptake (SUV > 2.5, MLN) were reported as suspicious for metastasis. Results: Of the 588 EBUS procedures, 109 were included in the analysis. Patient' mean age was 62.5 +/- 10.1 years; there were 35 men and 74 women. Primary malignancies were breast cancer in 33, gastrointestinal in 23, female genital tract in 17, head and neck in 14, genitourinary cancer in 13, malignant melanoma in 6, sarcoma in 2 and kaposi sarcoma in 1. According to EBUS-TBNA smear and cell block histopathologic evaluations, 16 patients' results (14.7%) were malignant compatible with metastasis of ETM. Among the 93 patients with non-malignant diagnosis, EBUS-TBNA revealed a granulomatous lympadenitis compatible with sarcoid reaction in 7 and tuberculosis in 2. A total of 9 patients underwent surgical procedures after EBUS-TBNA, with a definitive histological diagnosis of granulomatous lymphadenitis in 2, malignancy in 5 and, reactive lymph node in 2. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of EBUS-TBNA were 76.19% (95% CI 52.83-91.78), 100% (95% CI 95.89-100.00), 100%, 94.62% (95% CI 89.12-97.12) and 95.4%, respectively. Conclusion: EBUS-TBNA sampling has high diagnostic performance. Histopathological confirmation requirement for MLN should be kept in mind in patients with ETM, even they have negative EBUS results. Giriş: Endobronşial ultrason-kılavuzluğunda transbronşial iğne aspirasyonu (EBUS-TBİA), akciğer kanseri, sarkoidoz ve metastatik ekstra-torasik malignitelerde (ETM) iyi tanımlanmış bir tanı yöntemidir. Primer ETM evrelemesi ve tedavi sonrası takipte, mediastinal/ hiler lenf nodu (MLN) genişlemesi sık görülmektedir. ETM tanısı olan hastalarda EBUS-TBİA tanı performansı, PET-SUV değerleri ile malign metastaz tanısı arasındaki ilişkiyi araştırmayı hedefledik. Materyal ve Metod: Şüpheli malign metastaz olan ETM hastalarında yapılan EBUS-TBİA sonuçları retrospektif olarak analiz edildi (Mayıs 2016-Temmuz 2019). Malign olmayan sonuçlar cerrahi veya klinik/radyolojik takip ile konfirme edildi. Yüksek FDG-uptake olan (SUV > 2.5, MLN) lenf nodları metastaz şüpheli olarak raporlandı. Bulgular: Toplam 588 EBUS işleminden 109'u analize dahil edildi. Hastaların ortalama yaşı 62.5 ± 10.1; 35'i erkek, 74'ü kadın idi. Primer malignitelerin, 33’ü meme kanseri, 23'ü gastrointestinal, 17'si kadın genital sistem, 14'ü baş-boyun, 13’ü genitoüriner kanser, 6'sı malign melanom, 2'si sarkom ve 1'i kaposi sarkomu idi. EBUS-TBİA yayma ve hücre bloğu histopatolojik sonuçlarına göre 16 hastada (%14.7) ETM metastazı ile uyumlu malignite saptandı. Malign olmayan 93 hastadan 7'sinde sarkoid reaksiyon ile uyumlu granülomatöz lenfadenit, 2'sinde tüberküloz, 5'inde malignite bulundu. EBUS-TBİA sonrası cerrahi ile toplam 9 hastanın 2'sinde granülomatöz lenfadenit, 5'inde malignite ve 2’sinde reaktif lenf nodu saptandı. EBUS-TBİA için toplam duyarlılık, özgüllük, pozitif prediktif değer, negatif prediktif değer ve tanı doğruluğu, sırasıyla %76.19 (%95 GA 52.83-91.78), %100 (%95 GA 95.89-100.00), %100, %94.62 (%95 GA 89.12-97.12) ve %95.4 olarak saptandı. Sonuç: EBUS-TBİA örneklemesi tanı performansı yüksek bir yöntemdir. Negatif EBUS sonuçları olsa da, MLN genişlemesi olan ETM tanılı olgularda histopatolojik doğrulama gerekliliği akılda tutulmalıdır.

Background: A subgroup of patients with PBC has concomitant lung involvement. Occasionally lung involvement (LI) occurs first and/or predominates in the clinical course. The objective of our trial was to assess association of LI with other clinical and laboratory signs in PBC. Methods: 68 patients with PBC divided into 2 groups (with and without LI) were observed in Tareev clinic (Sechenov University) in 2018-2020. Diagnosis, age, gender, clinical and laboratory signs have been compared in both groups. Results: Computed tomography revealed LI in 36 (52,9%) cases: 27 – interstitial lung disease (ILD), 4 – multiple nodular lesions, 3 – combined interstitial and nodular lesions and 2 – bronchiolitis. Intrathoracic lymphadenopathy was observed in 15 (22.1%) patients. Among all patients with ILD, 6 (8.8%) had CT-pattern of organizing pneumonia, 1 (1.5%) – non-specific interstitial pneumonia, 1 (1.5%) – usual interstitial pneumonia, 9 (13.2%) – undifferentiated interstitial pneumonia and 9 (13.2%) – sarcoid-like pattern of ILD. Such laboratory tests as ESR (41.3±19.1 and 30.3±20.2 mm/h with and without LI; p = 0.025), IgM level (3.80±2.53 and 2.49±2.27 g/l with and without LI; p Conclusion: The results indicate the association between the presence of LI and some laboratory features in patients with PBC. Some patients may have pulmonary onset that must be taken into account in the diagnosis of this disease.

Background: Intrathoracic lymphadenopathy is a common problem in people living with human immunodeficiency virus (PLHIV). There is, however, limited literature on the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in these patients. Herein, we describe our experience with EBUS-TBNA in PLHIV. Materials and Methods: This is a retrospective study of all PLHIV who underwent EBUS-TBNA for the evaluation of intrathoracic lymphadenopathy. We also perform a systematic review of the English literature for studies reporting the yield of EBUS-TBNA in PLHIV. Results: During the study, 1733 EBUS procedures were performed. Among them, 22 (1.3%) were performed in PLHIV. The median age of the individuals (18.2% women) was 46 years. The median CD4 count was 144 cells/mm3. The common lymph node stations involved were station 7, 4R, and 11 L. On endosonographic examination, heterogeneous appearance and coagulation necrosis sign were observed in 14 (63.6%) and 11 (50%) individuals, respectively. EBUS-TBNA was diagnostic in 17 (77.3%) individuals, with tuberculosis being the most common diagnosis (68.2%). There were no major complications related to the procedure. Our systematic review yielded two studies describing the use of EBUS-TBNA in PLHIV. The mean diagnostic yield of EBUS-TBNA was 71% (95% confidence interval: 56–84). Conclusions: EBUS-TBNA is a safe and useful procedure in the evaluation of intrathoracic lymphadenopathy in PLHIV.

Objective: To determine the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in non-neoplastic patients with isolated intrathoracic lymphadenopathy (IL). Methods: This was a retrospective study of patients with isolated IL referred for EBUS-TBNA. We calculated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EBUS-TBNA in the diagnosis of granulomatous, reactive, and neoplastic lymphadenopathy. In cases of nonspecific granulomas, reactive lymphadenopathy, or inconclusive results, a definitive diagnosis was established by other diagnostic procedures or during a follow-up period of at least 18 months. Results: Among the 58 patients included in the study, EBUS-TBNA established a diagnosis of granulomatous disease in 22 (38%), reactive lymphadenopathy in 15 (26%), cancer in 8 (14%), and other diseases in 3 (5%). Results were inconclusive in 10 (17%), the diagnosis being established by other bronchoscopic procedures in 2 (20%) and by surgical procedures in 8 (80%). A final diagnosis of reactive lymphadenopathy was established in 12. Of those, 11 (92%) had their diagnosis confirmed during follow-up and 1 (8%) had their diagnosis confirmed by mediastinoscopy. In another 3, a final diagnosis of sarcoidosis or neoplasm was established. For the diagnosis of granulomatous disease, neoplasms, and reactive lymphadenopathy, EBUS-TBNA was found to have a sensitivity of 73%, 68%, and 92%, respectively; a specificity of 100%, 100%, and 93%, respectively; an accuracy of 86%, 93%, and 93%, respectively; a PPV of 100%, 100%, and 80%, respectively; and an NPV of 78%, 92%, and 98%, respectively. Conclusions: In non-neoplastic patients, granulomatous disease and reactive lymphadenopathy appear to be common causes of isolated IL. EBUS-TBNA shows promising results as a first-line minimally invasive diagnostic procedure. The results obtained by EBUS-TBNA can be optimized by examining clinical and radiological findings during follow-up or by comparison with the results obtained with other bronchoscopic methods. RESUMO Objetivo: Determinar o rendimento diagnóstico da endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, aspiração transbrônquica com agulha guiada por ultrassonografia endobrônquica) em pacientes não neoplásicos com linfonodomegalia intratorácica (LI) isolada. Métodos: Estudo retrospectivo com pacientes com LI isolada encaminhados para EBUS-TBNA. Foram calculados a sensibilidade, especificidade, precisão, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) da EBUS-TBNA no diagnóstico de linfadenopatia granulomatosa, reacional e neoplásica. Em casos de granulomas inespecíficos, linfadenopatia reacional ou resultados inconclusivos, o diagnóstico definitivo foi estabelecido por meio de outros procedimentos diagnósticos ou ao longo de pelo menos 18 meses de acompanhamento. Resultados: Nos 58 pacientes incluídos, a EBUS-TBNA permitiu que se estabelecesse o diagnóstico de doença granulomatosa em 22 (38%), linfadenopatia reacional em 15 (26%), câncer em 8 (14%) e outras doenças em 3 (5%). Os resultados foram inconclusivos em 10 (17%), nos quais o diagnóstico foi feito por meio de outros procedimentos broncoscópicos, em 2 (20%), ou de procedimentos cirúrgicos, em 8 (80%). O diagnóstico final de linfadenopatia reacional foi feito em 12. Destes, 11 (92%) receberam confirmação diagnóstica durante o acompanhamento e 1 (8%), por meio de mediastinoscopia. Em outros 3, o diagnóstico final foi sarcoidose ou neoplasia. Para o diagnóstico de doença granulomatosa, câncer e linfadenopatia reacional, a EBUS-TBNA apresentou sensibilidade de 73%, 68% e 92%, respectivamente; especificidade de 100%, 100% e 93%, respectivamente; precisão de 86%, 93% e 93%, respectivamente; VPP de 100%, 100% e 80%, respectivamente; VPN de 78%, 92% e 98%, respectivamente. Conclusões: Em pacientes não neoplásicos, doenças granulomatosas e linfadenopatia reacional parecem ser causas comuns de LI isolada. A EBUS-TBNA apresenta resultados promissores como procedimento diagnóstico minimamente invasivo de primeira linha. Os resultados obtidos pela EBUS-TBNA podem ser otimizados pelos achados clínicos e radiológicos durante o acompanhamento ou pela comparação com os resultados de outros métodos broncoscópicos.

Mycobacterium tuberculosis (MTB) as a causative organism of empyema thoracis is rare, especially in children. An 8-year-old boy with tuberculous empyema and no history of contact with tuberculosis presented with minimal symptoms other than mild deformity of the chest wall. He had been vaccinated with bacillus Calmette-Guerin. A chest CT scan demonstrated intrathoracic lymphadenopathy, thickened and calcified pleural rind and rib thickening adjacent to the empyema. The diagnosis was confirmed by post-operative histopathological examination, positive acid-fast stains and DNA PCR. In countries with a high burden of tuberculosis, MTB should be considered in the differential diagnosis of empyema despite minimal symptoms.

Intrathoracic tuberculous (TB) lymphadenitis is a diagnostic challenge to the clinician. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can obtain a sample from the affected lymph node, the diagnosis of TB lymphadenitis by cytopathology remains inaccurate.To evaluate the efficacy of EBUS-TBNA rinse fluid TB polymerase chain reaction (PCR) assay for the diagnosis of intrathoracic TB lymphadenitis.A retrospective study was conducted on 102 patients who underwent EBUS-TBNA for diagnostic evaluation of intrathoracic lymphadenopathy. EBUS-TBNA specimens were evaluated by cytopathological examination. Rinse fluid of the needle was routinely submitted for acid-fast bacillus (AFB) staining, mycobacterial culture, and TB-PCR using the AnyplexOf 102 patients, 16 were diagnosed with intrathoracic TB lymphadenitis by either microbiology, cytopathology, or on clinical grounds. The sensitivity, specificity, positive predictive value, and negative predictive value of rinse fluid TB PCR assay were 56.2%, 100.0%, 100.0%, and 92.5%, respectively. Using the area under the ROC curve (AUC) as a measure of a diagnostic performance, TB-PCR had the highest AUC, compared with mycobacterial culture, AFB smear, and finding of necrotizing granulomatous inflammation (0.78, 0.75, 0.56, and 0.72, respectively). A combination of TB PCR, mycobacterial culture, and finding of necrotizing granulomatous inflammation provided the best diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value, and AUC of 75.0%, 100.0%, 100.0%, 95.6%, and 0.88, respectively).EBUS-TBNA rinse fluid TB-PCR is useful in the diagnosis of intrathoracic TB lymphadenitis. Combining TB-PCR with mycobacterial culture and cytopathological findings improved the diagnosis performance.

Objective: to study the clinical, laboratory, and radiographic characteristics of early-stage sarcoidosis in a cohort of patients referred to a rheumatology center. Materials and methods. The investigation enrolled 125 patients (104 women and 21 men; mean age 42 ± 12 years) with the clinical and X-ray signs of Lofgren’s syndrome. All the patients were referred to a rheumatology center with diagnosed erythema nodosum (EN). The median disease duration was 1 (0.5–2.0) month. All the patients underwent comprehensive clinical examination and laboratory and instrumental studies of biochemical and immunological parameters, chest X-ray or computed tomography (CT), as well as postmortem examinations of skin and subcutaneous fat biopsy specimens were done in 15 cases. Results. EN was located on the lower leg mostly on its anterior surface (97 %), hip (35 %), upper limbs (25 %), and trunk (3 %). There was a symmetric pattern of eruptions in 50 % of the patients. Nodules fused into a conglomerate in 48 %. More than 50 % injury of the shin surface (68 %) was directly related to the number of nodules (p < 0.001; r = 0.60) and the level of C-reactive protein (p = 0.006; r = 0.38). There was a direct relationship of the number of nodules to the duration of EN (p = 0.04; r = 0.20) and their trend of fusion (p < 0.001; r = 0.39). The signs of joint injury were found in 106 (85 %) patients. The predictors of the CT frosted glass phenomenon were male sex (odds ratio (OR) 6.5; confidence interval (CI) 1.2–35.0; p = 0.026) and the presence of nodular conglomerates (OR 4.8; CI 1.4–16.1; p = 0.01). EN did not recur and articular syndrome virtually completely regressed in 90% of the patients during one-year follow-up. Conclusion. Patients with acute sarcoidosis require that physicians of different specialties, including rheumatologists, should coordinate their actions to determine the volume of further examination and to use adequate treatment.

Key Clinical Message Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has been widely used for diagnosing intrathoracic lymphadenopathy. Here, we present two cases of endobronchial polyp formation after an EBUS‐TBNA for suspicious malignant lymph nodes. An inflammatory polyp should be considered as a possible differential diagnosis for a newly developed mass after an EBUS‐TBNA.

Isolated intrathoracic lymphadenopathy (IT-LAP) is clinically challenging because of the difficult anatomic location and wide range of associated diseases, including tuberculosis (TB). Although sampling via endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histopathology is a major development, there is still room for improvement. This study aimed to investigate an algorithmic approach driven by EBUS-TBNA and conventional bronchoscopy to streamline the management of IT-LAP. Methods: Eighty-three prospectively enrolled patients with IT-LAP were subjected to an EBUS-TBNA diagnostic panel test (histopathology, cytology, and microbiology) and underwent conventional bronchoscopy for bronchoalveolar lavage. The results were structured into an algorithmic approach to direct patient treatment, workup, or follow-up. Results: The diagnostic yields of EBUS-TBNA based on histopathology were similar for each disease entity: 77.8% for malignancy, 70.0% for TB, 75.0% for sarcoidosis, 80.0% for anthracosis, and 70.0% for lymphoid hyperplasia (p = 0.96). The incidence of malignancy was 10.8% for total IT-LAP patients, and 12.0% and 33.7% for patients with TB and sarcoidosis, respectively. Thirty-five (42.2%) patients were symptomatic. The leading diagnosis was sarcoidosis (60%), followed by TB (20%), malignancy (11.4%), lymphoid hyperplasia (5.7%), and anthracosis (2.9%). By logistic regression analysis, granulomatous disease (odds ratio: 13.45; 95% confidence interval: 4.45–40.67, p

Background: Conventional TBNA has been used in the evaluation of intrathoracic lymphadenopathy with varied success rates depending upon size, site and aetiology of the node. Although mediastinoscopy has higher successes but it comes at the cost of general anaesthesia, more complications and limited access to the inferior and posterior mediastinum. Endobronchial ultrasound guided transbronchial needle aspiration has the advantage of real time nodal sampling with good success rates and minimal complications. The aim of our study was to assess the diagnostic yield and safety of EBUS TBNA in the evaluation of intrathoracic lymphadenopathy.Methods: This prospective observational study was conducted at government chest diseases hospital Srinagar over a period of two years from January 2016-December 2018 on 100 consecutive patients who underwent EBUS TBNA procedure for evaluation mediastinal and hilar lymphadenopathy. The data was collected and analysed for diagnostic yield and safety profile.Results: Out of the 100 subjects included in the study 52% were males and 48% were females. Mean age of the study population was 48.5±16.65 years. Most of the nodes sampled were subcarinal in location followed by paratracheal and hilar group. Granulomatous pathology (tuberculosis and sarcoidosis) was present in 41 patients followed by malignancy in 39 patients. Anthracosis was the cause of lymphadenopathy in 4 of the patients. There were no major complications in our study.Conclusions: EBUS TBNA is an effective and safe procedure for evaluation of mediastinal and hilar lymphadenopathy.

Background and Aims Intrathoracic lymphadenopathy usually occurs as a result of neoplasm, granulomatous diseases, infections or reactive hyperplasia. Conventional transbronchial needle aspiration (C-TBNA) is a cheap and safe procedure for diagnosing intrathoracic lymphadenopathy. The aim of this study was to assess the learning curve and diagnostic accuracy of C-TBNA after an observational education programme. Methods In the present study, we retrospectively evaluated our first 62 C-TBNA procedures at Erciyes University between May 2012 and December 2012 after an observational education programme. The first 31 patients were defined as group A, and the second 31 patients as group B. Results One hundred and seven lymph nodes were sampled in 62 patients by C-TBNA. Adequate lymph node samples were obtained in 52 of the 62 patients (83.8%). In these 52 patients, two patients had a diagnosis of ‘suspicious of malignancy’ by C-TBNA, and these patients were excluded from the analysis. In the remaining 50 cases who had adequate results, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy per patient were 80.6%, 92.9%, 96.7%, 65.0% and 84.0%, respectively. The diagnostic accuracy rates of C-TBNA for Group A and B were 72.0% (18/25) and 96.0% (24/25), and the difference was statistically significant (P

Endobronchial ultrasound (EBUS) findings can be used for benign/malignant differentiation of lymph nodes (LNs). Recently, EBUS elastography has been introduced as a complementary modality in the evaluation of intrathoracic lymphadenopathy. We evaluated the ability of EBUS elastography to differentiate between benign and malignant LNs.A prospective study was conducted on patients sent for evaluation of intrathoracic lymphadenopathy. LNs were classified qualitatively according to elastographic colour pattern: type 1, predominantly non-blue; type 2, partly blue, partly non-blue and type 3, predominantly blue. Quantitative elastography of LNs was measured by the strain ratio (SR). Qualitative and quantitative elastographies were compared for the final diagnosis of LNs.There were 120 LNs from 72 patients who underwent EBUS elastography. The final diagnosis included 96 malignant and 24 benign LNs. All of the 16 type 1 LNs proved to be benign diseases, while 95 of the 101 type 3 LNs were finally diagnosed as malignancies. Three LNs classified as type 2 proved to be two benign and one malignant. Malignant LNs presented a higher median SR than benign LNs (73.50 vs 1.29, P = 0.001). An SR of2.5 and non-type 1 elastographic pattern achieved similar diagnostic performance in benign/malignant differentiation (sensitivity, 100% vs 100%; specificity, 70.8% vs 66.7%; positive predictive value, 93.2% vs 92.3%; negative predictive value, 100% vs 100%).EBUS elastography is a promising diagnostic modality for the differentiation of benign and malignant LNs during EBUS-guided transbronchial needle aspiration (TBNA). Qualitative and quantitative EBUS elastographies provide similar diagnostic performance.

The presence of intrathoracic lymphadenopathy in patients with suspected malignancy remains concerning, often prompting further evaluation with tissue sampling. The presence of nodal granulomatous inflammation in patients with underlying malignancy is well reported. However, review of 3 recent large trials of endobronchial ultrasound-guided transbronchial needle aspiration in patients with granulomatous inflammation and malignancy did not identify the presence of coexisting, intranodal malignancy, and granulomatous inflammation, rather these diagnoses remained nodally exclusive. We present a case of coexisting granulomatous inflammation and metastatic carcinoma within the same lymph node aspirates, reviewing the potential diagnostic pitfalls and implications of this rare occurrence.

Transbronchial needle aspiration (TBNA) is an effective, safe and cost-effective technique that allows for sampling of the mediastinal lymph node and peribronchial lesions. It is used in bronchogenic carcinoma staging, peribronchial and submucosal lesions, diagnosis of sarcoidosis and tuberculosis, differentiating submucosal invasion, and in diagnosing mediastinal masses. From our experience at the University of Abant Izzet Baysal and from a review of the literature, we discuss the adequacy and the differential diagnosis of aspiration material obtained by TBNA and cytopathological-histopathological evaluation in intrathoracic lymphadenopathies to increase the success rate of the TBNA method.

Objectives: The aim of this study is to assess the value of chest radiographs (CXRs) and sputum examinations in detecting pulmonary involvement of tuberculosis (TB) in patients with extra-pulmonary tuberculosis (EPTB). Materials and Methods: A retrospective analysis was performed among 248 EPTB patients with culture-proven diagnosis of tuberculosis seen between January 2001 and December 2007 at a tertiary teaching hospital, Riyadh, Saudi Arabia. Demographics, clinical, laboratory and radiological findings were reviewed and assessed. This study was approved by the hospital ethics and research committee. Results: One hundred twenty five of 233 EPTB patients (53.6%) had abnormal CXR findings. There was a significant difference in the occurrence of positive sputum culture results between patients with abnormal CXR findings (30/57) and those with normal CXR findings (4/17) (P = 0.04). Of 17 HIV-negative/unknown HIV-status EPTB patients with normal CXR results, 4 patients (23.5%) had positive sputum culture results. Intrathoracic lymphadenopathy (P < 0.001), pleural TB (P < 0. 001) and disseminated TB (P = 0.004) were associated with an increased risk of abnormal CXR findings. Patients with cough (52.9%), weight loss (41.2%) and night sweats (26.5%) are more likely to have positive sputum culture results. Conclusion: CXR findings are predictive of positive sputum culture results. However, the rate of normal CXR among EPTB patients with positive sputum culture results was relatively high. Therefore, respiratory specimen cultures should be obtained in TB suspects with a normal CXR to identify potentially infectious cases of TB.

Endobronchial ultrasound (EBUS) features have been found to be a useful tool in differentiating malignant from benign lymph nodes, but the use of these features to distinguish benign intrathoracic lymphadenopathies, including tuberculosis, sarcoidosis and reactive lymphadenitis, has not been established. The goal of this study was to evaluate the use of EBUS features in predicting tuberculosis, sarcoidosis, and non-specific inflammation. One hundred eighty-eight patients with suspected benign lymphadenopathy were included in the study. The EBUS features studied were short axis, shape, calcification, central hilar structure, necrosis sign, margins, echogenicity, clustered formation and vascular patterns. The sonographic findings were confirmed by clinicopathologic results. EBUS-Guided transbronchial needle aspiration was performed on 452 lymph nodes. Thirty-seven tuberculous nodes, 193 sarcoid nodes and 150 reactive nodes were retrospectively analyzed. Excluded were 72 nodes. Multivariate analysis revealed that presence of the necrosis sign and absence of the clustered formation are independent factors predictive of tuberculous nodes. Short axis >1 cm, absence of central hilar structure, distinct margins, presence of clustered formation and non-hilar perfusion were predictive of sarcoid nodes. Presence of central hilar structure, absence of clustered formation and vascular pattern (hilar perfusion or avascularity) were predictive of reactive lymphadenitis. The sum score model of these combined predictive factors indicated that the best diagnostic accuracies for predicting tuberculous nodes, sarcoid nodes and reactive lymphadenitis were 77.1%, 89.2% and 87.1%, respectively. Sonographic features could be helpful in differentiating the type of benign intrathoracic lymphadenopathy during EBUS examination.

Aims: Patients with suspected tuberculosis without pulmonary lesions and with intrathoracic lymphadenopathy often pose a diagnostic challenge. The aim of this study was to describe the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with isolated intrathoracic lymphadenopathy due to tuberculosis (TB). Materials and methods: Cases with tuberculous lymphadenitis (TBLA) as the final diagnosis were analysed among patients in whom EBUS-TBNA had been performed. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, pathological findings, and microbiological results were recorded. All patients received 6-month antituberculous treatment, followed-up regularly and recovered both on clinical and radiological basis. Results: Fourty-four patients were included. EBUS-TBNA diagnosed TB intrathoracic lympadenopathy in 42 (95.4%) patients. In 2 patients, EBUS-TBNA was not able to confirm a diagnosis and additional procedures were required. Cytopathological findings alone revealed TB in 32 (72.7%) patients. One of the patients (2.2%) was smear positive while microbiological investigations provided a positive culture of TB in 22 (50%) patients. TB culture was positive in 10 of 12 patients in whom cytopathologic evaluation was not able to diagnose. Addition of mycobacterium culture to cytopathologic investigation has improved the diagnostic yield from 72.7% to 95.4%. Conclusion: EBUS-TBNA is a safe and effective first line investigation for evaluat- ing isolated intrathoracic tuberculous lympadenopathy. Addition of mycobacterium culture to cytopathologic investigation improves the sensitivity of EBUS-TBNA.

BACKGROUND Tuberculous meningitis (TBM) is diagnosed based on a combination of clinical, laboratory and radiological findings, including signs suggestive of tuberculosis (TB) on a standard chest X-ray (CXR). METHODS We describe the radiological features suggestive of intrathoracic TB in children diagnosed with TBM during a prospective evaluation of TBM suspects seen at Tygerberg Children's Hospital, Cape Town, South Africa. RESULTS Of 84 children treated for TBM, 31 (37%) had 'definite' TBM, 45 (55%) 'probable' TBM and 8 (9%) 'possible' TBM. In total, 37 (44%) TBM patients had CXR findings suggestive of TB, 9 (11%) with disseminated (miliary) TB. Only 1 in 4.39 children aged ≤3 years with TBM had suggestive CXR findings. The presence of complicated intrathoracic lymph node disease was significantly higher in children aged ≤3 years (OR 21.69, 95%CI 2.73-172.67, P < 0.01). Among 6 human immunodeficiency virus infected children, 3 (50%) had intrathoracic lymphadenopathy. CONCLUSION The majority of the children with TBM, including the very young, did not have signs suggestive of TB on CXR.

To evaluate the etiology and differential features of intrathoracic lymphadenopathy (LAD) in HIV patients, chest computed tomography (CT) records from an 18-month period were reviewed to identify all HIV-positive patients with intrathoracic LAD (nodal sizeor = 1 cm). Medical records were reviewed for the documentation of specific diseases causing LAD and the CD4 count at the time of imaging. Of 45 HIV-positive patients with LAD, 40 had specific diagnoses including 22 (55%) infections and 17 (43%) tumors; one patient had both (3%). Mycobacterial disease accounted for 78% of infections; five cases were secondary to bacterial pneumonia and sepsis. Of tumors, lymphoma (7 cases, 39%) was most common, followed by lung cancer, germ cell tumors, and Kaposi's sarcoma. Mean CD4 cell count in patients with tumors was much higher than in patients with infections (314 vs. 62, p.01). Patients with tumors were somewhat more likely than patients with infections to demonstrate axillary adenopathy (29 vs. 5%, p = .068). Cavitary disease was only observed in patients with infections (27%, p.03). CT and clinical findings may help direct the differential diagnosis of LAD in AIDS, and promote expedient definitive diagnosis and therapy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming more common for diagnosing intrathoracic lymphadenopathy, including tuberculous lymphadenopathy. We herein report two cases of complications possibly related to EBUS-TBNA for tuberculous lymphadenopathy. The first patient was a 26-year-old woman who developed intrabronchial polypoid granulomas exclusively at puncture sites two months after undergoing EBUS-TBNA. Although endobronchial extension may occur, the risk of aggravation caused by puncture should be considered. The second patient was a 39-year-old woman with transient smear-positive bloody sputum that developed immediately after EBUS-TBNA and persisted for three days. Temporary isolation following EBUS-TBNA should be considered for possible tuberculous lymphadenopathy.

BACKGROUND Traditionally, aspiration with high negative pressure is recommended to obtain a specimen in transbronchial needle aspiration (TBNA). Undeniably, however, the assistant experiences difficulty in the generation of the negative pressure and precise control of the syringe while performing the procedure. OBJECTIVE To evaluate the effectiveness of the autoaspiration method created by our plunger lock in comparison with the conventional manual aspiration in the diagnosis of intrathoracic lymphadenopathy by TBNA. METHODS A prospective study was conducted on all patients referred for diagnostic TBNA of enlarged intrathoracic lymph nodes. Both automatic and manual aspiration techniques were performed after the needle had been completely inserted into the nodes. The diagnostic yield and the numbers of diagnostic cells or benign lymphoid cells obtained by each technique were compared in the same node. RESULTS A total of 31 intrathoracic lymph nodes in 24 patients were prospectively studied. Twenty-four nodes (77.4%) were malignancies whereas 7 nodes (22.6%) were benign disease. Adequate lymph node samples were obtained in 30 targets (96.8%), and TBNA revealed definite diagnosis for 25 nodes (80.6%). Both aspiration techniques showed exactly the same diagnostic yield. However, the autoaspiration technique provided significantly more adequate samples than manual aspiration techniques did (P=0.003). CONCLUSION The autoaspiration method using our plunger lock was superior to the manual method in obtaining the numbers of adequate samples in TBNA procedures.

I read with interest the article on the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in tuberculous intrathoracic lymphadenopathy by Navani et al .1 EBUS-TBNA has been validated for the assessment of mediastinal nodes in lung cancer2 and to obtain a diagnosis in (presumed) centrally located lung cancer3 or sarcoidosis.4 In addition to a recent report,5 the study by Navani et …

Amyloidosis is an unusual cause of mediastinal lymphadenopathy. A localized form of amyloidosis manifesting solely in the intrathoracic lymphnode is extremely rare. We describe a case of intrathoracic lymphadenopathy caused by a localized form of amyloidosis. Calcification has been reported in amyloidosis; however, it has been considered as non-specific. In our case, serial CT carried out over a period of 3 years and 3 months showed an unusual and unsynchronized pattern of enlargement and calcification.

Study objectives Endobronchial ultrasonography (EBUS) is used as guidance for transbronchial needle aspiration (TBNA), and real-time imaging of the needle position cannot be confirmed with a single-channel bronchoscope. We assessed the usefulness of EBUS-guided TBNA using a double-channel bronchoscope (EBUS-D), which provides real-time needle position, and compared it with EBUS-guided TBNA using a single-channel bronchoscope (EBUS-S). Design Randomized, comparative prospective study. Setting Hiroshima City Hospital, a tertiary-referral teaching hospital. Patients Between January 2000 and August 2003, 55 patients with intrathoracic lymphadenopathy were included. Patients were randomized to undergo EBUS-D (n = 30) or EBUS-S (n = 25). Methods EBUS-D: The EBUS probe and TBNA catheter were inserted simultaneously through a double-channel bronchoscope. Once the needle placement in the lesion was confirmed by EBUS, TBNA was performed. EBUS-S: The EBUS probe was removed after the determination of the penetration site. Then, the TBNA catheter was inserted and TBNA was performed. Results All the lymph nodes could be visualized with EBUS in each group of patients. In the EBUS-D group, the TBNA needle was visualized as a hyperechoic point on the real-time EBUS image. The diagnostic accuracy rate of EBUS-D and EBUS-S were statistically significantly different (97% vs 76%, respectively; p=0.025). On second attempt of TBNA, the diagnostic rate of the EBUS-D group was superior to that of the EBUS-S group (85.7% vs 33.3%, respectively; p=0.036). The mean number of penetrations was 1.24 in the EBUS-D group and 1.36 in the EBUS-S group. No complications were observed in the EBUS-D group, but a self-limiting hemorrhage occurred in a patient in the EBUS-S group. Conclusion EBUS-D is useful for diagnosing intrathoracic lymphadenopathy, and the obtained specimen with real-time confirmation of the needle is directly proportional to an accurate diagnosis.

A 27-year-old man with widespread lymphadenopathy had multiple sites of accumulation on Ga-67 imaging. The diagnosis of sarcoidosis was confirmed by biopsy. In addition to Ga-67 uptake in intrathoracic lymphadenopathy, Ga-67 was seen at multiple extrapulmonary sites of sarcoidosis.

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) now provides an important alternative diagnostic modality in patients with intrathoracic tuberculosis lymphadenopathy. The procedure is well tolerated in the outpatient setting, provides access to the mediastinal and hilar lymph node locations commonly in tuberculosis and also allows bronchial washing to be performed at the same procedure. However, there is no report of EBUS-TBNA applied to children to diagnose tuberculosis. We report a case of EBUS-TBNA applied to children who had intrathoracic tuberculosislymphadenopathy. (Korean J Pediatr Infect Dis 2013;20:186-189)KeyWords:EBUS-TBNA, Intrathoracic lymphadenopathy, Tuberculosis

A case of Hodgkin's disease occurred with pulmonary involvement as the initial feature. The disease was initially seen clinically and roentgenographically as a diffuse pulmonary infiltrate. To our knowledge, the pattern of diffuse pneumonic involvement without intrathoracic lymphadenopathy at presentation has been reported only in one other case. Differentiation of this diffuse pneumonic pattern of primary pulmonary Hodgkin's disease from the more common pattern of a focal mass or infiltrate is important in considering appropriate therapy.

In the past, hilar or mediastinal lymphadenopathy was considered by many to be a feature of only the primary or first infection with Mycobacterium tuberculosis, and to exclude the diagnosis of reactivation or postprimary tuberculosis. In a series of 56 adult patients with documented postprimary disease due to M tuberculosis, we found hilar or mediastinal lymphadenopathy in three cases (5%). Although intrathoracic lymphadenopathy was more common in primary tuberculosis, we do not believe that intrathoracic lymphadenopathy is as specific for primary tuberculosis, particularly in the adult, as was once thought. For this reason, we believe that the roentgenographic demonstration of intrathoracic lymphadenopathy should not be used as a definitive research or clinical criterion for primary tuberculosis in an adult.

We studied the value of serum lysozyme as a helpful test in distinguising tuberculous involvement of intrathoracic glands from lymphoma. Nineteen of the 28 patients (all Asian immigrants) with intrathoracic glandular tuberculosis had raised serum lysozyme level as compared with 2 of the 29 patients with lymphoma. While a normal serum lysozyme level is unhelpful, a raised level in an Asian immigrant with hilar or mediastinal lymphadenopathy makes tuberculosis a highly probable diagnosis.

• A case of Hodgkin's disease occurred with pulmonary Involvement as the Initial feature. The disease was initially seen clinically and roentgenographically as a diffuse pulmonary infiltrate. To our knowledge, the pattern of diffuse pneumonic involvement without intrathoracic lymphadenopathy at presentation has been reported only In one other case. Differentiation of this diffuse pneumonic pattern of primary pulmonary Hodgkin's disease from the more common pattern of a focal mass or infiltrate Is important in considering appropriate therapy. ( Arch Intern Med 1982;142:1941-1943)