Haematogenous dissemination of tuberculous lymphadenitis.

OBJECTIVE: To determine whether Mycobacterium tuberculosis infection spreads through the blood to different lymph-node groups in patients with tuberculous lymphadenitis. DESIGN: Prospective analytical study. SETTING: The patients were recruited, managed and followed at the lymphodenopathy clinic, Central Police Hospital, Burr, Khartoum, Sudan. SUBJECTS: Fifty two sequential patients were enrolled. Thirty patients with FNAC diagnosis of tuberculous lymphadenitis and positive PCR for M. tuberculosis complex had a mean age of 26.9 +/- 11.2 years and similar male, female affection. Nine patients with FNAC tuberculous lymphadenitis, but negative PCR had a slightly higher mean age (32.6 +/- 18.2 years) with similar male: female proportions. Patients with reactive lymphadenopathy (9/52) were older than patients with tuberculous lymphadenitis with a mean age of 45 +/- 24.6 years. RESULTS: None of the patients were positive for HIV or had clinical or radiological evidence of pulmonary tuberculosis. M. tuberculosis DNA was detected in the blood samples of 30/39 (77%) patients with tuberculous lymphadenitis, but in none of the cases with reactive or malignant lymphadenopathy. The presence of M. tuberculosis DNA correlated strongly to multiple lymph-node involvement [OR (odds ratio) = 96.7, 95% confidence interval (CI) 9.0 - 1,039] and to caseating-granulomatous and predominantly necrotic cytomorphological categories [OR = 70, 95% confidence interval (CI) 7.0 - 703]. CONCLUSION: M. tuberculosis most probably disseminates through the blood from one node group to the other in patients with tuberculous lymphadenitis.

Diagnosis of tuberculous lymphadenitis by FNAC, microbiological methods and PCR: a comparative study.

Despite its usefulness in the diagnosis of tuberculous lymphadenitis, fine needle aspiration cytology (FNAC) faces several limitations, and its sensitivity and specificity are not well established. The diagnostic accuracy and limitations of FNAC were studied in comparison with conventional microbiological methods and polymerase chain reaction (PCR). Sixty patients with lymphadenopathy and a clinical diagnosis of tuberculous lymphadenitis were subjected to FNA. The aspirate was used for cytological examination, Ziehl-Neelsen staining, mycobacterial culture and PCR. PCR was performed using two sets of oligonucleotide primers for Mycobacterium tuberculosis and a single primer for M. bovis species. The results of FNAC, microbiological methods and PCR correlated with the clinical outcome after follow-up for an average period of 24 months. Twenty-five cases (41.6%) were treated and responded well to anti-tuberculosis therapy, among them 17 were correctly diagnosed by FNAC (68%), eight by microbiological methods (32%) and 24 by PCR (96%). When PCR is considered the gold standard, FNAC predicted the correct diagnosis in 62% of cases with a high false negative rate (38%) due to the absence of granuloma/necrosis in smears from cases of early tuberculosis. In the latter group PCR proved to be the most valuable and a diagnostic success of 100% was achieved when FNAC and PCR were combined. In addition, PCR allowed immediate characterization of M. tuberculosis in the vast majority (96.2%) of cases in the study population.

Granulomatous mammary disease: ten years' experience with fine needle aspiration cytology.

OBJECTIVE: To determine the aetiological types of granulomatous disease of the breast in women presenting with mammary complaints in the Sudan. METHODS: Clinical history and physical examination, complete blood counts, Mantoux test, histopathology and fine needle aspiration cytology (FNAC). RESULTS: Granulomatous mastitis was seen in 11/2500 (0.44%) patients with mammary disease over a 10-year period. All were of childbearing age (mean 26.0 +/- 5.9 years). Common presentations were diffuse swelling, well-circumscribed masses, nipple retraction, multiple sinuses and superficial skin ulcers. Lymphadenopathy was seen in more than 60% of the patients. Diagnosis was based on cytomorphological features in 10/11 cases and histopathology in one. Nine were diagnosed with tuberculous mastitis and two with idiopathic granulomatous mastitis. Acid-fast bacilli (AFB) could not be demonstrated in any of the cytology smears. Tuberculous mastitis responded to empirical anti-tuberculosis treatment, with a minimum follow-up of 2 years in seven women. CONCLUSION: Tuberculous mastitis is a rare entity in women with mammary disease in the Sudan. Alternative diagnoses such as idiopathic granulomatous mastitis should be made only after failure of an adequate trial of anti-tuberculosis treatment. FNAC is a useful diagnostic tool even if AFB cannot be demonstrated.

Supra-sternal notch tuberculous abscess: a report of three cases.

Extra-pulmonary tuberculosis remains a diagnostic and therapeutic challenge; its clinical presentation can mimic a wide range of pathological conditions. Here we report on 3 female patients who presented with supra-sternal masses that were suspected clinically to be of thyroid origin. By use of fine-needle aspiration cytology (FNAC), they were proved to be tuberculous lesions involving the pre-tracheal lymph nodes. Serological examination for HIV-I/II was not reactive in the 3 patients. The patients responded well to a regimen of multi-drug therapy. It is concluded that extra-pulmonary tuberculosis should be considered in the differential diagnosis of thyroid or para-thyroid swellings and that FNAC is a simple, quick and reliable procedure in the diagnosis of extra-pulmonary tuberculous lesions involving the neck.

Lysosomes and human liver disease: a biochemical and immunohistochemical study of beta-hexosaminidase.

Liver biopsies from 88 patients with different liver diseases were studied for beta-hexosaminidase activity. Liver specimens with normal light microscopical morphology showed no immunohistochemical reactivity for beta-hexosaminidase. Increased reactions were noted, mainly in hepatocytes, in biopsies from the patients with different liver diseases. A very large interindividual variation of biochemical liver beta-hexosaminidase activity occurred even within the same diagnostic group, and no group of patients showed any significant increase of liver beta-hexosaminidase activity compared with the patients with normal liver histology. Livers with positive immunohistochemistry showed increased biochemical values for beta-hexosaminidase. In patients with cholestasis due to alcohol abuse, the immunohistochemical reaction was intense and the biochemical beta-hexosaminidase activity was significantly increased compared with non-alcoholic cholestatic cases. Furthermore, blood samples taken from 50 patients at the same time as the liver biopsies. These patients showed significantly increased serum beta-hexosaminidase activity compared with normal controls, but no correlation was found between beta-hexosaminidase activities in the liver and serum of these patients.

Immunohistochemical studies of beta-hexosaminidase in neoplastic and normal tissues with monoclonal antibodies.

A total of 87 human specimens with 10 histological types of primary neoplasm were studied immunohistochemically with monoclonal antibodies specific for beta-hexosaminidase (Hex). High levels of Hex were found in malignant neoplasms of the skin, cervix, colorectum and in benign as well as neoplastic plasma cells, while no activity was detected in normal epidermis, normal colorectal epithelium or benign naevi. The strongest immunohistochemical reaction was revealed in tumor cells of malignant melanoma. Adenomas and adenocarcinomas of the colorectum showed high levels of Hex with a basal pattern of immunoreactivity more frequent in the tumor cells of adenocarcinomas than adenomas. Fibroblasts and macrophages in the tumors often disclosed immunoreactivity. In most of the sections (including those from plasma cell neoplasms), 7E4 antibody showed low immunoreactivity compared to 2E3, except for non-neoplastic plasma cells, which were as a rule positive with 7E4 and largely negative with 2E3 antibody. This result probably indicated different isoenzymes in benign and neoplastic plasma cells.

beta-hexosaminidase in cultured normal and mutant human fibroblasts: an immunohistochemical and biochemical investigation.

Fibroblasts from a genetically normal individual and mutant fibroblasts from patients with Tay-Sachs and Sandhoff's diseases were grown in vitro. The lysosomal enzyme beta-hexosaminidase (Hex) was determined biochemically and localized with monoclonal antibodies recognizing Hex A, and Hex A and Hex B, respectively. The biochemical results showed similar amounts of Hex A and Hex B in the normal fibroblasts, whereas only Hex B activity was detectable in the fibroblasts from the patient with Tay-Sachs disease. The fibroblasts from the patient with Sandhoff's disease showed small amounts of Hex A- and no Hex B activity. Immunohistochemically, Hex was detectable with both antibodies in the normal fibroblasts and in those from the patient with Tay-Sachs disease. The fibroblasts from the patient with Sandhoff's disease were reactive only with Hex A-specific antibody.

Immunohistochemical demonstration of beta-hexosaminidase in cirrhotic and cholestatic human livers with a monoclonal antibody.

The lysosomal enzyme beta-hexosaminidase (Hex) was studied immunohistochemically with a monoclonal antibody in normal human livers and in livers with cirrhosis and cholestasis. No reaction was detected in sections from normal livers. The reaction in diseased livers was prominent mainly in degenerating hepatocytes, whereas Kupffer cells and bile duct epithelium showed faint reactivity. The reaction product was intense in degenerated hepatocytes, especially in the periphery of the pseudolobules in cirrhotic livers. In cholestatic livers the positivity was localized around central veins in cells with bile pigment. The more pigment, the stronger was the reaction. It is suggested that the elevated level of serum Hex found in cirrhosis and cholestasis derives from degenerating hepatocytes and activated Kupffer cells.

Methodological approaches to immunohistochemical demonstration of beta-hexosaminidase in human placental and renal tissue with monoclonal antibodies.

The lysosomal enzyme, beta-hexosaminidase (Hex), was studied in full-term human placentas and in renal tissue using monoclonal antibodies raised against Hex purified from human placentas. The immunohistochemical reaction for Hex was pronounced in trophoblastic cells and macrophages of the basal plate and the smooth chorion, but was faint or negative in the amnion as well as in the syncytiotrophoblast and Hofbauer cells of the chorionic villi. The maternal decidual cells of the basal plate were negative. Biochemical enzyme analysis showed the highest activity in basal plate cells (containing trophoblast, decidual cells, macrophages and neutrophils) and a low activity in the chorionic villi. Placental tissue was less positive with monoclonal antibodies specific for Hex A, compared with antibodies reacting with both Hex A and Hex B. Epithelial cells of the renal proximal tubules were positive to the same degree with antibodies recognizing both Hex A and Hex B as well as those recognizing only Hex A.

Alkaline phosphatase in cholestatic and cirrhotic rats. A biochemical and histochemical study.

Alkaline phosphatase (ALP) was studied by enzyme histochemical methods and by biochemical quantitations in rat livers with chronic bile duct obstruction and experimental cirrhosis. The most evident ALP increase was histochemically found in portal tracts of rats with bile duct obstruction and localized to the walls of proliferating blood vessels. Furthermore, a slight canalicular membrane enzyme increase was histochemically found in both groups, most evident in cirrhosis, whereas the biochemical assay of ALP in serum and liver from both pathological groups showed 3 times higher values compared to controls. The portal tracts did not seem to contribute to the serum increase, since the rise of serum ALP was similar in chronic bile duct obstruction and in experimental cirrhosis without changes of the portal tracts. It is concluded that the increase ALP activity in serum from rats with bile duct obstruction and cirrhosis mainly has a hepatocytic origin.