Correlation of FNAC lymph node cytology with CD4 count in HIV seropositive adults
” Mukherjee Sumana1 , Mukhopadhyay Keya1 , Bhattacharya Pranab1
1. Department of Pathology, School Of Tropical Medicine, Kolkata
Corresponding Author:Sumana Mukherjee, BH-62, Sector-2, Salt Lake, KolkataPhone numbers +919830945575E-mail: email@example.com
Lymphoid tissues are common targets of HIV infection.FNAC is the initial investigation of choice inthese cases.Aims: To evaluate the usefulness of FNAC in HIV positive lymphadenopathy in our center..Methods and Material: FNAC was performed in 153 HIVpositive patients presenting with lymphadenopathy.Smears were stained with Giemsa, ZN and PAS/Grocotts/PAP according to cytological findings.Statistical analysis: The data was analysed using the T TestResults: Tuberculous lymphadenitis was the most common diagnosis (44%).Smear positivity was found in 29%cases. Necrotizing granulomas and smear positivity was significantly higher in cases with CD4 count<200.Reactive hyperplasia was significantly higher in the CD4> 200 category.Conclusions: FNAC is very useful and gives specific diagnosis in most cases of HIV lymphadenopathy. LowerCD4 count significantly increases the smear positivity for AFB.Key-words: FNAC, lymph node, HIV, CD4 count
How to cite this article: Sumana M, Keya M, Pranab B (2019): Correlation of FNAC lymph node cytologywith CD4 count in HIV seropositive adults, Ann Trop Med & Pub Health-Special issue; 19: 2002-19.
FNAC should be the chosen diagnostic method in HIV lymphadenopathy because it avoids unnecessary biopsy, saves time, is cost effective, safer for the operator and has yields mostly specific diagnosis.
Lymphoid tissues are commonly targeted in HIV infections . HIV positive individuals thus commonly present with enlarged lymph nodes. The degree of lymphadenopathy may range from progressive generalized to transient.The commonest infection is tuberculosis and extra pulmonary involvement is common . Occurrence of extra pulmonary tuberculosis has increased specially in those who are severely immunodeficient  . FNAC is the initial investigation of choice in these cases. Though FNAC may not clearly demarcate all pathologies, it is useful in diagnosis of specific infections and involves lesser risk to the performer than biopsies  . We tried to note the FNAC findings of all HIV positive patients sent to our department with lymphadenopathy and corelated it with CD4 counts. We aim to evaluate the usefulness of FNAC in HIV positive lymphadenopathy in our center .
Materials and Methods:
Subjects: This is a cross sectional observational study of HIV infected subjects diagnosed in an ICTC unit in a tertiary medical center. FNAC was performed on patients presenting with lymphadenopathy. Sample size: 153 HIV positive adults with lymphadenopathy. Inclusion criteria: Subjects above 18 years, seropositive for HIV, lymph node size at least 1 cm. Exclusion criteria: Retroperitoneal or non-palpable nodes, inadequate material. Data collection: Data collected included age, sex, site of lymph node enlargement, whether on ART therapy, clinical examination of nodes, CD4 cell count by flow cytometry and cytological features. All the smears from the aspirates were stained with Giemsa stain and ZN stain. PAS / Grocotts / PAP stains and culture were used depending on cytological findings. The following categories were used to record cytological data. The groups were (1) reactive hyperplasia, (2) necrotizing granulomatous with or without AFB, (3) necrotizing only with or without AFB, (4) other specific diagnosis like histoplasma, Cryptococcus, suspected lymphoma or metastasis, (5) inconclusive. Statistical analysis: The data was analysed using the T test. P-values were calculated. A p-value of < 0.005 was considered significant.
There were 108 males (70.5%) and 45 females (29.5%). The age range was 20 to 58 years. The commonest site was cervical (40%) followed by axillary (25%) and inguinal (5%). Some patients (30%) presented with multiple site involvement, commonly cervical and axillary. Most nodes (55%) were discrete, non-tender. Matted nodes constituted 25% cases, while abscess or sinus formation was seen in 20% cases (Table 1). 112 cases were onART, while 41 were ART naïveReactive hyperplasia accounted for 35% of diagnosis. There were 29% cases positive for AFB (figure 1). Only necrotizing pattern (figure 2) were noticed in 35% cases among the AFB positiveswhile most smear positives showed necrotizing granulomas (figure 3). Necrotizing granulomatous comprised 36%. Tuberculosis was diagnosed when there was AFB positivity irrespective of cytology and/or presence of caseation necrosis with epithelioid granulomas. Tuberculosis was diagnosed in 44% cases. Fungal infection comprised of 2 cases, proven by culture. Lymphomas comprised 3.2% cases. Out of the 5 cases of lymphoma, biopsy confirmed NHL in 4 cases and 1 was florid reactive hyperplasia. Most lymphomas and fungal infections (figure 4) were in CD4 count < 200 group (Table 2). The number of reactive hyperplasias was significantly higher in CD4 > 200 group (p=0.00). While necrotizing granulomas and AFB positivity was significantly higher in CD4 < 200 group (p=0.0066). Similarly, only necrosis with AFB was significantly higherin CD4 < 200 group. There was no significant difference among cases with necrosis and no AFB in the 2 CD4 groups (p=0.00). Cases with granulomas but no necrosis or AFB were considered inconclusive at FNAC.
Male predominance has been established in most studies5,6 and the higher age limit varies up to 65 years7,8,9 In our study , however, we did not get any case above 60 years of age. Agravatet al8 showed incidence of lymphadenopathy decreased with increasing age. Cervical nodes were most commonin our study like Neelima et al and others 9, 10, 11 Satyanarayana et al 4 found axillary nodes most commonly. Liatjos et al12 and Naser S et al13had categorized cytological findings in our line. Similar to our findings, most workers found tuberculous lymphadenitis as the most common diagnosis.1,5,8,9,11Chronic granulomatous lymphadenitis without caseous necrosis and no AFB or fungi, which we categorized as inconclusive 6,14 on FNAC comprised 12 of our cases (7.8%) is in between the 19% recorded by Satyanarayana et al4 and the single case reported by Neelima et al.10 CD4 count < 200 is considered advanced stage while counts 200-500 and >500 are early and intermediate stages.15We considered two groups based on similar cut off value. Our study corroborates with other workers 10 that fungal infections and lymphomas are common in the low CD4 categories. Kumar Guru et al 6 also found highest CD4 counts in reactive hyperplasias like our study. We found that metastasis has also been reported by some corroborating with our findings.15 We may have missed many opportunistic infections like viruses and toxoplasma in this cytomorphological study. Diagnostic accuracy could be increased by using appropriate immuno fluorescence kits.
FNAC is very useful and gives specific diagnosis in most cases of HIV lymphadenitis. Lower CD4 count significantly increases smear positivity for AFB and fungi and may help in considering segregation of these patients.
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