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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2015  |  Volume : 58  |  Issue : 4  |  Page : 439-442
Histopathological yield in different types of bronchoscopic biopsies in proven cases of pulmonary tuberculosis


1 Senior Histopathologist MD, DNB, PDCC Fortis Hospital, Faridabad, Haryana, India
2 Senior Pulmonologist MD, Fortis Hospital, Faridabad, Haryana, India
3 Junior Resident Pulmonology, Fortis Hospital, Faridabad, Haryana, India

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Date of Web Publication4-Nov-2015
 

   Abstract 

Background: Diagnosis of pulmonary tuberculosis (TB) is difficult and often requires a lung biopsy. The goal of this retrospective study was to determine the histopathological parameters useful for diagnosis of pulmonary TB in different types of bronchoscopic biopsies (transbronchial lung biopsy [TBLB], transbronchial needle aspiration [TBNA], and bronchial biopsy [BB]). Materials and Methods: The records of patients diagnosed to have pulmonary TB, over a period of 1-year were evaluated. Patients with positive acid-fast bacilli (AFB) culture and with three bronchoscopic biopsies including TBLB, TBNA, and BB were included in the study. Selected (14) histological parameters were evaluated retrospectively in a total of 27 biopsies from 9 patients with TB after hematoxylin-eosin and Ziehl-Neelsen staining. Results: Diagnostic yield in TBLBs and TBNA was similar for granulomas detection (66.6% each). Granulomas in TBNA were larger, caseating and confluent as compared to small interstitial granulomas seen in TBLB. AFB was demonstrated in only one patient in TBNA. Lymphocytic cell cuffing was seen around most TBLB granulomas. One patient also showed microfilaria in blood vessel in TBLB. BBs in all patients showed the presence of goblet cell metaplasia and increased peribronchial plasma cell infiltrate with or without eosinophils may be indicative of chronic injury. The yield of granulomas was low in BBs seen in only 2 patients (22.2%). Conclusion: Diagnostic yield of TBNA and TBLB for granulomas was similar; however, caseation was seen more frequently in TBNA than on TBLB. Of other histological parameters, bronchial metaplastic changes and peribronchial plasma cells infiltrate were constant findings in all tubercular biopsies indicative of chronic injury.

Keywords: Histology, transbronchial lung biopsies, tuberculosis

How to cite this article:
Gupta N, Singh GC, Rana MK. Histopathological yield in different types of bronchoscopic biopsies in proven cases of pulmonary tuberculosis. Indian J Pathol Microbiol 2015;58:439-42

How to cite this URL:
Gupta N, Singh GC, Rana MK. Histopathological yield in different types of bronchoscopic biopsies in proven cases of pulmonary tuberculosis. Indian J Pathol Microbiol [serial online] 2015 [cited 2019 Aug 21];58:439-42. Available from: http://www.ijpmonline.org/text.asp?2015/58/4/439/168881



   Introduction Top


Tuberculosis (TB) a major health problem in developing countries. Diagnosis of TB require sputum testing with acid-fast bacilli (AFB) which has very low sensitivity and specificity. Other tests including Mantoux and Quantiferon are also nonspecific. AFB culture has been considered the gold standard test for the diagnosis of TB although takes a long time (average 6–8 weeks). The study was designed to evaluate the diagnostic yield of various bronchoscopic guided biopsies for granulomas and analyze 14 other histological parameters in such biopsies in AFB positive culture proven cases and in whom three biopsies were obtained through bronchoscopy.


   Materials and Methods Top


This retrospective study included a total of 9 patients in whom the diagnosis of TB was confirmed by either bronchoalveolar lavage (BAL) fluid or transbronchial needle aspirate (TBNA) culture and who were responding to antitubercular treatment. The duration of treatment ranged from 1 to 6 months and response was assessed by a decrease in cough and fever.

Clinical data collection

For each of these patients, we reviewed the hospital information system to gather the following information-general demographic data, clinical presentation, data concerning the diagnostic procedure (laboratory findings, biopsies from three sites transbronchial lung biopsy [TBLB], TBNA, and bronchial biopsy [BB]) treatment response details were confirmed during regular visits and telephonically.

Analysis of data

All clinical records and histological material were reviewed by a senior pulmonologist and a senior histopathologist independently.

Bronchoscopy was carried out in all 9 patients using Olympus fiberoptic bronchoscope under sedation after proper preparation either through oral or nasal route. Three biopsies were obtained for each patient TBLB. TBNA and BB 2–3 bits were obtained for each.

Histological examination was performed on formalin fixed paraffin embedded tissue sections. Histological stains used were hematoxylin and eosin for routine examination and Ziehl-Neelsen (ZN) stain for AFB.

Each biopsy was examined for the presence of granulomas.

Granulomas were defined as round to oval collection of epithelioid histiocytes with or without the presence of Langhan's type of giant cells, lymphocytes and/or plasma cells. Location of granulomas: Peribronchial, interstitial, or perivascular noted [Figure 1]a.
Figure 1: (a) Interstitial granuloma in transbronchial lung biopsy (H and E ×20). (b) Bronchial epithelium goblet cell metaplasia (H and E ×20). (c) Large caseating granuloma in transbronchial needle aspiration (H and E ×20). (d) Caseation with epithelioid cells intransbronchial needle aspiration (H and E ×40)

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Plasma cell cuffing around granuloma, the presence or absence of caseation, the size of granulomas were noted.

Lung biopsies were also examined for distortion of alveolar architecture, inflammatory cells in the alveolar sac, and changes in blood vessels. BBs were examined for the presence of granulomas. Metaplastic changes of lining epithelium including goblet cells or squamous metaplasia, small vessel vasculitis, and peribronchial plasma cell infiltrate also noted.

TBNA biopsies were examined for granulomas and caseation.

Laboratory features evaluated were hemoglobin, erythrocyte sedimentation rate (ESR), lactate dehydrogenase levels, sodium and potassium, Mantoux testing, Quantiferon, sputum for AFB, and HIV testing.


   Results Top


Clinical and bronchoscopic features

Of total 9 patients, 7 were males and 2 were females. The age of patient ranged from 18 to 74 years. Patients presented with complaints of cough in all, fever in 6/9 and chest pain in 4/9 cases. Laboratory features were summarized in [Table 1]. ESR was raised in 7/9 cases. Mantoux was positive in only 1/9 patient. Quantiferon testing was performed in 3 patients in whom 2 were positive.
Table 1: Laboratory and Clinical features of all patients

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AFB stain performed on sputum was positive in one case, and BAL fluid AFB was negative in all cases.

Bronchoscopic findings

In all 9 patients, all segmental bronchi were visualized. 3/9 patients were show widened carina. 2/9 patients showed nodular mucosa.

Assessment of histological parameters in all three biopsies

Transbronchial lung biopsies

Granulomas: Seen in 6/9 patients. Caseation noted in 1/6 granulomas.

Location: All granulomas were located in the interstitium [Figure 1]a 2 patient had peribronchial granulomas.

Number of granulomas: More than 5 granuloma was seen in only 2 patients.

The size of granuloma: Only 2/6 patients had a large granuloma.

Lymphocytic cuffing around granulomas is noted in all 6 biopsies. 3/6 had moderately dense lymphocytic cuffing and 3 had mild cuffing.

Plasma cell cuffing: the predominance of a plasma cell is noted in only 1 patient with granulomas.

Interstitial inflammation comprising of lymphocytes is noted in all 9 patients. Of them, one also had marked interstitial eosinophils cell infiltrate [Figure 2]a and [Figure 2]b. This was a young female who was on treatment with the antitubercular drug for 1-month and was later found to be ethambutol induced eosinophilic lung disease associated with peripheral eosinophilia, which was later relieved by the discontinuation of ethambutol.
Figure 2: (a) Dense peribronchial and Interstitial eosinophilic infiltrate (H and E ×10). (b) Dense peribronchial and Interstitial eosinophilic infiltrate (H and E ×40). (c) Microfi laria noted in vessel (H and E ×20). (d) Microfilaria in blood vessel (H and E ×40)

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Alveolar architecture mildly distorted in all 9 biopsies.

Alveolar sac: show no significant inflammation in all patients. Focal areas of hemorrhage likely procedural were seen in three patients.

Blood vessels: appeared unremarkable in all, but 1 patient who showed the presence of microfilaria within vessels along with interstitial granulomas [Figure 2]c and [Figure 2]d.

Bronchial biopsies

Metaplasia of lining epithelium: All biopsies showed goblet cell metaplasia of lining epithelium [Figure 1]b.

Peribronchial inflammation: All biopsies mild to moderately increased peribronchial plasma cell infiltrate with one patient also had increased eosinophils.

Granulomas presence of peribronchial granulomas was noted in only 2/9 biopsies. Both granulomas were large, but without caseation.

Small vessel vasculitis: Noted in 3/9 biopsies.

Transbronchial needle aspirate

Granulomas were noted in 6/9 biopsies. Caseation was seen in 4/9 biopsies [Figure 1]c and [Figure 1]d. 5/6 biopsies showed large granulomas. One biopsy had only necrosis and ZN stain for AFB were positive in only 1 TBNA showing only necrotic material. Diagnosis yield in TBLBs and TBNA was similar for granulomas detection (66.6% each). However, in transbronchial lung aspirate granulomas were larger caseating and confluent as opposed to small interstitial granuloma in TBLB.


   Discussion Top


The detailed analysis of a variety of laboratory, bronchoscopic, and histological parameters in three different bronchoscopic biopsy specimens in clinically defined cases of TB has clearly identified significant differences.

The ESR was elevated in most patients higher so in older patients as also observed by others.[1],[2] The sensitivity of Mantoux testing, AFB sputum, and AFB BAL appeared as low 56.2%, 56.2%, and 50% respectively, comparable to those reported by others.[3]

The yield of granulomas though same in both TBLB and TBNA, granulomas in TBNA were larger, confluent and frequently shows caseation. Hence, emphasizing that TBNA had a better yield for granulomas compared to TBLB. The utility of TBNA and its high diagnostic yield has been reported by several authors who reported the yield between 74.6% and 91.6%.[4],[5],[6],[7],[8],[9] The yield of granulomas on TBNA in our series was 66.6%. However, the diagnostic yield was 77.7% as one biopsy had only necrotic material that was AFB positive comparable to those reported earlier.

Histological features of TB in lung biopsies revealed the interstitial location of granulomas in all cases with granulomas (6/6). These findings of interstitial location have also been reported by Aggarwal et al.[10]

Of the other histological findings plasma cell cuffing appeared to be less significant in TBLB biopsies. Features of chronicity, as indicated by chronic interstitial inflammation, were a constant findings all biopsies concordant with finding of Aggarwal et al.[10]

Histological Features of BBs showing goblet cell metaplasia and increased peribronchial plasma cell also infiltrate indicating toward chronic injury and might hint to look for granulomas either in the deeper section or other biopsies.

The yield of granulomas in TBLB was also comparable with those reported by others.[11],[12],[13],[14],[15],[16]


   Conclusion Top


The yield of TBNA and TBLB for granulomas was similar; however, TBNA yielded larger and caseating granulomas when compared with smaller granulomas seen in TBLB. TBNA had high diagnostic yield compared to TBLB and were thus a useful diagnostic tool for suspected cases of TB. The presence of metaplastic changes in the bronchial epithelium, peribronchial inflammation comprising of plasma cells, and interstitial location of granulomas can be additional histological parameters useful for diagnosing TB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Yanagisawa N, Takahashi M, Namiki M, Okajima S, Ichinose Y, Toyama K. Study of erythrocyte sedimentation rate in patients with pulmonary tuberculosis. Kansenshogaku Zasshi 1996;70:955-62.  Back to cited text no. 1
    
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Ukpe IS, Southern L. Erythrocyte sedimentation rate values in active tuberculosis with and without HIV co-infection. S Afr Med J 2006;96:427-8.  Back to cited text no. 2
[PUBMED]    
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Cattamanchi A, Dowdy DW, Davis JL, Worodria W, Yoo S, Joloba M, et al. Sensitivity of direct versus concentrated sputum smear microscopy in HIV-infected patients suspected of having pulmonary tuberculosis. BMC Infect Dis 2009;9:53.  Back to cited text no. 3
    
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Sherwani R, Akhtar K, Bhargava R, Goel S, Nangia V. Transbronchial needle aspiration in undiagnosed radiographic shadows. Indian J Tuberc 2005;52:37-44.  Back to cited text no. 4
    
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Khan MK, Ansari JK, Saeed W, Zaman F, Naseem A, Baig IM, et al. Diagnostic yield of transbronchial needle aspiration – Analysis of 30 cases. J Ayub Med Coll Abbottabad 2008;20:132-4.  Back to cited text no. 5
    
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Navani N, Molyneaux PL, Breen RA, Connell DW, Jepson A, Nankivell M, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study. Thorax 2011;66:889-93.  Back to cited text no. 6
    
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Sun J, Teng J, Yang H, Li Z, Zhang J, Zhao H, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic tuberculosis. Ann Thorac Surg 2013;96:2021-7.  Back to cited text no. 7
    
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Ren S, Zhang Z, Jiang H, Wu C, Liu J, Liang L, et al. Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques enhanced the diagnosis yields of pulmonary tuberculosis patients with lymphadenopathy. Panminerva Med 2013;55:363-70.  Back to cited text no. 8
    
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Ozgül MA, Cetinkaya E, Tutar N, Ozgül G, Onaran H, Bilaceroglu S. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A study in a tuberculosis-endemic country. J Cancer Res Ther 2013;9:416-21.  Back to cited text no. 9
    
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Aggarwal AN, Gupta D, Joshi K, Jindal SK. Bronchoscopic lung biopsy for diagnosis of miliary tuberculosis. Lung India 2005;22:116-8.  Back to cited text no. 10
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Willcox PA, Potgieter PD, Bateman ED, Benatar SR. Rapid diagnosis of sputum negative miliary tuberculosis using the flexible fibreoptic bronchoscope. Thorax 1986;41:681-4.  Back to cited text no. 11
[PUBMED]    
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Pant K, Chawla R, Mann PS, Jaggi OP. Fiberbronchoscopy in smear-negative miliary tuberculosis. Chest 1989;95:1151-2.  Back to cited text no. 12
    
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Al-Jahdali H, Al-Zahrani K, Amene P, Memish Z, Al-Shimemeri A, Moamary M, et al. Clinical aspects of miliary tuberculosis in Saudi adults. Int J Tuberc Lung Dis 2000;4:252-5.  Back to cited text no. 13
    
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Mert A, Bilir M, Tabak F, Ozaras R, Ozturk R, Senturk H, et al. Miliary tuberculosis: clinical manifestations, diagnosis and outcome in 38 adults. Respirology 2001;6:217-24.  Back to cited text no. 15
    
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Burk JR, Viroslav J, Bynum LJ. Miliary tuberculosis diagnosed by fibreoptic bronchoscopy and transbronchial biopsy. Tubercle 1978;59:107-9.  Back to cited text no. 16
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Correspondence Address:
Dr. Nalini Gupta
No. C6/18, Second Floor, Ardee City, Sector 52, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.168881

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