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EDITORIAL
Year : 2018  |  Volume : 35  |  Issue : 5  |  Page : 371-372  

Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) in HIV affected individuals: Is the (E)BUS ready for unchartered territories?


1 Institute of Pulmonology, Medical Research and Development, Mumbai, Maharashtra, India
2 Institute of Pulmonology, Medical Research and Development, Mumbai, Maharashtra, India; Department of Internal Medicine, Kantonsspital Baselland, Liestal and University of Basel, Basel, Switzerland

Date of Web Publication27-Aug-2018

Correspondence Address:
Dr. Prashant N Chhajed
Institute of Pulmonology, Medical Research and Development, A/405, Sangam Corner of Swami Vivekanand Road and Saibaba Road, Santacruz West, Mumbai 400052, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_312_18

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How to cite this article:
Agrawal N, Vaidya PJ, Chhajed PN. Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) in HIV affected individuals: Is the (E)BUS ready for unchartered territories?. Lung India 2018;35:371-2

How to cite this URL:
Agrawal N, Vaidya PJ, Chhajed PN. Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) in HIV affected individuals: Is the (E)BUS ready for unchartered territories?. Lung India [serial online] 2018 [cited 2018 Sep 22];35:371-2. Available from: http://www.lungindia.com/text.asp?2018/35/5/371/239864



Real-time convex-probe endobronchial ultrasound- transbronchial needle aspiration (EBUS-TBNA) has gained important place in clinical practice in diagnosing hilar and mediastinal lymphadenopathy since its inception.[1] It is established as a safe and minimally invasive procedure, performed under moderate sedation and local anesthesia on an outpatient basis with minimal complications.[2],[3] This procedure has brought a paradigm shift in clinical practice, considerably reducing the need of invasive procedures such as mediastinoscopy and associated morbidity with the procedure.[4]

EBUS-TBNA was initially used in the diagnosis and staging of lung cancer, but with time has established itself in accurately diagnosing mediastinal adenopathy due to both benign and malignant causes.[5],[6] EBUS-TBNA has shown to obtain the highest yield of tumor RNA material from small biopsies in lung cancer for adequate molecular biomarker testing when compared to bronchoscopy and computed tomography-guided biopsies.[7] EBUS-TBNA can provide a precise diagnosis of mediastinal adenopathy due to infections as well.[8],[9],[10]

Tuberculosis (TB) remains the leading cause of mortality in HIV-infected individuals. As per the WHO 2015, a majority of TB cases in HIV-infected population were not diagnosed or treated, leading to a large number of deaths.[11] Up to 40% of patients infected with HIV have mediastinal lymphadenopathy.[12] TB remains one of the commonest causes for mediastinal lymph adenopathy followed by atypical mycobacterial infections, fungal infections, lymphomas, and Kaposi sarcoma in people living with HIV. Rarely, Castleman's disease and immune reconstitution inflammatory syndrome may cause mediastinal lymphadenopathy in HIV infection.[10] The low lymphocytic state in HIV infection leads to poor granuloma formation in TB and thus poses a challenge in histological diagnosis.[13] However, the high bacterial load in HIV-TB co-infection helps in getting microbiological evidence. Malignancies have been reported more commonly in non-TB-endemic regions as a cause for mediastinal adenopathy in HIV-infected individuals. This makes sample acquisition indispensable in the optimum management of individuals with HIV having mediastinal adenopathy.

Prasad et al. have reported a retrospective study analyzing the utility and safety of EBUS-TBNA in people living with HIV in India.[14] This is the first study from India describing the utility of EBUS-TBNA in HIV-infected individuals. It is a small study analyzing 22 patients. The most common diagnosis was TB followed by lung cancer and lymphoma. EBUS-TBNA could achieve a diagnosis in 17 out of 22 patients. The median CD4 lymphocyte count was 144 cells/mm3. There was no surgical sampling of lymph nodes done to confirm the diagnosis in patients where EBUS-TBNA was inconclusive. However, the sample adequacy though defined was not one of the analyzed parameters. It would have been intriguing to know the adequacy of samples in patients where EBUS-TBNA was inconclusive. Nevertheless, the study definitely highlights the quality of lymph node samples in a low lymphocytic condition obtained by EBUS-TBNA. The sampling of mediastinal lymph nodes in HIV-infected population serves as an uncommon indication of EBUS-TBNA.

Out of the 15 patients diagnosed with TB lymphadenitis on EBUS-TBNA, only 3 had granulomas on cytological examination. Twelve patients had necrotic inflammation and 13 had acid-fast bacilli seen on smears. As the feasibility and performance of GeneXpert for MTB/RIF on EBUS-TBNA samples have been previously reported,[9],[15] it would have been worthwhile to have TB GeneXpert data in the current study by Prasad et al.[14] TB bacilli were demonstrated on EBUS-TBNA aspiration in a fair number of patients. This is an opportunity to perform line probe assay in such samples to help in the early initiation of the optimal TB regimen in HIV co-infected population.

The technical aspects to be aware of when using EBUS-TBNA in people living with HIV are the appropriate steps in disinfection of the scope to prevent transmission and handling of the EBUS-TBNA needle. There have been reports of infected bronchoscopes with HIV. The common sites of contamination include biopsy channel and insertion tube surface where HIV genetic material has been detected. Detergent cleaning prior to disinfection with glutaraldehyde has shown reduction in contamination as HIV virus is resistant to glutaraldehyde and retains its infectivity at room temperature even when dried. Hence, the potential risk of cross infection exists, and therefore precleaning should not be delayed until disinfection.[16] Flexible bronchoscopy helps in isolating the specific organism in the huge spectrum of possible infections in patients with HIV. The utility of EBUS-TBNA in paucilymphocytic situations to pinpoint the cause of mediastinal lymphadenopathy certainly sets the stage for unraveling the true potential of the pulmonologists weapon!



 
   References Top

1.
Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004;126:122-8.  Back to cited text no. 1
    
2.
Agarwal R, Srinivasan A, Aggarwal AN, Gupta D. Efficacy and safety of convex probe EBUS-TBNA in sarcoidosis: A systematic review and meta-analysis. Respir Med 2012;106:883-92.  Back to cited text no. 2
    
3.
Vaidya PJ, Munavvar M, Leuppi JD, Mehta AC, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds. Respirology 2017;22:1093-101.  Back to cited text no. 3
    
4.
Zwischenberger JB, Savage C, Alpard SK, Anderson CM, Marroquin S, Goodacre BW, et al. Mediastinal transthoracic needle and core lymph node biopsy: Should it replace mediastinoscopy? Chest 2002;121:1165-70.  Back to cited text no. 4
    
5.
Vaidya PJ, Kate AH, Yasufuku K, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer diagnosis and staging. Expert Rev Respir Med 2015;9:45-53.  Back to cited text no. 5
    
6.
Vaidya PJ, Kate AH, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: The standard of care for evaluation of mediastinal and hilar lymphadenopathy. J Cancer Res Ther 2013;9:549-51.  Back to cited text no. 6
    
7.
Schmid-Bindert G, Wang Y, Jiang H, Sun H, Henzler T, Wang H, et al. EBUS-TBNA provides highest RNA yield for multiple biomarker testing from routinely obtained small biopsies in non-small cell lung cancer patients – A comparative study of three different minimal invasive sampling methods. PLoS One 2013;8:e77948.  Back to cited text no. 7
    
8.
Thangakunam B, Isaac BT, Christopher DJ. Endobronchial ultrasound experience in a high tuberculosis prevalence setting. Indian J Tuberc 2017;64:196-200.  Back to cited text no. 8
    
9.
Dhooria S, Gupta N, Bal A, Sehgal IS, Aggarwal AN, Sethi S, et al. Role of xpert MTB/RIF in differentiating tuberculosis from sarcoidosis in patients with mediastinal lymphadenopathy undergoing EBUS-TBNA: A study of 157 patients. Sarcoidosis Vasculitis Diffuse Lung Dis 2016;33:258-66.  Back to cited text no. 9
    
10.
Alçada J, Taylor MN, Shaw PJ, Janes SM, Navani N, Miller RF, et al. High prevalence of malignancy in HIV-positive patients with mediastinal lymphadenopathy: A study in the era of antiretroviral therapy. Respirology 2014;19:339-45.  Back to cited text no. 10
    
11.
Available from: http//www.who.int/hiv/topics/tb/about_tb/en/. [Last accessed on 2018 Aug 11].  Back to cited text no. 11
    
12.
Jasmer RM, Gotway MB, Creasman JM, Webb WR, Edinburgh KJ, Huang L, et al. Clinical and radiographic predictors of the etiology of computed tomography-diagnosed intrathoracic lymphadenopathy in HIV-infected patients. J Acquir Immune Defic Syndr 2002;31:291-8.  Back to cited text no. 12
    
13.
Diedrich CR, O'Hern J, Wilkinson RJ. HIV-1 and the mycobacterium tuberculosis granuloma: A systematic review and meta-analysis. Tuberculosis (Edinb) 2016;98:62-76.  Back to cited text no. 13
    
14.
Prasad KT, Muthu V, Sehgal IS, Dhooria S, Sharma A, Gupta N, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in HIV-infected patients with undiagnosed intrathoracic lymphadenopathy. Lung India 2018;35:379-83.  Back to cited text no. 14
  [Full text]  
15.
Dhasmana DJ, Bradley CJ, George P, Connell DW, Molyneaux P, Singanayagam A, et al. P19 GeneXpert MTB. Rif assay improves the diagnostic yield of EBUS-TBNA in smear-negative intra-thoracic tuberculous lymphadenopathy. Thorax 2011;66 (Suppl 4):A75.  Back to cited text no. 15
    
16.
Hanson PJ, Gor D, Clarke JR, Chadwick MV, Gazzard B, Jeffries DJ, et al. Recovery of the human immunodeficiency virus from fibreoptic bronchoscopes. Thorax 1991;46:410-2.  Back to cited text no. 16
    




 

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