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American Journal of Laboratory Medicine
2022; 7(3): 43-48
http://www.sciencepublishinggroup.com/j/ajlm
doi: 10.11648/j.ajlm.20220703.12
ISSN: 2575-3878 (Print); ISSN: 2575-386X (Online)
Histopathologic Patterns of Lymph Node Diseases Among
Patients Diagnosed in Hawassa University Comprehensive
Specialized Hospital, Southern Ethiopia
Tesfalem Israel Korga
1, *
, Abebe Melis Nisiro
2
, Berhanu Lijalem Yigez
1
, Selamawit Abebe Ayele
2
,
Deginesh Dawit Woltamo
3
, Yohannes Zewde
1
, Abebe Sorsa Badacho
3
1
School of Medicine, College of Health Sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia
2
School of Medicine, College of the College of Health Science, Hawassa University, Hawassa, Ethiopia
3
School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia
Email address:
*
Corresponding author
To cite this article:
Tesfalem Israel Korga, Abebe Melis Nisiro, Berhanu Lijalem Yigez, Selamawit Abebe Ayele, Deginesh Dawit Woltamo, Yohannes Zewde,
Abebe Sorsa Badacho. Histopathologic Patterns of Lymph Node Diseases Among Patients Diagnosed in Hawassa University Comprehensive
Specialized Hospital, Southern Ethiopia. American Journal of Laboratory Medicine. Vol. 7, No. 3, 2022, pp. 43-48.
doi: 10.11648/j.ajlm.20220703.12
Received: June 20, 2022; Accepted: August 1, 2022; Published: August 9, 2022
Abstract:
Lymphadenopathy is one of the most typical clinical presentations in patients of all age groups. The causes are
different based on age, sex, duration, and patterns of involvement. There is a lack of evidence on histopathologic patterns of
lymph node diseases. This study aims to determine the histopathologic pattern of lymph node diseases diagnosed in Hawassa
university's comprehensive specialized hospital. An institution-based cross-sectional study was conducted among 188
histopathologically diagnosed lymph node biopsies received from September 2014 to August 2020 at Hawassa university's
comprehensive specialized hospital (HUCSH). All the samples collected for the diagnoses at a given period were included in the
study. The collected data was cleaned and entered into open Epi- version 3 and exported to SPSS version 20 statistical software
for analysis. Descriptive analyses like frequency distribution, proportion and dispersion were calculated. The finding was
presented using frequency tables, graphs, and charts. Both univariate and multivariate analyses were done. The Adjusted Odd
Ratio (AOR with 95% CI) was used to show the strength of the association, and a P-value of ≤ 0.05 was considered statistically
significant. Of the 188 lymph node biopsies, 119 (63.3%) were male cases, and 69 (36.7%) were female cases. The age range of
the study subjects is 1 to 84 years, with a mean of 31.28±18. 64 years. Localized lymphadenopathy (LAP) was found in 168
(89.4%) of the patients, and the remaining 20 (10.6%) were generalized. Among localized LN groups, cervical, mesenteric, and
inguinal LN groups are the most commonly biopsied groups accounting for 66 (35.1%), 55 (29.3%) and 14 (7.4%), respectively.
Regarding the size, 72.2% of benign reactive conditions were less than 2cm, whereas 74.5% of lymphomas have a size of at least
2cm. 86.9% of nonspecific reactive conditions have a duration of less than one month, whereas 89% of malignant conditions
collectively presented with LAP of more than 1-month duration. A third of 61 (32.4%) were identified as histopathologically
reactive nonspecific conditions and lymphomas consist 44 (23.4%) and metastatic lesions (40, 21.3%) and tuberculosis
lymphadenitis (36, 19.1%). This study's histopathologic pattern of Lymph Node (LN) disease was comparable with other
developing countries. Reactive nonspecific conditions and tuberculous lymphadenitis are more common before the age of 45
years. Metastatic lesions were found more common after the age of 45 years.
Keywords:
Reactive Nonspecific Conditions, Localized LAP, Histopathologic Pattern
44 Tesfalem Israel Korga et al.: Histopathologic Patterns of Lymph Node Diseases Among Patients Diagnosed in
Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia
1. Background
Lymph nodes are one of the components of the
lymphoreticular system, which play a vital role in filtering
and trapping viruses, bacteria, and other pathogens. Under
normal circumstances, they tend to be less than one
centimetre, but they can be as large as 1.5 cm in inguinal and
submandibular areas, particularly in adolescents and young
adults, due to repeated infections of the lower extremities and
oral cavity [1].
Lymphadenopathy is one of the common clinical problems
and based on the age and sites of involvement, and the causes
can be broadly classified as inflammatory (including
infectious and autoimmune causes), metastatic lesion and
lymphoma [2-4].
The specific disease process classifying as localized when
it involves a single region, such as cervical or inguinal, and
generalized when it involves more than one region is
paramount for a clinician. Head and neck infections like
Epstein-var virus and Cytomegalovirus can manifest by
anterior cervical lymphadenopathy. In contrast, the usual
presentation for malignancies like lymphoma and metastatic
carcinoma from the head and neck region is challenging
posterior cervical lymphadenopathy, particularly in the
elderly [1, 5].
Supraclavicular lymphadenopathy carries the highest risk
for harboring malignant conditions as evidenced by two
studies with an estimated risk of 34 and 50 percent,
particularly in patients above 40 [6, 7]. Malignant neoplasms
involving the lungs, mediastinum, and esophagus drain to
right supraclavicular lymph nodes, as left supraclavicular
lymph nodes (Virchow's node) usually harbour metastatic
lesions from abdominal and pelvic organs, stomach,
gallbladder, ovaries, testis, and the like [8].
Infections involving the upper extremities, thoracic wall,
and breast silicone breast implants may present as axillary
lymphadenopathy in the form of inflammatory and foreign
body reactions [9, 10]. The risk of the metastatic deposit is
higher in older women [11].
As it is draining from the lower extremities, which are
susceptible to different injuries, the frequent causes for
inguinal lymphadenopathy are infections and metastasis
from the respective sites. Infections and metastatic lesions
from the pelvic structures like the cervix, vulva, rectum,
and anus can also drain the inguinal lymph nodes [12].
Infections like HIV, infectious mononucleosis, and
tuberculosis canpresent as waning and waxing generalized
lymphadenopathy and matted lymph nodes at multiple
sites, respectively. Malignant lymphomas can also be
shown as indolent waxing and waning or massive
generalized lymphadenopathy, depending on the specific
types of lymphomas [13, 14].
2. Methods
2.1. Study Area and Period
The study was conducted from July to September 2020 in
HUCSH, which is found in Hawassa town, Sidama regional
state of South Ethiopia. HUCSH is located 270 km southeast
of Ethiopia's capital city, Addis Ababa, with an estimated
population of around 258,808. HUCSH is the first referral
hospital established in the region, serving as a teaching
hospital for the College of Medicine and Health Science of
Hawassa University, with a catchment population of 10-12
million. It serves about 43,384 patients of all types per year.
Cytology and Histopathology services are available in the
pathology department.
2.2. Study Design, Study Population and Sampling
A facility-based cross-sectional study design was used. All
tissue biopsy specimens received, processed, and reported at
the HUCSH department from September 2014 to August
2020 were used.
All LN specimens received, processed, and reported at the
HUCSH department of pathology are included in the study.
2.3. Data Collection and Quality Control
After approval from the Institutional Review Board (IRB)
of HUCSH, the principal investigator prepared a checklist
after reviewing pertinent literature. The training was given to
data collectors on data collection procedures, and the
principal investigator, principal investigator, and principal
investigator checked the completeness for any inconsistency
and ambiguity. Finally, it was fed into the computer and
analyzed and interpreted.
2.4. Data Analysis
The collected data is cleaned and manually entered into
open Epi- version 3 and exported to SPSS version 20 statistical
software for analysis. Descriptive analyses like frequency
distribution, proportion and dispersion were calculated. The
finding is presented using frequency tables, graphs and charts.
Both univariate and multivariate analyses were done. A P
value of≤0.05 was considered statistically significant.
2.5. Operational Definition
Lymphadenopathy: Lymph node enlargement > 1cm in
extra inguinal regions and > 1.5cm in inguinal region.
3. Result
3.1. Socio-demographic Data
In this study, a total number of 188 lymph node biopsies
were analyzed with 119 (63.3%) male cases and 69 (36.7%)
female cases (M:F = 1.7:1) The age range of the study
subjects is 1 to 84 years, with a mean of 31.28 18.64 years.
Clinical Data
Distribution of LAP with Regard to LN Groups
Localized LAP is found In 168 (89.4%) of the study
subjects and the remaining 20 (10.6%) are generalized.
Among localized LN groups, cervical, mesenteric, and
inguinal LN groups are the most commonly biopsied groups
±
American Journal of Laboratory Medicine 2022; 7(3): 43-48 45
accounting for 66 (35.1%) 55 (29.3%) and 14 (7.4%)
respectively (Figure 1). Regarding the size, 72.2% of benign
reactive conditions are with a size of less than 2cm, whereas
74.5% of lymphomas have a size of at least 2cm.
Figure 1. Distribution of LAP in patients with LN biopsy at HUCSH 2014-2020.
3.2. Patterns of Histopathologic Diagnosis
Histopathologically reactive nonspecific conditions
(including cortical, paracortical hyperplasia and sinus
histiocytosis) and lymphomas (both Hodgkin’s and non
Hodgkin’s) are the most common histopathologic findings
consisting of 61 (32.4%) and 44 (23.4%) respectively
followed by metastatic lesions (n=40, 21.3%) and
tuberculosis lymphadenitis (n=36, 19.1%) (Figure 2).
Figure 2. Patterns of histopathologic diagnosis of LN biopsy in HUCSH 2014-2020.
The majority, 86.9% of nonspecific reactive conditions have less than one month, whereas 89% of malignant
46 Tesfalem Israel Korga et al.: Histopathologic Patterns of Lymph Node Diseases Among Patients Diagnosed in
Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia
conditions collectively presented with LAP of more than 1-
month duration.
Histopathologically reactive nonspecific conditions
(including cortical, paracortical hyperplasia and sinus
histiocytosis) and lymphomas (both Hodgkin's and non-
Hodgkin's) are the most common histopathologic findings
consisting of 61 (32.4%) and 44 (23.4%) respectively
followed by metastatic lesions (n=40, 21.3%) and
tuberculosis lymphadenitis (n=36, 19.1%).
Cervical LNs are commonest groups to be involved by
tuberculous lymphadenitis (n=17, 47.2%) and to harbors
metastatic deposits (n=23, 57.5%). Generalized LAP is the
most typical presentation for NHL (n=16, 36.4%) whereas
mesenteric groups are the primary sites to be affected by
nonspecific reactive conditions (n=45, 73.8%).
Non-neoplastic conditions like reactive lymphoid
hyperplasia and tuberculous lymphadenitis are more common
in patients under 45 years of age. (Figure 3)., The majority of
metastatic lesions (70%), are seen in patients with the age of
older than 45 years with the age range of 12 – 75 years, and
mean age of 46 ± 14.942 years. which shows a strong
association between the patient's age and the risk of
harbouring metastatic lesions (X² = 41.639, df = 3, p <0.001).
As compared to patients with the age of <15 yrs, those with
the age of above 45 years have high probability of harboring
metastatic deposits with high statistical significance.
Figure 3. Correlation of age and histopathologic diagnosis at HUCSH and YMSC.
4. Discussion
Cervical LNs are the most affected groups comprising
35.1% in our study; similar results was also found in
Nigerian studies {Kano (46%), Lagos (39.3%), Ilorin
(42.6%)}, and Turkey (38.3%) [15-18].
Reactive nonspecific lymphadenitis comprises 32.4% in
our study which is comparable with some of Nigerian studies
{Lagos (34%) and Ibadan (35%)}, Nepal (36%) while higher
than the finding in some others Nigerian studies {Kano
(27%), Benin (19%)}, and TASH, Ethiopia (26%), this can
be explained by the inclusion of mesenteric LNs majority of
which are diagnosed as reactive nonspecific lymphadenitis.
[15, 16, 19-22].
19.1% of our study subjects are diagnosed with
tuberculous lymphadenitis which is in a proximity with the
results of Nigerian studies {Lagos (17.4%) and Benin city
(26%)}, and Iraqi (25%). [16, 21, 23]. Whereas this figure is
much lower than other studies in TASH, Ethiopia (47.8%),
Nepal (47%), and Pakistan (49.3%) [22, 20, 24] this could be
due to the growing utilization of HAART, selection or
referral bias and the figure is much higher than that of
Chicago (5.8%) [25] This is mainly due to low
socioeconomic status and associated unsanitary conditions
with subsequent risk of acquiring various infections
including tuberculosis.
Cervical groups of LN are the commonest site of
involvement for tuberculous lymphadenitis (47.2%) which is
also comparable with the result in Nepal (52.2%) [20], and
lower than studies in India (56%) and Benin (65%) [26, 21],
this can also be explained by the inclusion of mesenteric LN
groups in which tuberculous lymphadenitis is the second
most common finding as opposed to other studies which are
done on peripheral LAP exclusively.
Majorities of tuberculous lymphadenitis were found in
patients with age of fewer than 45 years of age (80.3%)
which is also comparable with Kano (80%) and Benin city
(75.4%) [15, 21].
Metastatic lesions are estimated to be 21.3% in our study;
similar results are also found in Nigerian studies {Kano
(19%), Ilorin (19.3%), Benin City (22.7%)}and TASH
Ethiopia (19.8%) [15, 17, 21, 22] whereas it is higher than
results of Iraqi (11.7%), and Nepal (10.9%) [23, 20] this
could also be due to referral and selection bias. Studies in
industrialized nations show higher figures of metastatic
American Journal of Laboratory Medicine 2022; 7(3): 43-48 47
lesions like Thailand (53.2%) [27]; this could contribute to
environmental and genetic factors. Cervical LNs are the
commonest LN groups to be involved by metastatic lesions
(57.5%), which is also closely parallel with a study in Turkey
(50%) and Benin city (52%) [18, 21].
Lymphomas cumulatively comprises 27.1% (86.3% of the
cases are NHL and the remaining 13.7% is Hodgkin's
lymphoma) which is in agreement with the figure in Ibadan
(24%), Ilorin (28.2%), and Benin city (26.3%) [19, 17, 21] all
with NHL predominance whereas the finding in Pakistan
(25.4%) [24] even though the cumulative figure is
comparable there is a slight HL predominance, this regional
discrepancy may be due to genetic and environmental
factors.
The majority of lymphoma cases in our study have the size
of at least 2cm (74.5%), comparable results are also seen in
Pakistan (88%) [24].
5. Conclusion
This study's histopathologic pattern of Lymph Node (LN)
disease was comparable with other developing countries.
Reactive nonspecific conditions and tuberculous
lymphadenitis are more common before the age of 45 years.
Metastatic lesions are more common after the age of 45
years. non-Hodgkin's lymphoma is more common than
Hodgkin's lymphoma. Early detection and investigation of
LN enlargement help avoid a delayed diagnosis of a
potentially curable disease. We recommend the further
studies to determine the predicators.
Authors' Contribution
TIK: Initiated the research, wrote the research proposal,
conducted the study, did data entry and analysis, and wrote the
manuscript. AMN: Involved in the -up of the submission, data
analysis and write-up of the manuscript. BLY: Involved in the
proposal and write-up of the manuscript. SAA: Involved in the
proposal and write-up of the manuscript. DDW: Involved in
the proposal and write-up of the manuscript. YZ; Involved in
the submission and write-up of the manuscript. ASB: Involved
in the proposal and write-up of the manuscript. All authors
read and approve the manuscript.
Author's Information
1. Tesfalem Israel Korga: MD, Pathologist, assistant prof,
at college of health science Wolaita Sodo university,
Wolaita Sodo.
2. Abebe Melis Nisiro: MD, Pathologist. Assistant
professor at the college of health science Hawassa
University, Hawassa.
3. Berhanu Lijalem Yigezu: MD, Pathology lecturer at
college of health science Wolaita Sodo University,
Wolaita Sodo.
4. Selamawit Abebe Ayele: MD, Pathology Resident at
college of health science Hawassa University, Hawassa.
5. Yohannes Zewude: MD, assistant professor of General
Surgery, at college of health science and medicine
Wolaita Sodo University, Wolaita Sodo.
6. Deginesh Dawit Woltamo: MPH, Lecturer
Epidemiology and Biostatistics, School of Public
Health, at college of health science Wolaita Sodo
University, Wolaita Sodo.
7. Abebe Sorsa Badacho: MPH, Assistant professor of
Health services management, School of Public Health,
at college of health science Wolaita Sodo University,
Wolaita Sodo.
Competing Interests
The authors declare that they have no competing interests.
Funding
Nil.
Acknowledgements
Our gratitude may go to Hawassa University Faculty of
medicine for the financial support, technical assistance, and
approval.
The Author's sincere gratitude goes to the data collectors,
supervisors and study participants.
References
[1] Ferrer R. Lymphadenopathy: differential diagnosis and
evaluation. Am Fam Physician 1998; 58: 1313.
[2] Herzog LW. Prevalence of lymphadenopathy of the head and
neck in infants and children. Clin Pediatr (Phila) 1983; 22: 485.
[3] Knight PJ, Mulne AF, Vassy LE. When is lymph node biopsy
indicated in children with enlarged peripheral nodes?
Pediatrics 1982; 69: 391.
[4] Roy A, Kar R, Basu D, Badhe BA. Spectrum of
histopathologic diagnosis of lymph node biopsies: A
descriptive study from a tertiary care center in South India
over 5½ years. Indian J Pathol Microbiol 2013; 56: 103-8.
[5] Datta PG, Hossain MD, Amin SA, et al. Tubercular
lymphadenitis - diagnostic evaluation. Mymensingh Med J
2011; 20: 233.
[6] Fijten GH, Blijham GH. Unexplained lymphadenopathy in
family practice. An evaluation of the probability of malignant
causes and the effectiveness of physicians' workup. J Fam
Pract 1988; 27: 373.
[7] Chau I, Kelleher MT, Cunningham D, et al. Rapid access
multidisciplinary lymph node diagnostic clinic: analysis of
550 patients. Br J Cancer 2003; 88: 354.
[8] Morgenstern L. The Virchow-Troisier node: a historical note.
Am J Surg 1979; 138: 703.
[9] Copeland EM, McBride CM. Axillary metastases from
unknown primary sites. Ann Surg 1973; 178: 25.
48 Tesfalem Israel Korga et al.: Histopathologic Patterns of Lymph Node Diseases Among Patients Diagnosed in
Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia
[10] Shipchandler TZ, Lorenz RR, McMahon J, Tubbs R.
Supraclavicular lymphadenopathy due to silicone breast
implants. Arch Otolaryngol Head Neck Surg 2007; 133: 830.
[11] de Andrade JM, Marana HR, Sarmento Filho JM, et al.
Differential diagnosis of axillary masses. Tumori 1996; 82: 596.
[12] Zaren HA, Copeland EM 3rd. Inguinal node metastases.
Cancer 1978; 41: 919.
[13] Mascaró JM Jr. Cutaneous signs of hematologic malignancies:
"Doctor, is there something wrong with my blood?". Arch
Dermatol 2011; 147: 342.
[14] Lai KK, Stottmeier KD, Sherman IH, McCabe WR.
Mycobacterial cervical lymphadenopathy. Relation of
etiologic agents to age. JAMA 1984; 251: 1286.
[15] Ochicha O, Edino S T, Mohammed A Z, Umar A B, Atanda A
T. Pathology of peripheral lymph node biopsies in Kano,
Northern Nigeria. Ann Afr Med 2007; 6: 104-8.
[16] C C Anunobi, A A F Banjo, F B Abdulkareem, A O
Daramola, E K Abudu, Review of the Histopathologic
Patterns of Superficial Lymph Node Diseases, in Lagos (1991-
2004). PMID.
[17] Ojo BA, Buhari MO, Malami SA, Abdulrahaman MB.
Surgical lymph node biopsies in University of Ilorin Teaching
Hospital, Ilorin, Nigeria. Niger Postgrad Med J. 2005 Dec; 12
(4): 299-304. PMID: 16380743.
[18] Özkan EA, Göret CC, Özdemir ZT, Yanık S, Göret NE, Doğan
M, et al. Evaluation of peripheral lymphadenopathy with
excisional biopsy: Six-year experience. Int J Clin Exp Pathol
2015; 8: 15234-9.
[19] Thomas JO, Ladipo JK, Yawe T. Histopathology of
lymphadenopathy in a tropical country. East Afr Med J 1995;
72: 703-5. [PUBMED].
[20] M Tiwari, G Aryal, R Shrestha, S K Rauniyar, H G Shrestha:
Histopathologic Diagnosis of Lymph Node Biopsies. Ann Afr
Med 2006; 4: 92-101.
[21] Olu-Eddo AN, Ohanaka CE. Peripheral lymphadenopathy in
Nigerian adults. J Pak Med Assoc 2006; 56: 405-8.
[22] A Getachew, M Demissie, T Gemechu, Pattern of
Histopathologic Diagnosis of Lymph Node Biopsies in a
Teaching Hospital in Addis Ababa, 1981-1990 G. C. PMID.
[23] Alkumasi HA, Al Ghadhban MR, Mohammed FT. Common
sites and causes of chronic cervical lymphadenopathy among
a sample of Iraqi patients. Int Surg J 2018; 5: 892-6.
[24] Hussain MI, Bukhari MH, Aftab MZ. Lymph node biopsies:
Evaluation of disease pattern and role of surgery – Our
experience from South Punjab, Pakistan. Acta Med Int 2019;
6: 7-10.
[25] Freidig EE, McClure SP, Wilson WR, Banks PM, Washington
JA Clinical-histologic-microbiologic analysis of 419 lymph
node biopsy specimens. Rev Infect Dis 1986; 8: 322-8.
[26] Mohan A, Reddy MK, Phaneendra BV, Chandra A. Aetiology
of peripheral lymphadenopathy in adults: analysis of 1724
cases seen at a tertiary care teaching hospital in southern
India. Natl Med J India 2007; 20: 78.
[27] Sriwatanawongsa V, Cardoso R, Chang P. Incidence of
malignancy in peripheral lymph node biopsy. Am Surg. 1985
Oct; 51 (10): 587-90. PMID: 4051335.
