Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:831
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size

 Table of Contents    
Year : 2019  |  Volume : 36  |  Issue : 2  |  Page : 128-130
Role of EBUS-TBNA in the diagnosis of tuberculosis and sarcoidosis

1 Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Click here for correspondence address and email

Date of Web Publication8-Mar-2019


Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has diagnostic accuracy and negative predictive value for the diagnosis of mediastinal tubercular lymphadenitis, especially when culture and cytological diagnosis is combined with high clinical suspicion. Both sarcoidosis and tuberculosis (TB) demonstrate granulomatous inflammation on cytology. Diagnosis of sarcoidosis in regions with a high burden of TB is challenging. We conducted a prospective study in 179 cases of suspected granulomatous pathology in mediastinal lymphadenopathy cases to evaluate the role of EBUS-TBNA in diagnosis of sarcoidosis and TB. It was found that extensive caseous necrosis, acid-fast bacilli positivity on Ziehl–Neelsen staining, and/or microbiological culture positivity have high positive predictive value for the diagnosis of TB.

Keywords: Endobronchial ultrasound-transbronchial needle aspiration, epithelioid cell granulomas, granulomatous inflammation, sarcoidosis, tuberculosis

How to cite this article:
Muthu V, Gupta N, Agarwal R, Dhooria S. Role of EBUS-TBNA in the diagnosis of tuberculosis and sarcoidosis. J Cytol 2019;36:128-30

How to cite this URL:
Muthu V, Gupta N, Agarwal R, Dhooria S. Role of EBUS-TBNA in the diagnosis of tuberculosis and sarcoidosis. J Cytol [serial online] 2019 [cited 2023 Mar 23];36:128-30. Available from:

Sarcoidosis and tuberculosis (TB) are the major causes of intrathoracic granulomatous lymphadenopathy. Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is currently the preferred initial modality for evaluating intrathoracic lymphadenopathy. The most definite evidence of TB is demonstration of Mycobacterium tuberculosis by culture or molecular methods. However, the diagnostic sensitivity of microbiologic techniques is low. Whether cytomorphologic features of granuloma can diagnose TB and distinguish it from sarcoidosis, its close mimic, remains unclear. We performed a prospective observational study of subjects undergoing EBUS-TBNA to evaluate the same.

A single cytopathologist (NG), who was blinded to the clinical data and final diagnosis, reported the TBNA. The following features were recorded: adequacy (either diagnostic or shows lymphocyte preponderance), the presence of granulomas, number of granulomas, average number of epithelioid cells in granulomas, necrosis [graded as 1 (focal), 2, and 3 (extensive)], stain for acid-fast bacilli (AFB), and the final impression (TB vs. sarcoidosis). The final diagnosis was made after 6 months' of follow-up.

The diagnosis of TB was based on the demonstration of two of the following: (a) consistent clinicoradiological presentation; (b) positive culture for Mycobacterium tuberculosis or Xpert MTB/Rif positivity; and (c) clinicoradiological response to anti-TB treatment. Sarcoidosis was diagnosed when all the following criteria were satisfied: (a) consistent clinicoradiological presentation; (b) non-necrotizing epithelioid cell granulomas on TBNA, TBLB, or EBB along with no AFB on Ziehl–Neelsen stain and no growth of mycobacteria on MGIT; and (c) clinicoradiological response after treatment with glucocorticoids. The procedural details and data of some patients included in this study have been described previously.[1]

Of the 179 consecutive subjects enrolled (January 2014 to March 2015), sarcoidosis and TB were diagnosed in 145 (81%) and 34 (19%), respectively. Granulomas were identified in 135 (75.4%), including 113 (77.9%) and 22 (67.6%) cases of sarcoidosis and TB, respectively [Table 1]; [Figure 1] and [Figure 2]. Necrosis was rare in sarcoidosis (n = 9, 6.2%), and it was never extensive. Based on the cytomorphology, a correct diagnosis was favored by the cytologist in 83 (61%) subjects, whereas misdiagnosis occurred in 40 (29.4%), when compared with the final diagnosis (after 6 months of follow-up).
Table 1: EBUS-TBNA cytology features of subjects with granulomatous intrathoracic lymphadenopathy

Click here to view
Figure 1: A panel of microphotographs showing epithelioid cell granulomas (a and b) and necrotizing inflammation (c and d) in tuberculosis (a: MGG 20×; b: H and E 20×, MGG: 20×, Pap 20×)

Click here to view
Figure 2: A panel of microphotographs showing epithelioid cell granulomas in sarcoidosis (a: MGG 20×; b: MGG 20×, H & E 40×, H & E in cell block 40×)

Click here to view

Diagnosing sarcoidosis in countries with a high TB burden poses a great challenge, and multiple features (clinical, imaging, microbiology, and cytology) should be taken into account. Despite decades of research, differentiating these two entities remains difficult, as both of them share similar clinical, radiological, and even pathological features.[2] A small retrospective study concluded that the morphology of granuloma did not help in differentiating TB and sarcoidosis.[3] Navani et al. in their study showed high diagnostic accuracy in diagnosing TB on EBUS-TBNA samples.[4] This study had more cases of sarcoidosis as EBUS-TBNA was done in a majority of suspected sarcoidosis cases and TB could be diagnosed by other investigations. This could be a reason for having lower diagnostic accuracy in this study. Though the cytomorphology in sarcoidosis and TB can overlap significantly, our observation suggests that certain features such as the presence of extensive necrosis may be highly suggestive of TB than sarcoidosis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Muthu V, Gupta N, Dhooria S, Sehgal IS, Bal A, Aggarwal AN, et al. A Prospective, Randomized, Double-Blind Trial Comparing the Diagnostic Yield of 21- and 22-Gauge Aspiration Needles for Performing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Sarcoidosis. Chest 2016;149(4):1111-3.  Back to cited text no. 1
Gupta D, Agarwal R, Aggarwal AN, Jindal SK. Sarcoidosis and tuberculosis: the same disease with different manifestations or similar manifestations of different disorders. Curr Opinion Pulmonary Med 2012;18(5):506-16.  Back to cited text no. 2
Kaur G, Dhamija A, Augustine J, Bakshi P, Verma K. Can cytomorphology of granulomas distinguish sarcoidosis from tuberculosis? Retrospective study of endobronchial ultrasound guided transbronchial needle aspirate of 49 granulomatous lymph nodes. CytoJ. 2013;10:19.  Back to cited text no. 3
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. 4

Correspondence Address:
Dr. Nalini Gupta
Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOC.JOC_150_18

Rights and Permissions


  [Figure 1], [Figure 2]

  [Table 1]

This article has been cited by
1 Komplikatives Hämatomediastinum einer 76-jährigen Patientin nach Durchführung einer endosonografisch gesteuerten transbronchialen Kryobiopsie (EBUS-TBKB) bei Verdacht einer Lymphomerkrankung
Björn Schwick, Svetlana Kintsler, Katharina Lindemann-Docter, Danny Jonigk, José Miguel Sodi Luna, Ingo Krüger
Pneumologie. 2023;
[Pubmed] | [DOI]
2 The diagnostic performance of endobronchial ultrasound with Xpert MTB/RIF Ultra in smear-negative pulmonary tuberculosis
Lan Yao, Shanhao Chen, Wei Sha, Ye Gu
BMC Infectious Diseases. 2023; 23(1)
[Pubmed] | [DOI]
3 Effect of Needle Size on Diagnosis of Sarcoidosis with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration: Systematic Review and Meta-Analysis
Shayan Kassirian, Stephanie N. Hinton, Alla Iansavitchene, Kayvan Amjadi, Alex Chee, Inderdeep Dhaliwal, Michael A. Mitchell
Annals of the American Thoracic Society. 2022; 19(2): 279
[Pubmed] | [DOI]
4 Evaluation of the Utility of Liquid-based Cytology, Cell-blocks, and Flow Cytometric Immunophenotyping on Endobronchial Ultrasound-guided Transbronchial Needle Aspiration Samples in the Diagnosis of Sarcoidosis
Dibyanshu S. Mohapatra, Parikshaa Gupta, Nalini Gupta, Sahajal Dhooria, Sehgal I. Singh, Shelly Sharma, Amanjit Bal, Manish Rohilla
Journal of Bronchology & Interventional Pulmonology. 2022; 29(4): 260
[Pubmed] | [DOI]
5 Clinical utility of endobronchoscopic ultrasound-guided fine-needle aspiration as the first modality of investigation in undiagnosed mediastinal lymph node in a TB-endemic country
AsmitaA Mehta, Arvind Perathur, Tisa Paul, S Divya, Nidhi Sudhakar, ArchanaGeorge Vallonthaiel, C Vidya
Lung India. 2022; 39(6): 583
[Pubmed] | [DOI]
6 High diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of adolescent pulmonary tuberculosis
Anne Geweniger, Ales Janda, Kristin Eder, Roland Fressle, Cecil Varna Kannan, Hubert Fahnenstich, Mirjam Elze, Christoph Müller, Philipp Henneke, Markus Hufnagel, Roland Elling
BMC Infectious Diseases. 2021; 21(1)
[Pubmed] | [DOI]
7 Chest Imaging in the Diagnosis and Management of Pulmonary Tuberculosis: The Complementary Role of Thoraci Ultrasound
Gaetano Rea, Marco Sperandeo, Roberta Lieto, Marialuisa Bocchino, Carla Maria Irene Quarato, Beatrice Feragalli, Tullio Valente, Giulia Scioscia, Ernesto Giuffreda, Maria Pia Foschino Barbaro, Donato Lacedonia
Frontiers in Medicine. 2021; 8
[Pubmed] | [DOI]
8 Endobronchial Ultrasound in Evaluating Mediastinal Lymphadenopathy
Nandakishore Baikunje, Giridhar Belur Hosmane, Sunil Kumar Y.
Journal of Health and Allied Sciences NU. 2021; 11(03): 201
[Pubmed] | [DOI]
9 The Diagnostic Utility of Endobronchial Ultrasound-Guided Trans-Bronchial Needle Aspiration (EBUS-TBNA) in Non-Malignant Mediastinal Lymphadenopathy: Experience from a High Tuberculosis Burden Tertiary Center
Agrima Mian, Animesh Ray, Achintya Dinesh Singh, Sandeep Mathur, Deepali Jain, Jigyasa Chaubey, Sanjeev Sinha
National Academy Science Letters. 2021; 44(6): 575
[Pubmed] | [DOI]
10 Utility of EBUS-TBNA in diagnosing mediastinal tuberculous lymphadenitis in East London
Olivia Lucey, Jessica Potter, William Ricketts, Lianne Castle, Mark Melzer
Journal of Infection. 2021;
[Pubmed] | [DOI]
11 Multidrug resistance in tubercular mediastinal adenopathy diagnosed by endobronchial ultrasound-transbronchial needle aspiration
Amit Dhamija, Saurabh Goyal, Abhinav Guliani, Reena Raveendran, ArupKumar Basu
Lung India. 2020; 37(2): 130
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded268    
    Comments [Add]    
    Cited by others 11    

Recommend this journal