Research Article: Epidemiology of tuberculous lymphadenitis in Africa: A systematic review and meta-analysis

Date Published: April 19, 2019

Publisher: Public Library of Science

Author(s): Daniel Mekonnen, Awoke Derbie, Andargachew Abeje, Abebe Shumet, Endalkachew Nibret, Fantahun Biadglegne, Abaineh Munshae, Kidist Bobosha, Liya Wassie, Stefan Berg, Abraham Aseffa, Pere-Joan Cardona.


Tuberculous lymphadenitis is the most frequent form of extra-pulmonary TB (EPTB) and accounts for a considerable proportion of all EPTB cases. We conducted a systematic review of articles that described the epidemiological features of TBLN in Africa.

Any article that characterized TBLN cases with respect to demographic, exposure and clinical features were included. Article search was restricted to African countries and those published in English language irrespective of publication year. The articles were retrieved from the electronic database of PubMed, Scopus, Cochrane library and Random effect pooled prevalence with 95% CI was computed based on Dersimonian and Laird method. To stabilize the variance, Freeman-Tukey double arcsine root transformation was done. The data were analyzed using Stata 14.

Of the total 833 articles retrieved, twenty-eight articles from 12 African countries fulfilled the eligibility criteria. A total of 6746 TBLN cases were identified. The majority of the cases, 4762 (70.6%) were from Ethiopia. Over 77% and 88% of identified TBLN were cervical in type and naïve to TB drugs. Among the total number of TBLN cases, 53% were female, 68% were in the age range of 15–44 years, 52% had a history of livestock exposure, 46% had a history of consuming raw milk/meat and 24% had history of BCG vaccination. The proportion of TBLN/HIV co-infection was much lower in Ethiopia (21%) than in other African countries (73%) and the overall African estimate (52%). Fever was recorded in 45%, night sweating in 55%, weight loss in 62% and cough for longer than two weeks in 32% of the TBLN cases.

TBLN was more common in females than in males. The high prevalence of TBLN in Ethiopia did not show directional correlation with HIV. Population based prospective studies are warranted to better define the risk factors of TBLN in Africa.

Partial Text

Tuberculosis (TB) is one of the oldest chronic and complex infectious diseases and is caused by a group of bacteria belonging to the Mycobacterium tuberculosis complex (MTBC). The complex includes the human adapted species of M. tuberculosis and M. africanum, and zoonotic pathogens; M. bovis, M. caprae, M. microti and M. pinnipedii which affect cattle, goats/sheep, voles and seals/lions, respectively [1, 2]. The current body of evidence suggests that these mycobacteria might have co-evolved along with early hominids in East Africa since as far back as 3 million years ago [3, 4].

The central thesis of this review was to determine the geo-spatial distribution of TB lymphadenitis in Africa and to characterize TBLN cases by different demographic (gender, age groups), exposure (previous TB treatment history, raw meat/ milk exposure, BCG vaccination) and clinical variables (HIV co-infection, fever, weight loss, night sweat, cough).

Tuberculous lymphadenitis (scrofula) has been recognized for thousands of years and remains one of the most common forms of EPTB [63]. Cervical TBLN is the most frequent form followed by axillary and inguinal TBLN. In the middle ages in Europe, it was believed that a touch from royalty could heal this disease [64]. Unlike PTB which is more common in males [5], our review identified a relatively higher percentage of females (53%) than males among TBLN cases (low quality of evidence) (Table 3 and Fig 4A). The link between being female and TBLN is not well known. However, reports have shown that differences in tumor necrosis factor, interleukin-10, CD4+ lymphocyte counts, endocrine, socioeconomic and cultural factors [64] might influence the development of TBLN. A review of 31 articles from Afghanistan, Pakistan, India and Bangladesh agrees with our report [18]. Katsnelson (2017) discussed pregnancy, diabetes, vitamin D deficiency and low protein consumption as potential factors associated with TBLN.




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