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American Journal of  Medical 
Science and Innovation (AJMSI) 

Frequency of  Tuberculous Lymphadenitis (TBLA) in Somalia: A Retrospective Study 
with GeneXpert PCR-Based Diagnosis

Md Biplob Hossain1, Abdirahim Ahmed1, Abdullahi Tukade1, Chomel Mahbub2, Afrin Haque2, Munasar Abdikarim Nor1, 
Omer Hassan Omer Ismail1, Saida Abdi Mohamed1, Md. Ashiqur Rahman3, Sadia Islam4*

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.4114
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: November 30, 2024
Accepted: January 01, 2025
Published: January 24, 2025

Tuberculous Lymphadenitis (TBLA) poses a significant public health burden globally, 
particularly in Somalia due to high tuberculosis prevalence. It often faces diagnostic 
challenges due to its nonspecific symptoms; making early treatment critical. Additionally, 
high HIV and MDR-TB burden can also exacerbate the scenario. Hence, this study aims 
to determine the rate of  TBLA in Somali population using GeneXpert PCR assay. This 
retrospective observational study was conducted at NOVA Diagnostic and Research, a 
leading diagnostic center in Mogadishu, Somalia, from January 2024 to August 2024. A 
total of  499 suspected cases were included. Among the study participants, the male-to-
female ratio was 0.98:1. 36.07% of  individuals tested positive for TBLA. The disease was 
found to be more prevalent among younger participants, particularly those under the age of  
40. A significant association was observed between the site of  aspiration and TB positivity 
(p<0.005), with cervical lymph nodes being the most commonly affected site, accounting for 
67.2% of  positive cases. Additionally, TB was detected in multiple lymph node sites in 8.3% 
of  the all specimens. In Somalia, the rate of  TBLA continues to remain elevated, especially 
in younger population. More strategic approach is necessary to reduce the burden effectively. 
Rapid and accurate diagnosis of  TBLA can be performed by GeneXpert real-time PCR, for 
early detection and treatment.  

Keywords
Cervical Lymph Node Site, Disease 
Burden, GeneXpert Real-Time 
PCR, Lymph Node, Tuberculous 
Lymphadenitis (TBLA)

1 NOVA Diagnostic and Research, Mogadishu, Somalia
2 BADAS COVID-19 and Molecular Diagnostic Lab, Dhaka, Bangladesh
3 Novus Clinical Research Services Limited (NCRSL), Bangladesh
4 Bangladesh Specialized Hospital PLC, Bangladesh
* Corresponding author’s e-mail: sadia.buhs.6700@gmail.com

INTRODUCTION 
Tuberculous lymphadenitis (TBLA), earlier known as 
scrofula, is one of  the most common manifestations 
of  extra-pulmonary tuberculosis (EPTB) (Prasad et al., 
2024). TBLA is observed when the infection caused by 
tuberculous mycobacteria disseminates to the lymphatic 
system, generally to the cervical lymph nodes. This leads 
to granulomatous inflammation, caseous necrosis, and 
eventually the enlargement of  the lymph nodes (Lucas, 
2017). Symptom is typically associated with fever, night 
sweats, fatigue, and weight loss. Treatment typically 
involves a six-month regimen, with isoniazid, rifampin, 
ethambutol, and pyrazinamide for the initial two months, 
followed by isoniazid and rifampin for the next four 
months, as recommended by the WHO (Strategy, W.S.T., 
2008). Due to its asymptomatic nature, TBLA often 
remains undiagnosed during its early stages. Hence, the 
severity of  the disease is often overlooked on a global 
scale, resulting in delayed treatment. However, the regions 
with high disease burden such as Sub-Saharan Africa and 
Southeast Asia face substantial health crisis due to TBLA.
Somalia, an East-African country, possesses a significant 
prevalence of  TBLA cases in conjunction with high overall 
Tb burden.  Risk factors such as the high prevalence of  
HIV in Somalia play a critical role in the development and 
spread of  TB. As HIV weakens the immunity, it might 
result in individuals to become more susceptible to co-

infections like TBLA. Several studies have demonstrated 
a strong relation between TBLA and HIV co-infection, 
further complicating the disease management landscape 
(Tesfaye et al., 2017; Gounden et al., 2018; Perenboom 
et al., 1994; Abebe et al., 2012). Age and gender may 
also play as a critical contributor to the disease. Some 
studies have found that females are disproportionately 
affected with TBLA compared to males (Muluye, 2023; 
Fader et al., 2010; Purohit et al., 2009). On the contrary, 
no association between them was also observed in some 
studies (Mathiasen et al., 2020). Moreover, the escalating 
prevalence of  multidrug-resistant TB (MDR-TB) is a 
significant public threat, complicating the treatment of  
TBLA (Hassan et al., 2024; Tukade et al., 2024). 
Over the decades, Somalia has continued to combat the 
TB epidemic, persistently working to eliminate it despite 
challenges. However, the Tb program management of  
the country has made remarkable improvements limiting 
the death rates by 14% in the last 14 years (WHO). Still, 
to eradicate the disease completely, it is crucial to improve 
surveillance, promote awareness, offer advanced and 
specialized diagnosis techniques, and effective treatment 
regime. 
For identifying Tb more accurately and rapidly, molecular 
testing proves to be very effective, even from samples 
such as lymph node aspirates or biopsy. Techniques 
such as PCR or real-time PCR can immediately detect 



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the presence of  DNA of  Mycobacterium tuberculosis, 
thereby providing quicker results than traditional culture 
methods. This is particularly efficient for determining 
TBLA, where the symptoms are often less specific 
(Mohamed et al., 2023; Mirghani et al., 2024). Molecular 
testing ensures timely treatment initiation, which is crucial 
in preventing further complications and transmission.
Given the circumstances, this research aims to determine 
the prevalence of  TBLA among the patients of  a hospital 
in Mogadishu, Somalia, using GeneXpert real-time PCR 
method. By leveraging real-time PCR, the study seeks to 
generate accurate and rapid diagnosis on the burden of  
TBLA in this region, which is necessary for advancing 
diagnostic accuracy, developing treatment strategies, and 
promoting public health interventions to address TBLA 
effectively in Somalia.

MATERIALS AND METHODS
Study Design, Period and Study Population
This retrospective observational study was conducted 
at NOVA Diagnostic and Research, a leading diagnostic 
center in Mogadishu, Somalia, from January 2024 to 
August 2024. The study enrolled participants with 
suspected cases of  tuberculous lymphadenitis. Data were 
systematically extracted from the laboratory’s registration 
logbook, and a total of  499 suspected cases were included. 
Records with incomplete demographic information were 
excluded to ensure data integrity and reliability.

Sample Collection and Processing
Fine-needle aspiration cytology (FNAC) of  lymph nodes 
was performed under aseptic conditions using a 20 mL 
disposable plastic syringe fitted with a 23-gauge needle. 
The obtained aspirates were analyzed using the GeneXpert 
assay. The diagnosis of  tuberculous lymphadenitis 
(TBLA) was established based on cytological findings, 
which included the presence of  chronic granulomatous 
inflammation, atypical hyperplasia, actinomycosis, 
secondary carcinoma, or secondary undifferentiated 
nasopharyngeal carcinoma, among other pathological 
features.

Data Analysis
Data were analyzed using SPSS. The descriptive variables 
were described as frequency (percent). The association 
test between the categorical variables was analyzed 
using the Chi-square test. P-value <0.05 was considered 
statistically significant.

RESULTS AND DISCUSSION
Demographical Findings
The study examined the aspirates in a total of  499 
suspected cases of  tuberculous lymphadenitis (TBLA), 
with an almost equal gender distribution of  49.1% 
males and 50.9% females. The mean (±SD) age of  the 
participants was 27.71±17.53 years. Participants were 
grouped into 10-year age intervals, with the largest 
proportion (26.7%) falling between 21 and 30 years, 

while only a small percentage (2.6%) were over 70 years 
of  age. When distributed regionally, the majority of  
participants (87.6%) were from Mogadishu, the capital 
city of  Somalia. The remaining participants were across 
other regions, with 7.0% from Southern Somalia, 3.6% 
from the Central region, and 1.8% from the Northern 
region (Table 1).
Aspirates were collected from various lymph node sites, 
as shown in Figure 1. The most affected site was cervical 
lymph node with a proportion of  68.3% amongst all. 
Followed by were supraclavicular, submandibular, and 
axillary with 6.6%, 5.6%, and 5.2% respectively.  Along 
with that, few participants were found with lymph node 
swelling at multiple sites (6.6%).

GeneXpert Real-Time PCR findings
PCR findings showed in that, among the total participants, 
180 (36.07%) had lymphadenopathy due to tuberculosis 
(p<0.005) (Figure 2). Male/female ratio did not have any 
significant difference (0.98:1). Based on age distribution, 
the highest rate of  TBLA was found in age group 11-20 
(41.7%), followed by 31-40 (39.2%) and 21-30 (38.3%) 
participants. Positivity rate was comparatively less in age 
group below 10 years and 41-50, with 26.3% and 21.6% 
respectively (Figure 3). 

PCR Findings Based on Sites of  Aspiration
A diverse positivity rate of  TBLA was observed in 
different aspirates depending on the site of  lymph node 
involvement. The presence of  the bacteria was observed 
in 35.5% cervical aspirates, accounting for 67.2% of  
all positive cases due to their high sample size. Higher 
positivity rates were observed in the supraclavicular 
(57.6%) and para-aortic (55.6%) lymph nodes as well, 
although the total number of  aspirates from each site was 
relatively low.

Discussion 
Tuberculous Lymphadenitis (TBLA) is a significant health 
concern worldwide, particularly in the African region, 
which is facing a disproportionate burden due to high 
tuberculosis rates and associated risk factors. As a localized 
form of  tuberculosis, TBLA is often characterized by 
swollen lymph nodes and can present diagnostic challenges 
due to its nonspecific symptoms, which may mimic other 
infectious or inflammatory conditions (Mathiasen et al., 
2020). In Somalia, where healthcare infrastructure is 
still developing and the population faces socioeconomic 
challenges, TBLA remains a critical public health issue. 
Hence, it underscores the need for enhanced diagnostic 
strategies, targeted public health interventions, and a better 
understanding of  the epidemiological factors contributing 
to its spread. However, Mogadishu has initiated improved 
diagnostic approaches in association with WHO to 
mitigate the overall public health burden, particularly Tb 
and associated diseases. Therefore, the present study aimed 
to evaluate the rate of  Tuberculous Lymphadenitis (TBLA) 
among patients with swollen lymph nodes.



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In the present study, the prevalence of  tuberculous 
lymphadenitis (TBLA) was found to be 36.07%, 
representing a substantial proportion and underscoring 
tuberculosis (TB) as a significant cause of  lymphadenopathy 
in the study population. Comparable studies conducted 
in Ethiopia and Tanzania reported higher prevalence 
rates of  69.5% (Muluye, 2023). This discrepancy may 
be attributed to variations in sample size. Several factors 
contribute to the increased risk of  tuberculosis (TB) 
progression in Somalia. These include the country’s 
demographic profile, densely populated living-setting, 
nutritional deficiencies, and behaviors such as cigarette 
and khat consumption. These factors collectively worsen 
the susceptibility to TB by compromising the immune 
system and increasing exposure to potential infections.
Regarding gender distribution, the male-to-female ratio 
in our study was 0.98:1, suggesting no association. This 
finding aligns with another study conducted in Ethiopia 
(Muluye, 2023). Along with demographical and genetic 
factors, addressing the interplay between behavioral 
factors like cigarette smoking and khat consumption 
is essential in understanding their combined impact on 
health. Khat is widely chewed traditionally and culturally 
in the Sub-Saharan countries by both males and females. 
Chronic khat consumption has been associated to weak 
immune system, impaired lymphocyte function, and 
accelerated inflammation, all of  which can add the risk of  
TB infections (Kebede, 2002).
The age distribution of  TBLA cases revealed 
preponderance among younger individuals, with 11–20 
years age group accounting for 41.7% of  cases, followed 
by 31–40 years age group with 39.2%. These findings are 
consistent with earlier studies, which have also identified 

that younger individuals are most commonly affected 
age group (Ali et al., 2014; Mohamed et al., 2023). This 
is possibly attributed to the fact that younger people are 
most likely to have a less developed immune system, which 
makes them more vulnerable to disease. Additionally, in 
densely populated areas, younger population may have 
greater exposure to Tb due to frequent interactions in 
schools, social gatherings, or crowded living-settings.
While looking into the site of  aspirates, the cervical lymph 
nodes were the most commonly affected site, accounting 
for 67.2% of  positive cases. These nodes are the most 
common site for aspirates in the diagnosis of  TBLA, due 
to its crucial role in the drainage of  respiratory system.  
This finding is congruent with observations from the 
previous studies done in Ethiopia (47.5% and 74.2% 
respectively) where cervical regions were the most affected 
region (Muluye et al., 2023; Bezabih et al., 2002; Mathiasen 
et al., 2020). Along with that, this study found that Tb 
was also detected in large proportion in supraclavicular, 
para-aortic and submandibular lymph nodes. Moreover, 
aspirates were collected from multiple sites, in which a 
high rate of  Tb was observed (44.1%), highlighting the 
advancement of  the disease. This is indicative of  the 
requirement of  intensive treatment, as the infection has 
disseminated to the bloodstream (Mathiasen et al., 2020).
The incidence of  TBLA underscores a global, collaborative 
effort to focus on early diagnosis and treatment, and 
effective prevention strategies to eradicate tuberculosis (Le 
Roux & Vlok, 2021). In this study, the laboratory diagnosis 
of  TBLA was performed by GeneXpert real-time PCR, 
which has proven to be a highly effective method for 
detecting the presence of  TB early. This is because; 
PCR allows quick diagnosis and treatment, significantly 

Table 1: Characteristics of  the subjects
Variables N (%)
Gender
Male 245 (49.1)
Female 254 (50.9)
Mean age±SD [IQR] 27.71±17.53 [12.5-63.5]
Age range
≤10 76 (15.2)
11-20 120 (24.0)
21-30 133 (26.7)
31-40 79 (15.8)
41-50 37 (7.4)
51-60 24 (4.8)
61-70 17 (3.4)
>70 13 (2.6)
Region
Mogadishu (Capital) 437 (87.6)
Central 18 (3.6)
Northern 9 (1.8)
Southern 35 (7.0)



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improving the accuracy of  detection even in low-bacterial 
load samples. However, there were few limitations. As 
this is a retrograde study, a significant limitation was the 
absence of  comprehensive patient records. Records of  
co-morbidity like HIV, lifestyle, and history of  Tb could 
not be retrieved. HIV is highly prevalent in Somalia, and 

may influence the risk of  TB. Other limitation was lack of  
latest comprehensive research on the prevalence of  TBLA 
in high-incidence countries like Somalia. The finding in the 
present study underscores the importance of  considering 
TB as a primary differential diagnosis in regions or 
populations with high TB prevalence.

Figure 1: Distribution of  sites of  aspiration

Figure 2: Incidence of  TBLA

Figure 3: Incidence of  TBLA based on age group



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CONCLUSION
Tuberculous Lymphadenitis (TBLA) remains a substantial 
burden in Somalia, despite public health initiatives and 
adherence to WHO-recommended treatment protocols. 
This study revealed that 36.07% of  the participants were 
found with TBLA, reflecting significant concern due to 
tuberculosis in the region. Moreover, TB was detected 
from multiple lymph node sites, indicating systemic 
dissemination of  the disease. Therefore, it strengthens 
the need for swift diagnosis and treatment to reduce 
the severity of  disease and effective patient outcomes. 
The study also highlights the integration of  molecular 
techniques such as PCR into routine diagnostics, as it 
allows early and accurate TBLA detection.

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Table 2: PCR results based on sites of  aspiration
Variables Total N (%) Positive N (%) Negative N (%) f/p value
Site of  aspirates
Axillary 26 (5.2) 7 (26.9) 19 (73.1)

0.032

Cervical 341 (68.3) 121 (35.5%) 220 (64.5)
Inguinal 10 (2.0) 3 (30.0) 7 (70.0)
Para-aortic 9 (1.8) 5 (55.6) 4 (44.4)
Parotid 10 (2.0) - 10 (100.0)
Preauricular 3 (0.6) - 3 (100.0)
Submandibular 28 (5.6) 9 (32.4) 19 (67.9)
Submental 5 (1.0) 1 (20.0) 4 (80.0)
Supraclavicular 33 (6.6) 19 (57.6) 14 (42.4)
Multiple sites 34 (6.8) 15 (44.1) 19 (55.9)
Number of  lymph node
Single 466 (93.4) 165 (35.4) 301 (64.6) 0.245
Multiple 33 (6.6) 15 (45.5) 18 (54.5)

Results are expressed as number (%). Chi-squared test was performed to calculate statistical difference. P-value <0.005 was considered 
as level of  significance.



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