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High expression of early secretory antigenic target 6 mRNA as a potential predictor of tuberculous lymphadenitis

  • Rita Cempaka ,
  • Titik Nuryastuti ,
  • Vincent Laiman ,
  • Fara Silvia Yuliani ,
  • Ahmad Musthafa ,
  • Hadis Pratiwi ,
  • Marcellus Marcellus ,
  • Didik Setyo Heriyanto ,


Purpose: Tuberculous lymphadenitis is one of the most common presentations of extrapulmonary tuberculosis. The diagnosis can be challenging due to its varying clinical manifestations and the low sensitivity of conventional bacteriological methods for confirming the causative agent, Mycobacterium tuberculosis. Early secretory antigenic target 6 (ESAT-6), which is released early during M. tuberculosis infection and plays a role in granuloma formation, determines the pathogen’s invasion, its severity, and virulence factors related to the immune response. This study aimed to analyze the potential diagnostic value of ESAT-6 using real-time polymerase chain reaction (RT-PCR) and compare it with histopathologic diagnostics.

Materials and methods: This retrospective observational study with the cross-sectional design was conducted using consecutive sampling. A total of 50 formalin-fixed, paraffin-embedded lymph node tissue samples from lymphadenectomy consisted of 25 tuberculous lymphadenitis and 25 granulomatous lymphadenitis were collected. The specimens were diagnosed with tuberculous and granulomatous lymphadenitis based on histopathologic features. Analyses using conventional PCR from commercial kit to detect TB and RT-PCR to determine the expression of ESAT-6 were performed. Statistical analysis of the categorical data was performed using the Mann-Whitney test. Statistical significance was set at p < 0.05.

Results: The mean age of the patients was 35.66 years old (range: 6–85 years). The age group between 16 and 30 years was the most common (40%). Almost two-thirds (62%) of the patients were female. Sixteen (64%) tuberculous lymphadenitis and 13 (52%) granulomatous lymphadenitis samples were positive by PCR TB. ESAT-6 expression was significantly higher in tuberculous lymphadenitis (p = 0.004).

Conclusion: ESAT-6 as a potential predictor of tuberculous lymphadenitis can be used in patients for whom histopathologic diagnostics fail to confirm the presence of M. tuberculosis.


  1. Global Tuberculosis Report 2019. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO
  2. Lestari T, Probandari A, Hurtig AK, Utarini A. High caseload of childhood tuberculosis in hospitals on Java Island, Indonesia: a cross-sectional study. BMC Public Health. 2011;11:784. doi: 10.1186/1471-2458-11-784
  3. Fontanilla JM, Barnes A, von Reyn CF. Current diagnosis and management of peripheral tuberculosis lymphadenitis. Clin Infect Dis. 2011;53(6):555–62. doi: 10.1093/cid/cir454
  4. Kumar V, Abbas AK, Aster JC. Lung. In: Kumar V, Abbas AK, Aster JC, editors. Robbins Basic Pathology, 9th ed. Philadelphia: Saunders; 2013. p. 459–515.
  5. Andersen P, Askgaard D, Ljungqvist L, Bennedsen J, Heron I. Protein released from Mycobacterium tuberculosis during growth. Infect Immun. 1991;59(6):1905–10.
  6. Rai RC, Dwivedi VP, Chatterjee S, Prasad DVR, Das G. Early secretory antigenic target-6 of Mycobacterium tuberculosis: enigmatic factor in pathogen–host interactions. Microbes Infect. 2012;14:1220–26. doi: 10.1016/j.micinf.2012.07.019
  7. Ganguly N, Siddiqui I, Sharma P. Role of M. tuberculosis RD-1 region encoded secretory proteins in protective response and virulence. Tuberculosis. 2008;88:510–17. doi: 10.1016/
  8. Brilha S, Sathyamoorthy T, Stuttaford LH, Walker NF, Wilkinson RJ, Singh S, Moores RC, Elkington PT, Friedland JS. Early secretory antigenic target-6 drives matrix metalloproteinase-10 gene expression and secretion in tuberculosis. Am J Respir Cell Mol Biol. 2016;56(2):223–32. doi: 10.1165/rcmb.2016-0162OC
  9. Carlsson F, Kim J, Dumitru C, Barck KH, Carano RAD, Sun M, Diehl L, Brown EJ. Host-detrimental role Esx-1-mediated inflammasome activation in mycobacterial infection. PLoS Pathog. 2009;6(5):e1000895. doi: 10.1371/journal.ppat.1000895
  10. Thierry D, Brisson-Noel A, Vincenty-Levy-Frebault V, Nguyen S, Guesdon JL, Gicquel B. Characterization of a Mycobacterium tuberculosis insertion sequence, IS6110, and its application in diagnosis. J Clin Microbiol. 1990;28(12):2668–73. doi: 10.1128/JCM.28.12.2668-2673.1990
  11. Marchetti G, Gori A, Catozzi L, Vago L, Nebuloni M, Rossi MC, Degli Esposti A, Bandera A, Franzetti F. Evaluation of PCR in detection of Mycobacterium tuberculosis from formalin-fixed, paraffin-embedded tissues: comparison of four amplification assays. J Clin Microbiol. 1998;36(6):1512–7.
  12. Huyen MNT, Tiemersma EW, Kremer K, de Haas P, Lan NTN, Buu TN, Sola C, Cobelens FGJ, van Soolingen D. Characterisation of Mycobacterium tuberculosis isolates lacking IS6110 in Viet Nam. Int J Tuberc Lung Dis. 2013;17(11):1479–85. Doi: 10.5588/ijtld.13.0149
  13. Chakravorty S, Sen M, Tyagi J. Diagnosis of Extrapulmonary Tuberculosis by Smear, Culture, and PCR Using Universal Sample Processing Technology. Journal of Clinical Microbiology. 2005;43(9):4357-4362. doi: 10.1128/JCM.43.9.4357-4362.2005
  14. Kesarwani RC, Pandey A, Misra A, Singh AK. Polymerase chain reaction: its comparison with conventional techniques for diagnosis of extra-pulmonary tubercular diseases. Indian J Surg. 2003;66:84–8.
  15. Asthana AK, Madan M. Study of Target gene IS 6110 and MPB 64 in Diagnosis of Pulmonary Tuberculosis. International Journal of Current Microbiology and Applied Sciences. 2015;4(8).
  16. Pahwa R, Hedau S, Jain S, Jain N, Arora V, Kumar N et al. Assessment of possible tuberculous lymphadenopathy by PCR compared to non-molecular methods. Journal of Medical Microbiology. 2005;54(9):873-878. doi: 10.1099/jmm.0.45904-0.
  17. Haldar S, Sharma N, Gupta VK, Tyagi SJ. Efficient diagnosis of tuberculous meningitis by detection of Mycobacterium tuberculosis DNA in cerebrospinal fluid filtrates using PCR. J Med Microbiol. 2009;58:616–24. doi: 10.1099/jmm.0.006015-0
  18. Nagdev KJ, Kashyap RS, Bhullar SS, Purohit HJ, Taori GM, Daginawala HF. Comparison of real-time PCR and conventional PCR assay using IS6110 region of Mycobacterium tuberculosis for efficient diagnosis of tuberculosis meningitis and pulmonary tuberculosis. Indian J Biotechnol. 2015;14:94–100. doi: 10.1371/journal.pone.0052001
  19. Bhigjee AI, Padayachee R, Paruk H, Hallwirth-Pillay KD, Marais S, Connoly C. Diagnosis of tuberculous meningitis: clinical and laboratory parameters. Int J Infect Dis. 2007;11:348–54. doi: 10.1016/j.ijid.2006.07.007
  20. Rana T, Singh UB, Kulshrestha V, Kaushik A, Porwal C, Agarwal N, Kriplani A. Utility of reverse transcriptase PCR and DNA-PCR in the diagnosis of female genital tuberculosis. J Med Microbiol. 2011;60:486–91. doi: 10.1099/jmm.0.025080-0
  21. Ryndak MB, Singh KK, Peng Z, Laal S. Transcriptional profile of Mycobacterium tuberculosis replicating in type II alveolar epithelial cells. PloS One. 2015;10(4):e0123745. doi: 10.1371/journal.pone.0123745
  22. Sumi S, Radhakrishnan VV. Evaluation of immunohistochemistry with a panel of antibodies against recombinant mycobacterial antigens for the diagnosis of tuberculous lymphadenitis. Int J Med Med Sci. 2009;1(5):215–9.
  23. Purohit MR, Mustafa T, Morkve O, Sviland L. Gender differences in the clinical diagnosis of tuberculous lymphadenitis—a hospital-based study from Central India. Int J Infect Dis. 2009;13:600–5. doi: 10.1016/j.ijid.2008.06.046
  24. Huda MM, Taufiq M, Yusuf A, Rahman MR, Begum F, Kamal M. Clinico-demographic characteristics of tuberculous lymphadenitis: experience of 50 cases in Bangladesh. J Tuberc Res. 2016;4(4):220–6. doi: 10.4236/jtr.2016.44024
  25. Kamal MS, Hoque HE, Chowdhury FR, Farzana R. Cervical tuberculous lymphadenitis: clinico-demographic profiles of patients in a secondary level hospital of Bangladesh. Pak J Med Sci. 2016;32(3):608–12. doi: 10.12669/pjms.323.9550

How to Cite

Cempaka, R., Nuryastuti, T., Laiman, V., Yuliani, F. S., Musthafa, A., Pratiwi, H., Marcellus, M., & Heriyanto, D. S. (2020). High expression of early secretory antigenic target 6 mRNA as a potential predictor of tuberculous lymphadenitis. Bali Medical Journal, 9(3), 794–798.




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