International Journal of Infectious Diseases 122 (2022) 741–746

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International Journal of Infectious Diseases

journal homepage: www.elsevier.com/locate/ijid

Xpert MTB/RIF Ultra outperformed the Xpert assay in tuberculosis

lymphadenitis diagnosis: a prospective head-to-head cohort study
Xia Yu a,†, Tingting Zhang a,†, Yaoyao Kong b,†, Fen Wang a, Lingling Dong a, Ming Han c,∗,
Hairong Huang a,∗
a
National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug-resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical
University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, China
b
Tuberculosis Department, Beijing Chest Hospital, Capital Medical University, Beijing, China.
c
Department of Thoracic Surgery, Beijing Chest Hospital, Capital Medical University, Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) Ultra (Xpert-Ultra) has shown better
Received 20 June 2022 sensitivity in comparison with Xpert MTB/RIF (Xpert) in extrapulmonary tuberculosis (TB), whereas the
Revised 12 July 2022
head-to-head comparison of these methods in TB lymphadenitis had barely been performed.
Accepted 13 July 2022
Methods: Patients with undiagnosed lymphadenopathy were recruited prospectively and consecutively,
and fine-needle aspiration (FNA) biopsy or lymph node tissue was collected. The specimen was subjected
Keywords: to smear, culture, Xpert, and Xpert-Ultra assays. Culture and/or smear for acid-fast bacilli (AFB) or AFB
Tuberculosis lymphadenitis observed on histopathology were performed as a reference.
Xpert MTB/RIF Ultra Results: A total of 106 participants were recruited, including 41 confirmed TB, 33 probable TB, and 32
Fine-needle aspiration
non-TB lymphadenopathies. The head-to-head comparison for MTB detection showed that Xpert-Ultra
Xpert MTB/RIF
produced the highest sensitivity when compared with smear, culture, and Xpert (75.7% vs 5.4 %, 13.5%,
Lymph node tissue
and 48.7%). When Xpert-Ultra outcomes were integrated for diagnosis, the percentage of confirmed TB
lymphadenitis cases increased from 55.4% (41/74) to 85.1% (63/74). The sensitivities of Xpert-Ultra and
Xpert on tissue were 73.6% (95% CI: 59.4-84.3) and 39.6% (95% CI: 26.8-54.0), respectively. The sensitivity
of Xpert-Ultra on FNA samples (81.0%, 95% CI: 57.4-93.7) was higher than that of Xpert (71.4%, 95% CI:
47.7-87.8).
Conclusion: Xpert-Ultra detected significantly more TB lymphadenitis cases than Xpert or culture. This
superiority was particularly distinct using lymph node tissue than FNA detection.
© 2022 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious
Diseases.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction
Tuberculosis (TB) is a highly prevalent disease that accounted
for an estimated 9.96 million new cases in 2019, as reported by
the World Health Organization (WHO). Among these, an estimated
16% of the cases corresponded to extrapulmonary TB (EPTB). Be-
cause of the nonspecific symptoms and inaccessibility of the ap-
propriate specimen required for bacteriological examination, EPTB
cases are currently considered an underestimation (Bomanji et al.,
2020; Solovic et al., 2013). TB lymphadenitis, one of the most com-
∗
Corresponding authors.
E-mail addresses: hansiyu@sohu.com (M. Han), huanghairong@tb123.org (H.
Huang).
†
These authors contributed equally to this study.
mon forms of EPTB, accounts for ∼35% of the total EPTB cases
(Gautam et al., 2018). In recent years, fine-needle aspiration (FNA)
biopsy of lymph nodes and biopsy tissue through core-needle are
used more and more frequently for etiologic diagnosis of periph-
eral lymphadenopathy. With the increased accessibility of clini-
cal specimens integrated with advanced molecular testing, such
as Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) (Xpert), an
improved bacteriological finding has been acquired for TB lym-
phadenitis (Huang et al., 2020; Zhou et al., 2021).
In 2017, the WHO endorsed the new generation Xpert tech-
nology, Xpert MTB/RIF Ultra (Xpert-Ultra), to replace Xpert for
TB-HIV co-infection, pediatric TB, or EPTB (World Health Orga-
nization, 2017). The Xpert-Ultra differs from its earlier counter-
part mainly in the amplification target design: two different in-
sertion sequence fragments (IS6110 and IS1081), which have mul-

https://doi.org/10.1016/j.ijid.2022.07.039
1201-9712/© 2022 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
X. Yu, T. Zhang, Y. Kong et al.
tiple copies in the MTB genome, had been added to improve the
detection sensitivity. The Xpert-Ultra also has an additional semi-
quantitative category named “trace call,” indicating very low lev-
els of MTB DNA amplified, i.e., IS6110/IS1081 positive and rpoB
negative (Kendall et al., 2017). Therefore, a lower limit of detec-
tion (LOD) for Xpert-Ultra was obtained than Xpert (15.6 bacte-
rial colony-forming units [CFU] per ml compared with 114 CFU per
ml with Xpert) (Chakravorty et al., 2017). On-site evaluations of
Xpert-Ultra, in contrast with Xpert, have demonstrated that this
new generation test had distinct improvement in the detection
of paucibacillary specimens, such as smear-negative but culture-
positive sputum, pleural fluid, and cerebrospinal fluid (Gao et al.,
2021; Huang et al., 2021; Wang et al., 2020). Several studies have
previously evaluated the performance of Xpert-Ultra for TB lym-
phadenitis diagnosis: one study tested 10 frozen FNA samples with
Xpert-negative-culture-positive outcomes and found that half of
these samples yielded positive Xpert-Ultra results (Bisognin et al.,
2018); Another study tested specimens of 99 TB lymphadenitis sus-
pects (51% were HIV positive) with Xpert-Ultra and obtained sen-
sitivity on FNA or tissue at 70% (21/30) or 67% (16/24), respec-
tively. The specificity of Xpert-Ultra was 100% (43/43) using FNA,
whereas 96% (55/57) using tissue (Antel et al., 2020). A recent
study performed with FNA (n = 92) in a high HIV setting (61% HIV
positive cases) showed that Xpert-Ultra had an increased sensitiv-
ity (91%) in contrast to Xpert (72%) but demonstrated decreased
specificity (76% versus 93%) (Minnies et al., 2021). Until now, no
study has been performed to compare Xpert and Xpert-Ultra’s per-
formances in diagnosing TB lymphadenitis from low HIV settings,
which might have different patient characteristics from the pa-
tients in high HIV burden countries.
Materials and methods
Ethical approval
This study was approved by the ethics committee of Beijing
Chest Hospital, Capital Medical University. Written informed con-
sent forms were signed by patients.
Patient enrollment
Patients who met the following criteria were recruited prospec-
tively and consecutively from October 2019 to February 2021 in
the Beijing Chest Hospital, a specialized tertiary hospital for TB
and chest tumors: (1) had one or more palpable lymph nodes of
1 cm or larger; (2) showed persistence beyond 4 weeks despite
oral antibiotic therapy; (3) demonstrated clinically solid suspicion
or microbiological confirmation of mycobacterial infection. Before
enrollment, patients had undergone a clinical workup for enlarged
lymph nodes, including chest radiograph, sputum examinations for
evidence of TB (including smear, culture, and molecular tests), bio-
chemistry test with blood, and microbiological investigations with
rupture, when available.
Patient category
Patients were assigned to one of three diagnostic categories ac-
cording to the outcomes of smear, culture, pathological examina-
tion, and other tests: (1) confirmed TB: smear-positive or culture-
positive on FNA/tissue or AFB was observed, or TB DNA was de-
tected by polymerase chain reaction during a pathological exam-
ination. Some patients had negative outcomes for TB examina-
tion at the time of enrollment, but their subsequent examinations
yielded positive mycobacteriological evidence with lymph node
specimens. Therefore, these patients were categorized into the con-
firmed TB group; (2) probable TB: smear and culture were nega-
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International Journal of Infectious Diseases 122 (2022) 741–746
tive for FNA/tissue, granulomatous inflammation was observed, but
both AFB smear and TB DNA tests were negative, microbiologically
confirmed TB at a site other than lymph node (e.g., pulmonary)
or responded well to anti-TB therapy; (3) non-TB: cancer or other
diseases diagnosed by histopathological or other examinations.
Study procedures and specimen collection
The biopsy method was chosen according to the clinician’s esti-
mation of the caseous and liquefied tissue volume. If the estimated
volume was <0.5 ml, the tissue sample was collected by MC1810
core needle (Argon, USA). One pass was made, and two biopsy tis-
sue specimens (20 mm × 1 mm) were collected: one was ran-
domly assigned for histological examination, and the second was
used for the microbiological examination, which included smear,
culture, Xpert, and Xpert-Ultra. When the estimated volume was
≥0.5 ml, the aspirate sample was collected with a 22G needle and
10 ml syringe. Aspiration was collected by negative suction with
a cutting motion while the needle was inserted. Approximately
0.5 ml aspirate was used for histological examination. The remain-
ing volume was used for the previously mentioned microbiological
tests.
Pathologic examination
The tissue samples were fixed with 10% formaldehyde, subse-
quently dehydrated, and embedded with paraffin. Each specimen
was incised into 6-10 4-μm thick slices. After dewaxing with xy-
lene, the slices were gradient eluted using 95%, 90%, 85%, and 70%
ethanol and then finally with deionized water. The sections were
stained by hematoxylin and eosin or Zeihl-Neelsen method, re-
spectively. Then, the pathological features or AFB were observed
by light microscopy. In addition, an MTB DNA detection kit (Daan
Gene Co., Ltd., Beijing, China) was used for patients with a sugges-
tive pathological image of TB. The diagnosis of TB lymphadenitis
is based on finding the AFB and granulomatous inflammation, fre-
quently with caseous necrosis.
Xpert and Xpert-Ultra detection
The tissue/FNA specimens were collected in a sterile 2 ml cen-
trifuge tube for testing within 2 hours after sampling. The biopsy
tissue was homogenized with MP fastprep-24 homogenizer (MP
Biomedicals, USA) and then suspended with phosphate buffer. The
homogenate/FNA was divided into three equal aliquots: 500 μl for
smear and culture and 500 μl each for Xpert and Xpert-Ultra. The
tissue homogenate and FNA were mixed with the sample reagent
in a 1:2 ratio and subjected to Xpert and Xpert-Ultra assays per the
manufacturer’s instructions. In case, the test could not be carried
out in time, the sample was frozen at -80°C for storage. Moreover,
the “trace positive” category referred to the samples from which
IS6110/IS1081 were detected, but rpoB was negative for detection.
Smear and mycobacterium culture
Smear microscopy with auramine-O staining was performed
by following the China National Tuberculosis Program (NTP) Spu-
tum Smear Standard Operation Procedures (SOPs) and then ex-
amined by light-emitting diode microscopy. Next, the tissue ho-
mogenate/FNA was processed with N-acetyl-cysteine-NaOH for de-
contamination and digestion before inoculation into the growth
vial for MGIT960 culture. The culture operations were performed
per the instructions of the manufacturer.
X. Yu, T. Zhang, Y. Kong et al.
Figure 1. Flow chart of the patient enrollment. AFB = acid-fast bacilli; FNA = fine-needle aspiration;TB = tuberculosis
Data analysis
SPSS 20.0 was used to compare baseline clinical characteristics
and the demographic data through the Mann-Whitney U test for
continuous variables and the chi-squaretest for categorical vari-
ables. The sensitivity, specificity, positive predictive values, and
negative predictive values of the Xpert, Xpert-Ultra, and culture as-
say were calculated against the reference standard of confirmed TB,
probable TB, or non-TB for our primary analysis from the following
URL: http://vassarstats.net.
Results
Patient characteristics
From October 2019 to February 2021, 116 patients with sus-
pected TB lymphadenitis were recruited that had successfully un-
dergone FNA or core-needle biopsy without any severe complica-
tions. Four participants were excluded from the study because of
insufficient specimens for the required tests. Two patients failed
the Xpert-Ultra testing, and another four defaulted in the follow-
up. Thus, the final sample size for the study was 106 patients, 74
of these were diagnosed with TB lymphadenitis. The other 32 cases
were classified as non-TB patients and included nine lung cancer
metastasis patients and 23 patients with other infectious diseases
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International Journal of Infectious Diseases 122 (2022) 741–746
(Figure 1). All patients were HIV-negative, and the characteristics
of the recruited patients are listed in Table 1.
The performance of Xpert-Ultra in TB lymphadenitis diagnosis
Among the 74 patients with TB lymphadenitis, four (5.4%)
were smear-positive, 10 (13.5%) were MGIT960 culture-positive,
47 (63.5%) observed necrotizing granuloma by pathological ex-
amination, 36 (48.7%) were Xpert-positive, and 56 (75.7%) were
Xpert-Ultra-positive (Table S1). The direct head-to-head perfor-
mance comparison for MTB detection showed that Xpert-Ultra pro-
duced the highest sensitivity in contrast with smear, culture, and
Xpert (P <0.001, χ 2 = 75,794; P <0.001, χ 2 = 57.865; P <0.05,
χ 2 = 11.491). Both Xpert-Ultra and Xpert successfully detected all
four smear-positive patients and 10 culture-positive cases. Notably,
15 and 22 of the 33 probable TB lymphadenitis cases produced
positive outcomes by Xpert or Xpert-Ultra, separately. Therefore,
by integrating Xpert or Xpert-Ultra for TB lymphadenitis diagno-
sis, the percentage of the confirmed cases among the enrolled pa-
tients with TB lymphadenitis increased from 54.4% (41/74) to 75.7%
(56/74) or 85.1% (63/74), respectively. Among the 32 non-TB pa-
tients, the specificities of smear, culture, Xpert, and Xpert-Ultra
were 100% (32/32, 95% CI: 86.7-10 0), 10 0% (32/32, 95% CI: 86.7-
100), 100% (32/32, 95% CI: 86.7-100), and 96.9% (31/32, 95% CI:
82.0-99.8), respectively (Table 2). One non-TB patient yielded a
“trace” result by Xpert-Ultra.
X. Yu, T. Zhang, Y. Kong et al. International Journal of Infectious Diseases 122 (2022) 741–746

Table 1
Demographic and clinical characteristics of the study participants

Characteristics TB (n = 74) Non-TB (n = 32) P-value

Total (n = 74) Confirmed TB (n = 41) Probable TB (n = 33)

Gender: male/female 0.661

Male 29 (39.2%) 10 (24.4%) 19 (42.4%) 15 (46.9%)
Female 45 (60.8%) 31 (75.6%) 14 (57.6%) 17 (53.1%)
Age, average (median [IQR]) 32 (16-89) 32 (16-89) 33 (19-65) 40 (19-88) 0.161
TB history 0.868
Yes 22 (29.7%) 13 (31.7%) 9 (27.3%) 7 (21.9%)
No 52 (70.3%) 28 (68.3%) 24 (72.7%) 25 (78.1%)
On TB treatment 0.979
Yes 21 (28.4%) 12 (29.3%) 9 (27.3%) 7 (21.9%)
No 53 (71.6%) 29 (70.7%) 24 (72.7%) 25 (78.1%)
Patient type 0.009
Inpatient 18 (24.3%) 17 (41.5%) 1 (3.0%) 1 (3.1%)
Outpatient 56 (75.7%) 24 (58.5%) 32 (97.0%) 31 (96.9%)
Location of lymph nodes 0.532
Left 24 (32.4%) 13 (31.7%) 11 (33.3%) 14 (43.8%)
Right 37 (50%) 20 (48.8%) 17 (51.5%) 13 (40.6%)
Bilateral 13 (17.6%) 8 (19.5%) 5 (15.2%) 5 (15.6%)
Blood results (median [IQR])
LDH (units/l) 160 (90-244) 150.5 (90-244) 173 (131-226) 187.5 (140-232) 0.191
Hb (g/dl) 13.2 (9.6-17.9) 12.8 (9.6-16.3) 14.4 (11.2-17.9) 14.7 (12.0-17.9) 0.795
WCC (cells × 10^9) 6.63 (3.09-12.00) 6.55 (3.54-10.44) 7.01 (3.09-12.00) 5.91 (2.55-12.00) 0.097
Lymphocytes (cells × 10^9) 1.67 (0.43-7.02) 1.60 (0.43-2.90) 1.81 (0.97-7.02) 1.44 (0.93-7.02) 0.437
ESR 22.18 (2.00-88.00) 18.58 (2.00-54.00) 16 (3.00-88.00) 18.00 (2.00-34.00) 0.655

Data are n/N; % (95% CI).

CI = confidence interval; ESR = erythrocyte sedimentation rate; Hb = hemoglobin; IQR = interquartile range; LDH = lactate dehydrogenase;
TB = tuberculosis; WCC = white cell count.

Table 2
Performance of different methods for tuberculosis lymphadenitis diagnosis on different types of specimens

Diagnostics Specimen TB Non-TB Sensitivity Specificity PPV % (95% CI) NPV % (95% CI)
type % (95% CI) % (95% CI)

Confirmed Probable Total N = 32

TB (n = 41) TB (n = 33) (n = 74)

Xpert-Ultra FNA 9/10 8/11 17/21 1/10 81.0 90.0 94.4 (70.6-99.7) 64.2
(57.4-93.7) (54.1-99.5) (38.9-89.6)
Xpert-Ultra Tissue 25/31 14/22 39/53 0/22 73.6 100 (81.5-100) 100 (88.8-100) 61.1
(59.4-84.3) (43.5-76.4)
Xpert FNA 8/10 7/11 15/21 0/10 71.4 100.0 100 (74.7-100) 62.5
(47.7-87.8) (65.5-100) (35.9-83.7)
Xpert Tissue 13/31 8/22 21/53 0/22 39.6 100 (80.8-100) 100 (80.8-100) 40.7
(26.8-54.0) (27.9-54.9)
Culture FNA 3/10 0/11 3/21 0/10 14.3 (3.8-37.3) 100 (65.5-100) 100 (31.0-100) 35.7
(19.3-55.9)
Culture Tissue 7/31 0/22 7/53 0/22 13.5 (6.0-26.4) 100 (83.4-100) 100 (56.1-100) 35.7
(24.9-48.1)
CI = confidence interval; FNA = fine-needle aspirates biopsy; NPV = negative predictive values; PPV = positive predictive values; TB = tuberculosis.

Performance of Xpert and Xpert-Ultra on the different types of
specimens
Of the 74 patients with TB lymphadenitis, 21 had FNA, and
53 had tissue specimens. With FNA specimens, Xpert-Ultra pro-
duced higher sensitivity (81.0%, 17/21) than Xpert (71.4%, 15/21;
P = 0.469, χ 2 = 0.525) and culture (14.3%, 3/21, P <0.001,
χ 2 = 18.709) (Table 2). The sensitivity and specificity of Xpert-
Ultra with FNA were 81.0% (95% CI: 57.4-93.7) and 90.0% (95%
CI: 54.1-99.5), respectively. With the tissue specimens, Xpert-Ultra
produced significantly higher sensitivity (73.6%, 39/53) than Xpert
(39.6%, 21/53; P <0.001, χ 2 = 39.328) and culture (13.5%, 7/53, P
< 0.001, χ 2 = 39.328) (Table 2). The sensitivity and specificity of
Xpert-Ultra with tissue were 73.6% (95% CI: 59.4-84.3) and 100%
(95% CI: 81.5-100), respectively. For both specimen types, Xpert-
Ultra successfully detected all the specimens that yielded culture-
positive and/or Xpert-positive outcomes. Furthermore, two FNA
and 18 tissues were detected by Xpert-Ultra only (Figure 2).
Among the 32 non-TB patients, 10 had FNA, and 22 had tissue
specimens. One FNA specimen produced a “trace” outcome with
Xpert-Ultra, resulting in 90% specificity. All the other tests on both
specimen types and Xpert-Ultra on tissue examination acquired
100% specificities.
RIF resistance detection
All the specimens that yielded positive outcomes either by
Xpert or Xpert-Ultra assay produced rifampin sensitive outcomes
in this study.
Discussion
The diagnosis of paucibacillary TB is challenging because the
conventional diagnostic methods often have poor yields (Bates
et al., 2013). In this study, we prospectively assessed the perfor-
mance of Xpert assay and Xpert-Ultra for diagnosis from FNA and

744
X. Yu, T. Zhang, Y. Kong et al.
Figure 2. Venn diagram of the overlap between methods for FNA and tissue testing. (A) FNA; (B) tissue.
FNA = fine-needle aspiration.
lymph node tissue collected by core-needle biopsy in a low HIV
burden setting. A total of 74 patients with TB lymphadenitis were
enrolled, from which 41 (55.4%) acquired bacteriological evidence
of TB by smear, culture, or pathological examination with AFB
detection and TB DNA testing. The overall sensitivities of Xpert
and Xpert-Ultra were 48.7% (36/74) and 75.7% (56/74), respectively.
Both Xpert and Xpert-Ultra improved the TB lymphadenitis diagno-
sis to a great extent. The percentage of confirmed cases increased
by 20.3% (15/74) or 29.7% (22/74) when Xpert or Xpert-Ultra were
integrated for TB diagnosis, respectively. Xpert-Ultra presented su-
perior performance than the Xpert assay as a whole. These out-
comes are generally consistent with those reported from high HIV
countries, except for the low specificity of Xpert-Ultra reported in
one study (76%). The strength of this study is the prospective com-
parison of a wide range of diagnostic tests applied to the same
subject on FNA and lymph node tissue.
Even though Xpert and Xpert-Ultra were developed mainly to
detect MTB from sputum, many studies proved that they also
worked well on other nonsputum specimen types (Bahr et al.,
2018; Wang et al., 2020). A recent meta-analysis showed that the
pooled sensitivity of Xpert varied greatly over different types of
specimens, from 31% in pleural tissue to 97% in bone or joint
fluid (Kohli et al., 2018). The obvious higher sensitivity of Xpert
on FNA than on tissue of lymph node was reported, regardless of
the application of the gold standard (culture or composite refer-
ence standards) (Kohli et al., 2018; Yu et al., 2019). In this study,
both Xpert and Xpert-Ultra acquired significantly higher sensitivi-
ties on FNA than on tissue, which was consistent with other stud-
ies (Antel et al., 2020). Notably, a significant incremental value was
observed with tissue examination by Xpert-Ultra in contrast with
Xpert assay, but not for the FNA specimen type. We presumed that
the main reason which caused this discrepancy lies in that FNA
could only be applied to a patient with a more significant volume
of caseous and liquefied lesions, which generally indicates the late
stage of infection and means more bacilli, dead or alive, in the le-
sion. Therefore, the advantage of Xpert-Ultra of lower LOD could
not be fully displayed. Another reason might relate to the speci-
men volume. The volume of FNA is often more than 2 ml, whereas
the biopsy tissue was about 10 mm × 1 mm in size, which addi-
tionally affects the final bacilli quantity for detection. In our study,
14 of the 39 positive outcomes of Xpert-Ultra on tissues belonged
to “trace”; this outcome supports our speculation. Compared with
the lymph node tissue, FNA collection is less invasive, the sample
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International Journal of Infectious Diseases 122 (2022) 741–746
processing procedure is simpler, and most importantly, both Xpert-
Ultra and Xpert acquired higher sensitivities. Thus, FNA should be
prioritized over tissue for sample collection when a patient has
enough caseous and liquefied lesions in their lymph nodes.
Compared with the Xpert cartridge, an additional semi-
quantitative category of “trace” was introduced for Xpert-Ultra
to define the negative outcome of rpoB detection but positive
IS6110/IS1081 detection (Chakravorty et al., 2017). Kendall et al.
demonstrated that when compared with Xpert, Xpert-Ultra had in-
creased sensitivity but decreased specificity with sputum testing,
but not with EPTB specimens (Kendall et al., 2017). The WHO rec-
ommended Xpert-Ultra in the diagnostic workup of EPTB and pedi-
atric tuberculosis, but the interpretation of “trace call” on different
types of specimens was not included. Therefore, more data would
help understand the exact value of “trace” outcomes in different
specimen types. We previously evaluated Xpert-Ultra with tissues
and pleural fluid collected from unexplained exudative pleural ef-
fusion patients and obtained a high percentage of “trace” positive,
i.e., 36.4% for pleural tissue and 38.5% for pleural effusion. In con-
trast, the specificity for Xpert-Ultra was very good for both pleural
fluid and tissue (100% and 97.1%). These outcomes strongly encour-
age using “trace” as a positive result for diagnostics of tuberculous
pleurisy (Gao et al., 2021). In addition, Biswas et al. demonstrated
that 8 of 16 Xpert-Ultra “trace” sputum retests with Xpert-Ultra
turned categorically positive (Biswas et al., 2022). We confronted
many trace outcomes by Xpert-Ultra in this study as well. Eight of
the 41 confirmed TB cases yielded trace outcomes. Nine of the 22
patients in the probable TB group who produced positive Xpert-
Ultra outcomes belonged to trace. One FNA in the non-TB group
also had a trace outcome by Xpert-Ultra, which resulted in 90%
(9/10) specificity on this specimen type, but the specificity on tis-
sue was 100% (22/22). Overall, treating the Xpert-Ultra trace result
as true positive improved the detection sensitivity to a significant
scale without any noticeable loss in specificity. Therefore, we sug-
gest taking “trace” as a positive result for diagnostics of TB lym-
phadenitis.
This study had several limitations. First, the total number of the
recruited patients with different specimen types was small; there-
fore, bias might exist. Second, only one specimen type, either FNA
or lymph node tissue, was collected from each patient. Thus, a di-
rect specimen type comparison in the same patient could not be
performed.
X. Yu, T. Zhang, Y. Kong et al.
In conclusion, Xpert-Ultra outperformed Xpert on both FNA and
tissue examinations for TB lymphadenitis diagnosis. In contrast,
significantly more added value was acquired with tissue collected
by core-needle biopsy.
Ethical approval
This study was approved by the ethics committee of Beijing
Chest Hospital, Capital Medical University. Written informed con-
sents were signed by patients.
Author contributions
Hairong Huang, Ming Han and Xia Yu contributed to the con-
ception of the study. Tingting Zhang, Ming Han, Fen Wang, and Lin-
gling Dong performed the experiments. Yaoyao Kong helped collect
and analyze data. Xia Yu and Hairong Huang wrote the manuscript.
Declaration of Competing Interest
The authors have no competing interests to declare.
Funding
This study was supported by research funding from the Nat-
ural Science Fund of China (82072328), Beijing Hospitals Author-
ity Youth Program (QML20211602), and Tongzhou “Yun He” Talent
Project (YHLD2019001).
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.ijid.2022.07.039.
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