Atypical lymphoid cells in cerebrospinal fluid in acute Epstein Barr virus infection: a case report demonstrating a pitfall in cerebrospinal fluid cytology

BACKGROUND: Cytologic examination of cerebrospinal fluid (CSF) continues to be important in the diagnosis of malignancies involving the leptomeninges. A well-recognized pitfall is overinterpretation of the presence of atypical lymphocytes that resemble malignant lymphoid cells in the CSF. A definite diagnosis is often difficult because of limited viability of cells and small sample size of CSF. CASE: A 25-year-old patient with a past history of treated large granular lymphocytic leukemia and presence of a predominant population of large, atypical lymphoid cells in the CSF, giving us the impression of involvement with large cell lymphoma. However, a timely call to the hematologist revealed that the serology was positive for acute Epstein-Barr virus infection. Flow cytometry of CSF confirmed polyclonal population of B-cells and T-cells. CONCLUSION: The presence of atypical cells in the CSF certainly warrants a detailed look at the patient's laboratory investigations and communication with the hematologist, because it may be the only specimen available for diagnosis on which therapy and prognosis is based.     

CD-30(Ki-1)-positive anaplastic large cell lymphoma in a pleural effusion. A case report with diagnosis by cytomorphologic and immunocytochemical studies.

BACKGROUND: Reports on cytodiagnosis of Ki-1-positive anaplastic large cell lymphoma (ALCL) are rare. This report describes one such case diagnosed by cytologic examination of a pleural effusion and confirmed by immunocytochemistry. CASE: An 87-year-old male presented with breathlessness, fever and a cough. Computed tomographic scan of the thorax showed a small, right, pleura-based nodule with infiltration of the immediate surroundings in addition to a massive, right-sided pleural effusion. Cytologic examination of pleural fluid revealed a heterogeneous population of cells comprising small mature lymphocytes, and numerous medium and large atypical lymphoid cells having frequent nuclear irregularity. Occasional very large cells resembling Reed-Sternberg cells or multinucleated cells with a horseshoe or wreathlike arrangement of nuclei (doughnut cells) were also present. Cytomorphology was suggestive of Ki-1 anaplastic large cell lymphoma (ALCL). Immunocytochemistry revealed intense positivity for CD-30, positivity for LCA and EMA in a variable number of cells and a negative result for cytokeratin except for occasional cells. CONCLUSION: Cytologic examination of pleural fluid can serve as a useful tool for the initial diagnosis of Ki-1-positive ALCL.     

Immunocytochemical diagnosis of lymphoma from urine sediment

Cytologic studies were done on the urine sediment of a patient with an indolent lymphoma of 20 years' duration. The patient had localized disease in his groins and developed marked swelling in his penis and scrotum and pedal edema shortly after radiotherapy was instituted to the inguinal areas. The urine specimen obtained after chemotherapy showed many large mononucleated malignant cells. These cells were extremely fragile and were best demonstrated by supravital staining of wet preparations. Although morphologic examination could not confidently indicate the origin of these malignant cells, cytochemical and immunocytochemical studies showed them to be monoclonal B lymphocytes. This study suggests that, even under unusually difficult circumstances, a combined cytologic, cytochemical and immunocytochemical approach can be successfully applied for cytodiagnosis.     

Leptomeningeal carcinomatosis presenting as eosinophilic meningitis

The case of a 67-year-old man with underlying carcinomatous meningitis who presented with meningismus and cerebrospinal fluid (CSF) eosinophilia is reported. CSF eosinophilia can reflect a number of underlying conditions; however, carcinomatous meningitis is not generally considered. In this case, studies for bacterial, fungal and parasitic agents were negative. Cytologic examination of a lumbar puncture specimen revealed malignant epithelial cells in an inflammatory background. When unexplained eosinophilia is found in the CSF, a thorough search for coincident meningeal carcinomatosis should be undertaken.     

Leukocyte immunophenotypes in bronchoalveolar lavage fluid and peripheral blood of paracoccidioidomycosis, sarcoidosis and silicosis.

Leukocyte subsets in bronchoalveolar lavage (BAL) fluid and peripheral blood of patients with paraccoccidioidomycosis, sarcoidosis and silicosis were characterized using monoclonal antibodies and an immunoperoxidase technique. In paraccocidioidomycosis, the number of T-helper/inducer CD4-positive lymphocytes was lower in peripheral blood than in BAL fluid. Additional analysis showed that the expression of HLA-DR was very similar in alveolar macrophages, lung and blood T-cells. In sarcoidosis and silicosis there were higher proportions of T-helper/inducer cells in peripheral blood than in BAL fluid. The alterations in the T-helper/inducer/T-suppressor/cytoxic CD4/CD8 ratio in sarcoidosis and silicosis were more appreciable in peripheral blood than in BAL fluid, contrasting with the results in paracoccidioidomycosis. The expression of HLA-DR by alveolar macrophages in sarcoidosis was the highest of all the disease studied. No statistically significant differences were observed between chronic multifocal and chronic unifocal paracoccidioidomycosis disease, stage II and stage III sarcoidosis, and chronic and accelerated silicosis. The three granulomatous diseases analyzed had a few alveolar macrophages expressing the CD4 molecule on their surface. These findings and the technique of analyzing both peripheral blood and BAL leukocyte subsets may help to understand the pathogenesis of interstitial lung diseases.     

Reactive type II pneumocytes in bronchoalveolar lavage fluid

OBJECTIVE: To evaluate the prevalence of reactive type II pneumocytes (RPII) in bronchoalveolar lavage (BAL) fluid samples obtained from patients with various pulmonary disorders. STUDY DESIGN: Consecutive BAL fluid samples were screened for the presence of RPII on May-Grünwald-Giemsa-stained cytocentrifuge preparations. BAL fluid samples with and without RPII were compared with regard to prevalence, associated clinical diagnoses and cytologic findings. RESULTS: RPII were generally large cells with a high nuclear:cytoplasmic ratio and deeply blue-stained, vacuolated cytoplasm. Most RPII occurred in cohesive cell groups, and the vacuoles tended to be confluent. Cytologic findings associated with RPII were foamy alveolar macrophages, activated lymphocytes and plasma cells. RPII were present in 94 (21.7%) of 433 included BAL fluid samples. The highest prevalences were noted in patients with systemic inflammatory response syndrome and alveolar hemorrhage. In addition, RPII tended to occur more frequently in ventilator-associated pneumonia, Pneumocystis carinii pneumonia, extrinsic allergic alveolitis and drug-induced pulmonary disorders. In contrast, RPII were not observed in BAL fluid samples obtained from patients with sarcoidosis. CONCLUSION: RPII were prevalent in about 20% of BAL fluid specimens. They were associated mainly with conditions of acute lung injury and not observed in sarcoidosis.     

Peripheral blood lymphocyte subpopulations in sarcoidosis.

We have determined the numbers of thymus-derived (T) and bone marrow-derived (B) lymphocytes in the peripheral blood of 20 patients with sarcoidosis and 15 healthy controls. T cells were estimated from the number of lymphocytes forming rosettes in vitro with unsensitized sheep red blood cells, and B cells were enumerated by immunofluorescent assesssment of membrane-bound immunoglobulins. The total lymphocyte count was lower in patients with sarcoidosis owing to a depletion of T lymphocytes from the blood. Nonetheless, the relative and absolute numbers of B lymphocytes were significantly increased. These alterations in lymphocyte subpopulations did not show any consistent correlation with the duration of the disease, clinical stage, activity, or treatment. Changes in the subpopulations may be related to both decreased cellular immunity and increased reactivity of the antibody-forming system as commonly seen in sarcoidosis.     

Fine needle aspiration cytologic findings in pseudolymphoma cutis.

Skin nodules in three patients were sampled by fine needle aspiration. Cytologic study of the aspirated material showed a polymorphic cell population composed of small and large lymphocytes, eosinophils, plasma cells and tingible macrophages. Occasional giant cells and mast cells were also seen. These cytologic features suggested Hodgkin's lymphoma, lymphomatoid papulosis, large-cell non-Hodgkin's lymphoma and regressing atypical histiocytosis. However, because of the lack of typical Reed-Sternberg cells and due to the presence of polymorphic cells with fine chromatin, regular nuclear borders and inconspicuous nucleoli, these cases were diagnosed cytologically as a benign lymphoproliferative disorder, pseudolymphoma cutis. Biopsy of the lesions confirmed the cytologic diagnoses.     

The cytopathology of bone marrow transplantation

Bone marrow transplantation (BMT) is an increasingly effective treatment for patients with hematologic disorders and malignant neoplasms. From 1975 to 1986, 1,457 specimens were obtained for cytologic evaluation from 328 of the 635 patients who received BMTs at Memorial Sloan-Kettering Cancer Center. These specimens consisted of 1,049 cerebrospinal fluids (CSFs) from 265 patients, 292 bronchoscopy specimens from 92 symptomatic patients and 116 other specimens (including brushings from the liver and gastrointestinal tract, sputa, urines and cervico-vaginal smears). CSF specimens examined before and after BMT from 80 (30%) patients showed an increased number of benign, nonepithelial cells, which were mainly lymphocytic or histiocytic in origin. Malignant cells were detected in CSF specimens from 44 (17%) patients. Bronchoscopy specimens from 3 patients had suspicious cells present; those from 27 patients contained opportunistic organisms. Atypical epithelial or lymphoreticular cells were seen in bronchial specimens from 49 patients. All cytologic findings were correlated with the pertinent clinical information as well as biopsy and autopsy material, including histopathologic evidence of graft-versus-host disease. Cytologic evaluation, especially of bronchial and CSF specimens, was useful in diagnosing the presence of malignant neoplasms, infectious organisms, inflammatory responses, reactive lesions and cellular atypia due to treatment.     

Carcinomatous meningitis as the initial manifestation of breast cancer

Report is made of an elderly woman in whom carcinomatous meningitis was the initial manifestation of breast cancer. The patient presented with nonfocal neurologic symptoms. Cytologic examination of cerebrospinal fluid (CSF) revealed malignant cells arranged either in loose clusters or as isolated single cells. The morphology of the cells, some of which had a signet-ring configuration with a crescent-shaped nucleus as well as prominent round nucleoli, suggested a breast primary, which was proven by subsequent histologic study.     

Cytopathology of alpha chain disease involving the central nervous system and pleura

Alpha chain disease, a lymphomatous disorder characterized by the synthesis and secretion of an abnormal IgA immunoglobulin devoid of light chains, involves mainly the gastrointestinal tract. This paper presents the cytologic and histologic findings in two cases of alpha chain disease involving the central nervous system and pleura. Most of the cell populations in the cerebrospinal fluid (CSF) and pleural fluid resembled immature plasma cells (immunoblasts); many of these cells were degenerated, with well-preserved plasma cells seen more rarely. While the definitive diagnosis of alpha chain disease depends on immunochemical analysis of serum proteins, cytology can play a role by the identification of malignant cells in CSF and pleural fluid specimens. A positive staining of such cells by the methyl green pyronin reaction may permit the correct diagnosis to be suggested.     

In-depth analysis of the human CSF proteome using protein prefractionation

The identification of disease markers in human body fluids requires an extensive and thorough analysis of its protein constituents. In the present study, we have extended our analysis of the human cerebrospinal fluid (CSF) proteome using protein prefractional followed by shotgun mass spectrometry. After the removal of abundant protein components from the mixture with the help of immunodepletion affinity chromatography, we used either anion exchange chromatography or sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) to further subfractionate the proteins present in CSFs. Each protein subfraction was enzyme digested and analyzed by tandem mass spectrometry and the resulting data evaluated using the Spectrum Mill software. Different subfractionation methods resulted in the identification of a grant total of 259 proteins in CSF from a patient with normal pressure hydrocephalus. The greatest number of protein, 240 in total, were identified after prefractionating the CSF proteins by immunodepletion and SDS-PAGE. Immuno-depletion combined with anion exchange fractionation resulted in 112 proteins and 74 proteins were found when only immunodepletion of the CSF samples was carried out. All methods used showed a significant increase in the number of identified proteins as compared with nondepleted and unfractionated CSF sample analysis, which yielded only 38 protein identifications. The present work establishes a platform for future studies aimed at a detailed comparative proteome analysis of CSFs from different groups of patients suffering from various psychiatric and neurological disorders.     

Primary malignant melanoblastosis of the meninges. Clinical, cytologic and neuropathologic findings in a case

A 66-year-old man presented with a six-month history of neurologic symptoms suggestive of a craniospinal tumor or a diffuse inflammatory process in the subarachnoid space. Cytologic examination of cerebrospinal fluid (CSF) revealed inflammatory changes and malignant melanin-containing cells, leading to a diagnosis of meningeal spread of a melanoma. There was no history of skin excisions and no clinical evidence of primary melanoma of the eye. Neuroradiologic investigations, including CT and myelography, to confirm the diagnosis were negative. Despite intrathecal cytostatic therapy, the patient died eight months after the onset of symptoms. Autopsy disclosed diffuse meningeal melanoblastosis of the spinal cord and the base of the brain, confirming the cytologic diagnosis. In addition, two micrometastases in the liver were found as only extraneural manifestation. This case emphasizes the importance of CSF cytology in the diagnosis of diffuse infiltrating processes in the subarachnoid space.     

Pleural effusions in non-Hodgkin's lymphoma. A cytomorphologic, cytochemical and immunologic study

Review of the records of 243 cases of cytologically diagnosed non-Hodgkin's lymphomas (NHL) revealed pleural effusions in 21 (8.6%). Cytologic examination of pleural fluid was done in 17 cases, of which 16 were reported as positive. Cytologic examination was supplemented with cytochemical staining (acid phosphatase, alpha naphthyl acetate esterase and periodic-acid-Schiff reactions) and E-rosetting studies in 12 cases. Of the 16 positive cases, 11 were malignant lymphomas consisting of convoluted lymphocytes. Acute lymphatic leukemia of the prothymocytic type (T-ALL) and chronic lymphocytic leukemia of the T-cell type (T-CLL) comprised one case each, and there were three cases of follicular center cell lymphomas, two of the cleaved-cell type and one of the Burkitt-type. Comparison of the cytomorphology of the tumor cells in the pleural effusion with those in fine needle aspiration smears from the solid tumors in 14 cases showed an identical appearance in 13 cases; in one, the Burkitt-type lymphoma, the cells were larger and more pleomorphic in the pleural effusion. This study indicates that the cytologic diagnosis and categorization of NHL of the convoluted-cell type is greatly enhanced by the study of neoplastic lymphocytes in a pleural effusion.     

Polymorphous exudates and atypical mononuclear cells in the cerebrospinal fluid of patients with Sj?gren's syndrome

Central nervous system (CNS) complications of Sj?gren's syndrome are now well recognized. To determine if any of the pathologic changes in the CNS in patients with Sj?gren's syndrome were reflected in the cellular composition of cerebrospinal fluid (CSF), we examined the CSF of 14 patients with Sj?gren's syndrome and neurologic symptoms and compared the differential cell counts in those cases with those of 14 control patients with similar neurologic symptoms. Patients with Sj?gren's syndrome had polymorphous (mixed) inflammatory exudates in CSF, composed predominantly of lymphocytes, but including variable numbers of plasma cells, neutrophils and erythrocytes. In addition, the CSF of all patients with Sj?gren's syndrome contained large, atypical, morphologically distinct mononuclear cells. The mean percentage of these cells in the CSF of patients with Sj?gren's syndrome (8.3 +/- 1.9) was significantly higher (p less than 0.001) than that observed in the control patients (0.7 +/- 0.2). These results suggest that involvement by Sj?gren's syndrome may be suspected by noting a polymorphous exudate containing characteristic atypical mononuclear cells in CSF obtained by lumbar puncture.     

Chronic meningitis and Lyme disease in Sweden.

We studied 35 patients with chronic meningitis. The neurological abnormalities included aseptic meningitis, cranial neuropathy (mostly facial palsy), motor and sensory peripheral radiculoneuropathy, and myelitis. Neurological symptoms were sometimes preceded by erythema chronicum migrans or an insect bite and were often accompanied by fever, malaise, profound fatigue, and weight loss. The cerebrospinal fluid (CSF) abnormalities consisted of a predominantly mononuclear pleocytosis, an elevated CSF protein (mean 2.3 g/l), intrathecal synthesis of oligoclonal immunoglobulin G, and, in half of the patients, a fall in the CSF/blood glucose ratio. High antibody titers to the Lyme spirochete and the Swedish Ixodes ricinus spirochete were demonstrated by immunofluorescence in 26 of the 35 patients. By imprint immunofixation of electrofocused samples of serum and CSF, intrathecal production of oligoclonal Lyme-spirochete-specific IgG was demonstrated in one patient with chronic meningitis. Four sequential paired samples of serum and CSF from this patient showed local synthesis of spirochete-specific antibodies in CSF. The 35 patients improved or recovered, sometimes dramatically, during a two-week course of intravenous penicillin G.     

Ascites as a presenting feature of relapsed multiple myeloma. Report of a case diagnosed by aspiration cytology.

A 68-year-old woman with IgG-type multiple myeloma (MM) in remission and a chief complaint of ascites was found to have peritoneal fluid involvement by myeloma cells on cytologic study. There are only a few reports describing the cytologic features in patients presenting with ascites as the first manifestation of relapsed MM. IgG myeloma, however, is one of the rarest types. The patient had had pancreatic involvement months before her presentation with ascites, which itself is a rare manifestation of relapsed MM. Cytologic smears of ascitic fluid showed isolated and incoherent groups of cells with plasmacytoid features. To recognize myeloma as a cause of ascites is important because it may respond well to therapy. Aspiration cytologic study can be considered a useful method for follow-up and diagnosis of MM relapse even without a biopsy.     

Unusual presentations of inflammatory conditions in cerebrospinal fluid

Unusual inflammatory reactions in cerebrospinal fluid (CSF) in five patients were explicable by the type of intracranial injury or surgical intervention that they had received or by their basic disease process. Lumbar puncture fluid from a 64-year-old man with multiple facial fractures contained neutrophils, bacteria, Candida sp. and ciliated columnar cells, findings consistent with a basilar skull fracture allowing paranasal sinus contents to enter the subarachnoid space. A 59-year-old man with angioimmunoblastic lymphadenopathy developed meningitis and suffered a respiratory arrest; a ventricular fluid contained acute inflammatory cells as well as numerous corpora amylacea. Lumbar CSF obtained during surgery from a 26-year-old man with a pontine glioma contained numerous histiocytes clustered around polarizable filaments, probably strands of gauze introduced during surgery. A specimen of CSF obtained intraoperatively from a 54-year-old man with an acoustic neuroma undergoing a second craniotomy contained multinucleated giant cells bearing suture material. A 19-year-old girl with systemic sarcoidosis had noncaseating granulomas in the right temporal lobe and multinucleated giant cells in her CSF.     

Quantitative cytocentrifugation in the evaluation of cerebrospinal fluid

Five hundred sixteen samples of cerebrospinal fluid (CSF) were subjected to cytocentrifugation to determine whether this technique is reliable in quantifying the cells present while simultaneously allowing precise cytologic identification of the types of malignant and atypical cells present. Cell counts obtained by the cytocentrifuge method were comparable to those obtained by the standard hemocytometer method. Because of the larger volume of fluid used in cytocentrifugation, cells (0.2/cu mm) were found in 264 specimens that would have been considered devoid of cells by hemocytometry. Six of these samples contained malignant cells. The Wright's-stained cytocentrifuged specimens also allowed precise identification of hematopoietic cell types. CSF cytocentrifugation offers the advantages of (1) a simple and rapid method of quantifying the number of cells present, (2) use of larger volumes than the hemocytometer method, thereby minimizing the possibility that the specimen will be classified as acellular, and (3) improved morphology of hematopoietic cell types by use of the Wright's stain. We conclude that the cytocentrifugation method is useful in the routine quantification and diagnosis of CSF specimens.