Atypical squamous cells as a diagnostic pitfall in pulmonary Wegener's granulomatosis. A case report

BACKGROUND: Wegener's granulomatosis (WG) is characterized by systemic, necrotizing, granulomatous inflammation accompanied by vasculitis. It classically involves the triad of the upper respiratory tract, lungs and kidneys. Isolated pulmonary lesions of WG may present in some patients as pulmonary masses, simulating neoplasms. The features of WG can be suggested by cytologic study. Atypical epithelial cells associated with WG have previously been reported as a cause of a false positive diagnosis of bronchoalveolar carcinoma. CASE: In this case the cytologic findings included atypical squamous cells in a background of acute, chronic and granulomatous inflammation. In several respiratory specimens the atypical squamous cells were incorrectly interpreted as diagnostic of squamous cell carcinoma. The correct diagnosis of WG was confirmed with open lung biopsy, which demonstrated necrotizing granulomatous inflammation with geographic necrosis and associated vasculitis. CONCLUSION: Markedly atypical squamous cells mimicking squamous cell carcinoma can be found accompanying the inflammatory process associated with WG and are a possible diagnostic pitfall. The possibility of WG as well as other inflammatory processes should always be considered in the differential diagnosis of squamous cell carcinoma of the lung. This case is the only reported case of WG in which atypical squamous cells were a diagnostic pitfall, initially suggesting a diagnosis of squamous cell carcinoma.     

Scleroma of the Nose and Pharynx

Scleroma of the respiratory tract was first recognized just over a century ago. The disease is endemic in a number of North African, Central American and Latin American countries. However, it has been only rarely seen in the United States. The progression of scleroma takes place through three stages. The first stage of rhinitis has an early catarrhal phase which progresses to one of atrophic rhinitis. The second stage is seen as a proliferative granulomatous growth which obliterates the nasal fossae. The third cicatricial stage is usually accompanied by pronounced scarring and retraction of the tissues involved.Because of the increased ease of international travel by both sea and air, more cases can be expected to occur in the United States. This paper is presented to alert physicians to suspect scleroma in any case of granulomatous disease of the respiratory tract.     

Intravesical BCG administration in the guinea pig. A histomorphological study

Intravesical BCG administration is used as an adjuvant therapy after transurethral resection for superficial bladder cancer in man. The mechanisms of its antitumor activity are not known. The aim of this study was to characterize the histomorphological changes in various organs of the guinea pig after intravesical BCG administration. The BCG preparation used was BCG-RIVM, a Dutch BCG preparation. Instillations were performed in previously undamaged bladders weekly for 6 consecutive weeks and lasted 30 min or 1 h. Different doses were used ranging from 10(3) culturable particles (c.p.) to 5 x 10(7) c.p. of BCG. After 6 weeks, the animals were killed and postmortem examination was performed. The bladder wall, retroperitoneal lymph nodes, spleen, liver, lungs and distant lymph nodes were examined histologically. The BCG therapy, with a dose of 10(6) culturable particles and higher, induced an inflammatory reaction consisting of mononuclear infiltrates in the subepithelial tissue of the bladder wall. In approximately 50% of the animals investigated, the infiltrates were accompanied by non-caseating granulomatous lesions indicated by the presence of epithelioid cells. In general, the epithelial layer of the bladder showed no visible alterations. Similarly, a granulomatous inflammatory reaction was observed in the first retroperitoneal (iliac) lymph nodes draining the bladder. Granulomatous lesions were occasionally also present in liver and lung. In three of the 29 animals investigated, lesions were present both in liver and lungs, and in two of these three animals a granulomatous reaction was observed in the spleen and distant lymph nodes indicating a generalized inflammatory response induced by BCG.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intravesical BCG administration in the guinea pig

Intravesical BCG administration is used as an adjuvant therapy after transurethral resection for superficial bladder cancer in man. The mechanisms of its antitumor activity are not known. The aim of this study was to characterize the histomorphological changes in various organs of the guinea pig after intravesical BCG administration. The BCG preparation used was BCG-RIVM, a Dutch BCG preparation. Instillations were performed in previously undamaged bladders weekly for 6 consecutive weeks and lasted 30 min or 1 h. Different doses were used ranging from 10³ culturable particles (c.p.) to 5 × 10⁷ c.p. of BCG. After 6 weeks, the animals were killed and postmortem examination was performed. The bladder wall, retroperitoneal lymph nodes, spleen, liver, lungs and distant lymph nodes were examined histologically. The BCG therapy, with a dose of 10₆ culturable particles and higher, induced an inflammatory reaction consisting of mononuclear infiltrates in the subepithelial tissue of the bladder wall. In approximately 50% of the animals investigated, the infiltrates were accompanied by noncaseating granulomatous lesions indicated by the presence of epithelioid cells. In general, the epithelial layer of the bladder showed no visible alterations. Similarly, a granulomatous inflammatory reaction was observed in the first retroperitoneal (iliac) lymph nodes draining the bladder. Granulomatous lesions were occasionally also present in liver and lung. In three of the 29 animals investigated, lesions were present both in liver and lungs, and in two of these three animals a granulomatous reaction was observed in the spleen and distant lymph nodes indicating a generalized inflammatory response induced by BCG. No microorganisms were detected by Ziehl-Neelsen (ZN) staining or culture in L?wenstein-Jensen medium in the first draining (iliac) lymph nodes of the bladder or in the spleen. In this study we found that BCG could induce inflammatory reactions in the bladder wall after its introduction into the previously undamaged bladder. Ulceration of the epithelium covering the mononuclear infiltrates was not observed. Occasionally a generalized inflammatory response to BCG was present in the animals investigated.     

Mouse hepatitis virus S in weanling Swiss mice following intranasal inoculation

Three-week-old outbred mice were inoculated intranasally with a mildly pathogenic strain of mouse hepatitis virus (MHV-S). Tissues were analyzed for distribution of infectious virus, lesions, and viral antigen at intervals up to 49 days after inoculation. Sera were tested for neutralizing antibody to MHV-S. Within the first week of infection, virus was isolated from lung and brain of most mice and liver of one mouse, but not from blood, spleen, or intestine. Microscopic lesions consisted of mild olfactory mucosal necrosis, neuronal necrosis of olfactory bulbs and tracts, lymphoplasmacytic infiltrates and vacuolation in the brain, mild nonsuppurative pulmonary perivascular lymphocyte infiltration, focal interstitial pneumonia, and focal necrotizing hepatitis. The presence and distribution of MHV antigen, as determined by indirect immunofluorescence, correlated with virus recovery and acute lesions. No virus or antigen was demonstrable beyond day 7. Serum antibody was first detected on day 10, and titers peaked on day 28 after infection.     

Brugia pahangi: Histopathological study of golden hamsters

Sixteen male hamsters were inoculated subcutaneously with 95 to 150 infective larvae of B. pahangi and were examined for histopathologic lesions at 39–109 days postinfection. The basic microscopic lesion observed was obstructive granulomatous lymphangitis. Analogous lymph node changes sometimes occurred along with lymphoreticular hyperplasia and increased numbers of eosinophils. Cellular infiltration of perivascular and perinodal tissues was common, with plasma cells and eosinophils predominating. Genital lesions included funiculitis, epididymitis, and mild orchitis. Live and dead worms were found in the testicular parenchyma. Pulmonary changes in hamsters infected more than 105 days included multiple small, granulomatous foci and periarteriolar, peribronchiolar, and subpleural cellular accumulations of plasma cells and eosinophils. Granulomatous obstruction of pulmonary arteries associated with dead worms was observed in two hamsters infected for 39–45 days and in one hamster infected for 109 days. Small liver granulomas were common. Disintegrating microfilariae occurred within giant cells in the lymph nodes, spleen, lungs, and testes.     

Severe acute respiratory syndrome coronavirus infection of golden Syrian hamsters

Small animal models are needed in order to evaluate the efficacy of candidate vaccines and antivirals directed against the severe acute respiratory syndrome coronavirus (SARS CoV). We investigated the ability of SARS CoV to infect 5-week-old Golden Syrian hamsters. When administered intranasally, SARS CoV replicates to high titers in the lungs and nasal turbinates. Peak replication in the lower respiratory tract was noted on day 2 postinfection (p.i.) and was cleared by day 7 p.i. Low levels of virus were present in the nasal turbinates of a few hamsters at 14 days p.i. Viral replication in epithelial cells of the respiratory tract was accompanied by cellular necrosis early in infection, followed by an inflammatory response coincident with viral clearance, focal consolidation in pulmonary tissue, and eventual pulmonary tissue repair. Despite high levels of virus replication and associated pathology in the respiratory tract, the hamsters showed no evidence of disease. Neutralizing antibodies were detected in sera at day 7 p.i., and mean titers at day 28 p.i. exceeded 1:400. Hamsters challenged with SARS CoV at day 28 p.i. were completely protected from virus replication and accompanying pathology in the respiratory tract. Comparing these data to the mouse model, SARS CoV replicates to a higher titer and for a longer duration in the respiratory tract of hamsters and is accompanied by significant pathology that is absent in mice. Viremia and extrapulmonary spread of SARS CoV to liver and spleen, which are seen in hamsters, were not detected in mice. The hamster, therefore, is superior to the mouse as a model for the evaluation of antiviral agents and candidate vaccines against SARS CoV replication.     

Preliminary evaluation of neuroendocrine cells in the respiratory tract in rats with experimental uremia

The goal of this study was to investigate the influence of experimetally induced chronic renal failure on endocrine cells in the respiratory tract in rats. After 30 days of uremia, the fragments of rat lungs were collected. Paraffin sections were stained using H+E, silver impregnation and immunohistochemistry with specific antibodies against calcitonin (CT), synaptophysin (SY), somatostatin (ST), and neuron-specific enolase (NSE). A large number of endocrine cells with a strong calcitonin immunoreactivity were observed in the respiratory tract of rats with experimental uremia, as compared with the control group. Other immunoreactions were weakened.     

Experimental duck plague in blue-winged teal and Canada geese

Ten adult blue-winged teal (Anas discors) and six Canada goose (Branta canadensis) goslings were inoculated with liver tissue from a natural case of duck plague in a wild mallard (Anas platyrhynchos). Four additional teal were placed in contact with the inoculated ducks. Inoculated teal died 63.5-68 hr after inoculation; two of the contact teal died 161-162 hr after exposure. Three of the goslings died 119-133 hr after inoculation, the others were killed when moribund 90-133 hr postinfection. The clinical course of disease was extremely rapid in both species. Signs were limited to sudden onset of profound weakness, ataxia, tremors and terminal convulsions. The only consistent gross lesion in the teal was a small dark spleen; half the teal also had inconspicuous foci of epithelial necrosis in the distal esophagus and in the cloaca. Goslings had more severe lesions, with focal hepatic necrosis visible in all, and mucosal necrosis over the intestinal lymphoid tissue, and intestinal hemorrhage in three birds each. Microscopic lesions in both species were similar to those reported in mallards. Duck plague might be overlooked at necropsy of blue-winged teal, because of the paucity of gross lesions.     

Sequential pathological studies in Japanese quails infected experimentally with Aspergillus fumigatus

Intratracheal inoculation of young quail chicks with Aspergillus fumigatus spores resulted in the development of characteristic gross and microscopic lesions. The lesions were restricted to respiratory tract and there was no dissemination of infection to other tissues of the body.Gross changes in lungs and air sacs were observed within 24 hours and continued up to 20 days while in trachea these were noticed from the 3rd to the 9th day post-infection. The lesions, in general, included congestion and focal haemorrhages in the first 2 days followed by the development of varying-sized greyish-white nodules in the lungs, air sacs and trachea.Microscopic changes consisted of congestion, haemorrhages and a diffuse cellular infiltration in the first 2 days followed by granulomatous reaction with well developed granulomas in lungs, air sacs and trachea. Spores and developing hyphae of Aspergillus could be demonstrated in sections from 24 hours to 20 days of infection.Reisolation of the fungus was consistently achieved from the lungs, air sacs and trachea up to 14 days.     

Disseminated tuberculoid lesions in infants following BCG vaccination.

The records of 830 consecutive autopsies at Children''s Hospital, Winnipeg revealed that 26 of the 36 infants (34 Canadian Indian, 1 Inuit and 1 Caucasian) given BCG vaccine shortly after birth had tuberculoid granulomas in various sites, including the vaccination site, regional lymph nodes, liver, spleen, lung, bone marrow and salivary gland. Mycobacterium bovis, BCG type, was identified in three of the four cases in which isolation was attempted. The principal causes of death had been sudden infant death syndrome and respiratory tract infections. None of the infants had histologic evidence of an immune deficiency. However, it is possible that in two cases the dissemination of BCG was enhanced by a temporary immunologic defect induced by malnutrition.     

<Emphasis Type="Italic">Mycobacterium avium</Emphasis> disease in wild red-legged partridges (<Emphasis Type="Italic">Alectoris rufa</Emphasis>)

Three wild red-legged partridges (Alectoris rufa) from intensively managed hunting areas in Spain were received for necropsy. They showed granulomatous lesions in different parts of the body, mainly in liver and spleen. Microscope examination of the granulomas showed central caseous necrosis and large amounts of acid-fast bacilli, surrounded by epitheloid cells, giant cells, and lymphocytes. Attempts to isolate and culture the bacillus in Colestsos medium were unsuccessful, but the polymerase chain reaction technique revealed the presence of microorganisms belonging to the Mycobacterium avium complex in one of the partridges. This is the first report of avian tuberculosis in free-living red-legged partridges.     

Epizootic fatal amebiasis in an outdoor group of Old World monkeys

Background Entamoeba (E.) histolytica is an obligate parasite of humans and non‐human primates. Methods This report describes the pathomorphological, immunohistological, and microbiological findings of fatal E. histolytica infection in two mantled guerezas (Colobus guereza) and one Hanuman langur (Semnopithecus entellus) from an epizootic outbreak of amebiasis in an open‐range recreation park. Results Pathomorphological examination revealed multifocal necrotizing and granulomatous hepatitis with intralesional protozoan trophozoites in all three cases. In addition, necrotizing and ulcerative gastritis was detected in both mantled guerezas. Furthermore, oligofocal acute pulmonary embolization was detected in one of these cases. No extra‐hepatic lesions were observed in the Hanuman langur. Immunohistological examination confirmed the etiologic diagnosis of E. histolytica‐induced lesions. Conclusions Although E. histolytica is a rarely diagnosed pathogen in Western European countries, veterinarians and animal keepers involved in handling and care taking of non‐human primates should be aware of the potential threat caused by this zoonotic parasite.     

The inducibility of TNF-alpha production is different in the granulocytic and monocytic differentiated forms of wild type and CGD-mutant PLB-985 cells

Chronic granulomatous disease is an inherited disorder associated with a defect in phagocytic cell oxidative metabolism resulting in ineffective microbicidal activity. Consequently, patients with chronic granulomatous disease suffer from recurrent infections. Published data show that besides the failure to produce superoxide and its derivatives, other functional problems can also be found in chronic granulomatous disease-mutant cells. Since in innate immune responses other mediators, such as cytokines, also play an important role, we hypothesized that there may be a disturbance in cytokine production by chronic granulomatous disease-mutant cells as well. To prove this hypothesis, the production of tumour necrosis factor-alpha, an important proinflammatory cytokine, was determined by enzyme-linked immunosorbent assay in wild-type and chronic granulomatous disease-mutant myelomonoblastic PLB-985 cells in their immature, granulocytic and monocytic/macrophage differentiated forms. Tumour necrosis factor-alpha production was induced with N-formyl-L-methionyl-L-leucyl-L-phenylalanine (100 nmol/L), lipopolysaccharide (10 micro g/mL), opsonized zymosan (100 micro g/mL) or phorbol 12-myristate 13-acetate (100 nmol/L) for 24 h. We could demonstrate that: (i) there were marked differences in tumour necrosis factor-alpha production only in the differentiated forms of both wild-type and chronic granulomatous disease-mutant cells, while there were no differences in the case of their immature counterparts; (ii) only chronic granulomatous disease-mutant cells retained sensitivity to phorbol 12-myristate 13-acetate both in their granulocytic and monocytic forms, although phorbol 12-myristate 13-acetate responsiveness was a characteristic of both types of immature cells; (iii) the granulocytic form of wild-type cells produced tumour necrosis factor-alpha after opsonized zymosan stimulation, but such a response was not observed in cells originating from the chronic granulomatous disease-mutant cell line; (iv) with the monocytic forms, significantly higher tumour necrosis factor-alpha production could be induced by lipopolysaccharide in the wild-type cells than in the chronic granulomatous disease-mutant cells, although there was no difference in their lipopolysaccharide receptor CD14 expression. In summary, these data show an altered inducibility of tumour necrosis factor-alpha production by chronic granulomatous disease-mutant cells. Our observations suggest a further defect in differentiated chronic granulomatous disease-mutant cells in addition to the known defect in reduced nicotinamide adenine dinucleotide phosphate oxidase, which may contribute to the development of susceptibility to infections in people with chronic granulomatous disease.     

Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India

P. K. Sarma, A. K. Chowhan, V. Agrawal and V. Agarwal
Fine needle aspiration cytology in HIV‐related lymphadenopathy: experience at a single centre in north India Objective: Fine needle aspiration (FNA) is emerging as a rapid and minimally invasive tool in evaluating lymphadenopathy associated with human immunodeficiency virus (HIV). We evaluated the role of FNA in differentiating various causes of lymphadenopathy in patients with HIV and correlated the cytological diagnosis with CD4 counts. Methods: Seventy‐nine HIV‐positive patients (median age 35 years, 68 male) underwent ultrasound‐guided (n = 16) and unguided (n = 63) FNA from 1999 to 2006. Smears were stained with May–Grünwald–Giemsa, haematoxylin & eosin and Papanicolaou stains. Ziehl–Neelsen (ZN) staining for acid‐fast bacilli (AFB) was performed in all cases. Staining for fungus was performed whenever required. Results: The aspirates were adequate in 75 cases (95%). Non‐specific reactive hyperplasia was the most common FNA diagnosis (39, 52%) followed by granulomatous necrotizing lymphadenitis (15, 20%), necrotizing lymphadenitis (13, 17.3%) and granulomatous lymphadenitis (4, 5.2%). Fungal infection and non‐Hodgkin lymphoma (NHL) were seen in two patients each. ZN staining was positive for AFB in 25 (33.3%) cases. One of these was morphologically interpreted as reactive hyperplasia, 12 as necrotizing lymphadenitis and 12 as granulomatous necrotizing lymphadenitis. Both patients with NHL had CD4 counts below 100/dl. Necrotizing lymphadenitis and granulomatous lymphadenitis were significantly associated with CD4 counts below and above 200/dl, respectively (P = 0.0002). Conclusions: FNA is an important tool for assessing the cause of lymphadenopathy in HIV patients. Necrotizing inflammation is more often seen in patients with low CD4 counts. AFB are commonly found in necrotic aspirates with or without granulomas. However, a stain for AFB should be performed in all aspirates from HIV‐related lymphadenopathy including reactive hyperplasia.     

Smear morphology of cryptococcosis presenting as a subcutaneous swelling in healthy adults: a report of three cases

OBJECTIVE: To highlight the various morphological smear pattern in cases of subcutaneous Cryptococcus infection in healthy adults. METHOD: Cryptococcus is an opportunist fungus and primary infection is acquired through respiratory tract. Dissemination by blood stream results in systemic infection. Ten to 15% of systemic infection present as cutaneous lesions. Between December 2002 and April 2004 three healthy adults presented to us consecutively with subcutaneous swelling. RESULTS: We diagnosed these cases on FNAC as Cryptococcus. In all the three patients there was no history of local penetrating injury and any signs or symptoms of systemic disease. They were two male and one female, immuno competent and were negative for HIV 1 & 2 tested by ELISA. The sites were right abdominal flank, occipital and left anterior upper thigh. Aspirated materials were oily fibro fatty tissue and necrotic purulent materials. Cryptococcus numbers varied in all the smears so also their size and capsule thickness. Background smear morphology and tissue reaction were also different. It could be gelatinous, granulomatous, and cellulitic response or mixed responses and this can be picked up on cytological smears. Cultures were confirmatory in all the three cases. These lesions were resolved with antifungal treatment. CONCLUSION: Our brief article highlights the morphological spectrum on FNAC smears and diagnostic problems faced in these uncommon circumstances where the aspirates were purulent and the yeasts were small, few and thin walled. In the acute inflammatory smear with occasional giant cells and/or granulomas special stains like PAS or Mucicarmine are necessary to look for budding yeast of Cryptococcus with thin neck.     

Fine needle aspiration cytodiagnosis of clinically suspected tuberculosis in tissue enlargements

A retrospective study of the use of fine needle aspiration (FNA) cytology to confirm a clinical suspicion of tuberculosis in tissue enlargements was performed, using 70 cases. The criteria required to make an FNA cytodiagnosis of tuberculosis were reassessed, and the sensitivity and predictive value of cytology for diagnosing such aspirates was determined. All but 2 of the 70 aspirates contained adequate cellularity. The adequate samples were diagnosed as 40 cases of caseating tuberculosis, 11 cases of noncaseating tuberculosis and 17 cases of acute necrotizing granulomatous inflammation suspicious for tuberculosis. Subsequent histologic study verified the cytologic diagnosis in 27 of 27 biopsied caseating lesions, 4 of 7 biopsied noncaseating cases and 5 of 8 necrotizing cases. The six cases with a false-positive cytodiagnosis of tuberculosis were histologically diagnosed as one Lennert's lymphoma, two reactive lymph nodes and three necrotizing metastatic carcinomas. The sensitivity of FNA cytology for the diagnosis of tuberculosis was 100%, with the predictive value of a positive result being 88%. The findings in this study emphasize that all criteria for the diagnosis of tuberculosis in FNA samples must be utilized and that particular caution should be exercised in making a diagnosis of acute necrotizing tuberculosis.     

Chlamydiosis in a red-tailed hawk (Buteo jamaicensis).

A red-tailed hawk (Buteo jamaicensis) with signs of respiratory distress and diarrhea was captured in the Manchac Wildlife Management Area, Louisiana (USA) and died the following day. At necropsy, the carcass was emaciated and there were splenomegaly, and fibrinous pericarditis, airsacculitis, and perihepatitis. Microscopically, there were fibrinous pericarditis and airsacculitis, myocardial necrosis, necrotizing hepatitis, splenic necrosis with reticuloendothelial cell hyperplasia, interstitial pneumonia and focal pancreatic necrosis. Intracytoplasmic chlamydial inclusion bodies were noticed in macrophages in the fibrinous exudate covering air sac and pericardium, and in spleen, liver, heart, lung, and pancreas. Schizonts compatible with a Sarcocystis sp.-like protozoon were present in the walls of air capillaries in the lung. A Chlamydia sp.-like organism was isolated in embryonating chicken eggs and cell culture and identified as C. psittaci with immunofluorescent staining.