Cytopathology of Infectious Diseases
Cytopathology of Infectious Diseases
Cytopathology of Infectious Diseases
ESSENTIALS IN CYTOPATHOLOGY
Dorothy L. Rosenthal, MD, FIAC, Series Editor
Editorial Board
Syed Z. Ali, MD
Douglas P. Clark, MD
Yener S. Erozan, MD
Cytopathology
of Infectious Diseases
Including Chapters 2 & 14 Co-authored by:
Tanvier Omar, MB BCH, FC Path (S.A.)
Chapters 3, 9, 10 & 13 Co-authored by:
Sara E. Monaco, MD
Chapter 4 Co-authored by:
Gladwyn Leiman, MBBCh, FIAC, FRCPath
Lynne S. Garcia, MS, CLS, FAAM
Chapter 5 Co-authored by:
R. Marshall Austin, MD, PhD
Chapter 6 Co-authored by:
Rodolfo Laucirica, MD
Chapter 7 Co-authored by:
Robert M. Najarian, MD
Helen H. Wang, MD, PhD
Chapter 8 Co-authored by:
Anil V. Parwani, MD, PhD
and Chapter 15 Co-authored by:
Robert A. Goulart, MD
Rafael Martnez-Girn, MD, PhD
ISSN 1574-9053
e-ISSN 1574-9061
ISBN 978-1-4614-0241-1
e-ISBN 978-1-4614-0242-8
DOI 10.1007/978-1-4614-0242-8
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011932800
Springer Science+Business Media, LLC 2011
All rights reserved. This work may not be translated or copied in whole or in part
without the written permission of the publisher (Springer Science+Business Media,
LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in
connection with reviews or scholarly analysis. Use in connection with any form of
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The use in this publication of trade names, trademarks, service marks, and similar
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at the date of going to press, neither the authors nor the editors nor the publisher
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The publisher makes no warranty, express or implied, with respect to the material
contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
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Foreword
vii
viii
Foreword
Series Preface
ix
Series Preface
Contents
Foreword................................................................................. vii
Series Preface.......................................................................... ix
1 Introduction.....................................................................
13
4 Microbiology...................................................................
37
5 Gynecological Infections................................................
85
xi
hgbjkdfg
Contributors
xiii
xiv
Contributors
Contributors
xv
Introduction
Liron Pantanowitz1 and Pam Michelow2
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
2
Cytology Unit, Department of Anatomical Pathology, University of
the Witwatersrand and National Health Laboratory Service,
Johannesburg, Gauteng, South Africa
1
Specimen procurement: Rapid, minimally invasive, and costeffective procedure with minimal contamination. Specimens submitted for cytologic evaluation may be obtained via exfoliation,
abrasion, aspiration, or touch preparation.
1. Introduction
Cytology specimens can be obtained from clinics and outpatient settings, hospitalized, and even critically ill or intraoperative
patients. The emergence of opportunistic infections in transplant
recipients and AIDS patients has increased the need for minimally
invasive rapid diagnostic methods. The resurgence of previously
rare infections is also largely due to the increasing incidence of
immunocompromised patients. Fine needle aspiration (FNA)
biopsy permits the evaluation of superficial and deep masses.
Cytologists can play a key role in the immediate interpretation of
material, rapidly identifying infectious cases at the patients bedside that may benefit from additional material and/or ancillary
studies. Consequently, cytology as an accepted modality to reliably diagnose infectious disease has come a long way from one of
the first recorded instances in 1904 when FNA was employed to
diagnose trypanosomiasis.
Microorganisms are frequently encountered in cytology specimens. The identification of these microorganisms based upon cytomorphologic appearance can on occasion be challenging and hence
require ancillary studies. For example, numerous collapsed pneumocystis cysts may appear to be budding, while capsule deficient
cryptococcus may be mistaken for other microorganisms such as
histoplasmosis. Evaluation of the host response to organisms provides important clues to the diagnosis of infections. The potential to
render a false positive diagnosis of malignancy exists when inflammatory atypia and/or repair accompanies an infection. Conversely,
there is increased risk for a false negative diagnosis when neoplasms have a prominent inflammatory component or concomitant
infection. Endogenous structures and contaminants may also mimic
pathogens. There have been numerous texts describing the microbiology and pathology of microorganisms seen in tissue specimens.
Introduction
Suggested Reading
Atkins KA, Powers CN. The cytopathology of infectious diseases. Adv
Anat Pathol. 2002;9:5264.
Grieg EDW, Gray ACH. Note on the lymphatic glands in sleeping sickness.
Br Med J. 1904;1:1252.
Jannes G, De Vos D. A review of current and future molecular diagnostic tests for use in the microbiology laboratory. Methods Mol Biol.
2006;345:121.
Kradin RL, editor. Diagnostic pathology of infectious disease. Philadelphia:
Saunders Elsevier; 2010.
Lal A, Warren J, Bedrossian CW, Nayar R. The role of fine needle aspiration in diagnosis of infectious disease. Lab Med. 2002;11:86672.
Powers CN. Diagnosis of infectious diseases: a cytopathologists perspective.
Clin Microbiol Rev. 1998;11:34165.
Silverman JF, Gay RM. Fine-needle aspiration and surgical pathology of infectious lesions. morphologic features and the role of the
clinical microbiology laboratory for rapid diagnosis. Clin Lab Med.
1995;15:25178.
Specimen Collection
and Handling
Pam Michelow1, Tanvier Omar2, and Liron Pantanowitz3
Cytology Unit, Department of Anatomical Pathology,
University of the Witwatersrand and National Health
Laboratory Service, Johannesburg, Gauteng, South Africa
2
Division of Cytopathology, Department of Anatomical Pathology,
National Health Laboratory Service and University of Witwatersrand,
Johannesburg, Gauteng, South Africa
3
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
1
Nuclear
inclusions
Cytoplasmic
inclusions
Syncytia
Yes
Yes
No
No
Yes
Yes
No
Yes
No
No
No
Yes
Yes
No
No
Yes
No
Yes
Specimen Type
Pap test (smear) involves scraping of the cervix with a cervical brush, broom, or wooden/plastic spatula. For anal Pap tests
a small brush or cotton-tipped rod is inserted into the anus.
Rinsing the collection device or detaching and placing it in
a vial containing proprietary preservative fluid (liquid-based
cytology) permits material to be processed for ancillary studies
(e.g., DNA testing for HPV, gonorrhea, and Chlamydia) and for
infections that cannot be reliably identified morphologically.
Conventional smears can also be used for ancillary studies
(e.g., HPV tests), by scraping material off slides.
Specimen Type
10
Specimen Sites
Specimen Sites
11
12
Suggested Reading
Murray PR, Witebsky FG. The clinician and the microbiology laboratory.
In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice
of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone
Elsevier; 2010. p. 23365.
Winn W, Allen S, Janada W, Koneman E, Procop G, Schreckenberger P,
etal. Konemans color atlas and textbook of diagnostic microbiology.
6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 67110.
Woods GL, Gutierrez Y. Diagnostic pathology of infectious diseases.
Philadelphia: Lea & Febiger; 1993. p. 539637.
Cytomorphologic Features
13
14
Fig. 3.1. Acute suppurative lymphadenitis (Diff-Quik stain, high magnification; inset: Pap stain, high magnification). The smears are cellular
and show numerous neutrophils in a background of acute inflammatory
debris.
15
Differential Diagnosis
Ancillary Studies
Cytomorphologic Features
Differential Diagnosis
16
Fig. 3.2. Charcot-Leyden crystals (Pap stain, high magnification). Needleshaped eosinophilic crystals are seen in association with numerous eosinophils (inset), which have weakly orangeophilic cytoplasmic granules and
bilobed nuclei.
Ancillary Studies
Granulomatous Inflammation
Granulomatous Inflammation
17
Cytomorphologic Features
Epithelioid macrophages have kidney bean or boomerangshaped nuclei, prominent nucleoli, and abundant ill-defined
cytoplasm.
Multinucleated giant cells may be seen including Langhans
giant cells (with nuclei arranged around the periphery of the cell
in a horseshoe pattern) or foreign body-type giant cells (with
scattered nuclei).
There may be evidence of phagocytosis of microorganisms or
other debris within macrophages.
Intermixed inflammatory cells are usually lymphocytes and
plasma cells, but neutrophils may also be seen.
Aspirates may have suboptimal cellularity if procured from
long-standing hyalinized granulomas.
Differential Diagnosis
18
Ancillary Studies
Mildmoderate
Continuum (benign to reactive)
Frequent
Boomerang to oval with smooth
contours
Present in epithelioid macrophages
Vacuolated and ill-defined
Necrotic or non-necrotizing
Cellularity
Range of cell types
Background
Nucleoli
Cytoplasm
Granulomatous inflammation
Cytomorphologic features
Uncommon
Smooth nuclear membrane
Lowmoderate
Continuum (benign to reactive)
Reactive atypia
Table 3.2. Cytomorphology of granulomatous and reactive host reactions compared to neoplasia.
Necrotic
Usually high
Two populations (normal
and tumor)
Uncommon
Large with irregular
nuclear membrane
Prominent and irregular
Scant cytoplasm
Neoplasia
20
3. Host Reactions to Infection
Necrosis
21
Necrosis
Cytomorphologic Features
22
Differential Diagnosis
Ancillary Studies
Cytomorphologic Features
Nuclear changes may include nuclear enlargement (e.g., cytomegalovirus), smudgy chromatin (e.g., adenovirus in bronchial
epithelial cells), glassy chromatin (e.g., human polyoma virus
in urine), multinucleation (e.g., herpes simplex virus), large
prominent macronucleolus (e.g., owl eye appearance of cytomegalovirus), intranuclear inclusions (margination of chromatin or
eosinophilic Cowdry bodies seen with Herpes simplex virus), or
koilocytic change (human papillomavirus in cervical Pap tests).
23
Differential Diagnosis
Ancillary Studies
Cytomorphologic Features
24
Differential Diagnosis
Ancillary Studies
25
Cytomorphologic Features
Differential Diagnosis
Granulomatous inflammation
Conditions with numerous foamy histiocytes such as fat necrosis,
lipoid pneumonia, and Gaucher disease
Malignant histiocytosis
Ancillary Studies
26
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
27
Cytomorphologic Features
Differential Diagnosis
28
Ancillary Studies
Ciliocytophthoria
Ciliocytophthoria refers to the finding of anucleate apical portions of ciliated epithelial cells (also referred to as detached
ciliary tufts). This may be seen in respiratory, gynecologic and
peritoneal cytology specimens.
Ciliocytophthoria can occur as a result of certain viral infections
(e.g., adenovirus infection in the lung), but may also be traumatic in nature (Fig.3.9).
Cytomorphologic Features
Xanthogranulomatous Inflammation
29
Differential Diagnosis
Ancillary Studies
Xanthogranulomatous Inflammation
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
30
Malakoplakia
Malakoplakia
31
Fig. 3.11. Malakoplakia (H&E stain, high magnification; inset: Pap stain,
high magnification). Macrophages are shown with characteristic eosinophilic cytoplasm and targetoid, round intracytoplasmic inclusions known
as Michaelis-Guttman bodies.
Cytomorphologic Features
32
Differential Diagnosis
Ancillary Studies
Cytomorphologic Features
Crystal Formation
33
Differential Diagnosis
Granulation tissue
Granulomatous inflammation
Spindle cell neoplasms: Renal cell carcinoma, melanoma, mesenchymal neoplasms including Kaposi sarcoma (LNA-1 immunoreactive for HHV8) and EBV-associated smooth muscle tumors
Ancillary Studies
Special stains for organisms (e.g., acid fast stains for mycobacterial spindle cell pseudotumor)
EBV in situ hybridization (EBER) positivity may be seen in
EBV-associated smooth muscle tumors
PCR for mycobacteria
Immunostains to characterize lesional cells (macrophages are
S100 and CD68 positive, ALK negative, and myofibroblastic
cells may express smooth muscle actin)
Crystal Formation
Charcot-Leyden crystals are seen in association with eosinophilia. They consist of lysophospholipase, which is produced
by eosinophils, and results from the breakdown of eosinophils.
Birefringent calcium oxalate crystals may be seen in association
with Aspergillus infection, particularly with Aspergillus niger.
Crystals are believed to form when oxalic acid precipitates and
undergoes crystallization when produced via a fermentation
process by Aspergillus.
Cytomorphologic Features
Calcium oxalate crystals form rosettes or wheat sheaf-like clusters and polarize under polarized microscopy (Fig.3.12).
Charcot-Leyden crystals are needle- or rhomboid-shaped eosinophilic crystals seen in association with eosinophilic inflammation (Fig.3.2).
The background may be inflammatory or necrotic.
34
Differential Diagnosis
Ancillary Studies
Splendore-Hoeppli Phenomenon
Splendore-Hoeppli Phenomenon
35
Fig. 3.13. Splendore-Hoeppli phenomenon (H&E stain, high magnification). A case of Actinomyces infection in the bone in which an eosinophilic
stellate band can be seen at the edge of the filamentous organisms (sulfur
granule) and surrounding acute inflammatory cells.
Cytomorphologic Features
The characteristic finding is a stellate or club-shaped acellular band-like structure surrounding microorganisms or sulfur
granules (in the case of actinomycosis), which separates them
from the background inflammatory cells and debris.
36
Differential Diagnosis
Ancillary Studies
Suggested Reading
Brummer E. Human defenses against Cryptococcus neoformans: an
update. Mycopathologia. 1999;143:1215.
Gupta M, Venkatesh SK, Kumar A, Pandey R. Fine-needle aspiration cytology of bilateral renal malakoplakia. Diagn Cytopathol.
2004;31:1167.
Hadziyannis E, Yen-Lieberman B, Hall G, Procop GW. Ciliocytophthoria
in clinical virology. Arch Pathol Lab Med. 2000;124:12203.
Kradin RL, Mark EJ. The pathology of pulmonary disorders due to
Aspergillus spp. Arch Pathol Lab Med. 2008;132:60614.
Kumar N, Jain S, Murthy NS. Utility of repeat fine needle aspiration
in acute suppurative lesions: follow-up of 263 cases. Acta Cytol.
2004;48:33740.
Pantanowitz L, Balogh K. Charcot-Leyden crystals: pathology and diagnostic utility. Ear Nose Throat J. 2004;83:48990.
Pantanowitz L, Omar T, Sonnendecker H, Karstaedt AS. Bone marrow
cryptococcal infection in the acquired immunodeficiency syndrome.
JInfect. 2000;41:924.
Rodig SJ, Dorfman DM. Splendore-Hoeppli phenomenon. Arch Pathol
Lab Med. 2001;125:15156.
Sereti I, Rodger AJ, French MA. Biomarkers in immune reconstitution
inflammatory syndrome: signals from pathogenesis. Curr Opin HIV
AIDS. 2010;5:50410.
Zeppa P, Vetrani A, Ciancia G, Cuccuru A, Palombini L. Hemophagocytic
histiocytosis diagnosed by fine needle aspiration cytology of the spleen:
a case report. Acta Cytol. 2004;48:4159.
Microbiology
Liron Pantanowitz1, Gladwyn Leiman2, and Lynne S. Garcia3
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
2
Fletcher Allen Health Care, Professor of Pathology,
University of Vermont, Burlington, VT, USA
3
LSG & Associates, 512-12th Street, Santa Monica, CA 90402, USA
1
Viruses
37
38
4. Microbiology
Tumor
Non-Hodgkin lymphoma (e.g., Burkitt
lymphoma, post-transplant lymphoproliferative disorder, plasmablastic lymphoma)
Hodgkin lymphoma
Carcinoma (e.g., nasopharyngeal carcinoma,
gastric carcinoma)
Smooth muscle tumor
Follicular dendritic cell sarcoma
Kaposi sarcoma
Non-Hodgkin lymphoma (e.g., primary
effusion lymphoma)
Castleman disease
Anogenital dysplasia and carcinoma
Oropharyngeal dysplasia and carcinoma
Hepatocellular carcinoma
Adult T-cell leukemia/lymphoma
Merkel cell carcinoma
Papillomaviruses
Viruses
39
Fig. 4.1. Viral cytopathic changes. (a) HPV showing a large binucleate
koilocyte and adjacent smaller high grade squamous intraepithelial lesion
(HSIL) cell. (b) Herpes simplex virus showing a large multinucleated
epithelial cell with cowdry A inclusions and a smaller cell with an intranuclear cowdry B inclusion. (c) CMV infected cell showing enlargement (cytomegaly), an intranuclear inclusion (owls-eye appearance),
and intracytoplasmic inclusions. (d) Molluscum contagiosum infection
showing a keratinocyte with an intranuclear inclusion (molluscum body).
(e) Measles (or RSV) infected syncytial giant cell with intranuclear inclusions. (f) BK polyomavirus infected epithelial cells (decoy cells) showing
early (ground glass) and late (fish-net stocking) intranuclear inclusions,
as well as a comet cell in the middle with eccentric cytoplasm. (g) Adenovirus infected pneumocytes showing smudge cells with inclusions filling the nucleus and decapitated ciliated cells (ciliocytophthoria).
40
4. Microbiology
Herpesviruses
Virus name
Herpes simplex virus type 1 (HSV-1)
Herpes simplex virus type 2 (HSV-2)
Varicella-Zoster virus (VZV)
Cytomegalovirus (CMV)
Roseolovirus
HHV type
HHV1
HHV2
HHV3
HHV4
HHV5
HHH6
HHV7
HHV8
Target cells
Mucoepithelium
Mucoepithelium
Mucoepithelium
Disease
Oral and/or genital herpes
Oral and/or genital herpes
Chickenpox
Shingles
Infectious mononucleosis
Non-Hodgkin lymphoma
Hodgkin lymphoma
Nasopharyngeal carcinoma
Lymphomatoid granulomatosis
Gastric carcinoma
Oral hairy leukoplakia
Acute (mono-like) illness
Systemic illness (e.g., pneumonia, hepatitis)
Retinitis
Sixth disease (roseola infantum or exanthem
subitum)
Sixth disease (roseola infantum or exanthem
subitum)
Kaposi sarcoma
Non-Hodgkin lymphoma
Multicentric Castleman disease
Viruses
41
42
4. Microbiology
Acute infection
+
+
+
+
+
+
Burkitt lymphoma
+
Hodgkin lymphoma
+
+
+
+
Latency II
Nasopharyngeal
carcinoma
+
+
+
+
PCNSL primary central nervous system lymphoma; PTLD post-transplant lymphoproliferative disorder
EBV gene
EBNA1
EBNA2
EBNA3
LMP1
LMP2
EBER
Latency I
PCNSL
+
+
+
+
+
+
Latency III
PTLD
+
+
+
+
+
+
Viruses
43
44
4. Microbiology
Respiratory Viruses
Influenza and Parainfluenza viruses can cause severe respiratory tract disease (e.g., pneumonia, bronchitis, and bronchiolitis). As infection usually does not cause characteristic cytologic
findings, the diagnosis requires isolation and identification of
the virus in the laboratory or a rise in serum antibodies.
Coronavirus causes illness ranging from the common cold to
severe acute respiratory syndrome (SARS). Respiratory samples
may show atypical reactive pneumocytes with or without background inflammation and marked fibrin exudate in cases with
diffuse alveolar damage (DAD).
Respiratory syncytial virus (RSV) causes lower respiratory tract
infections mainly in childhood. RSV belongs to the same Paramyxoviridae family as measles (Rubeola) and mumps viruses.
Both RSV and measles pneumonia can cause multinucleated syncytial giant cells containing intranuclear and inconspicuous usually
paranuclear cytoplasmic inclusions. Multinucleated giant cells are
usually rare, but when identified may contain up to 35 nuclei.
Adenoviruses. They were named after being first isolated from
adenoid samples. There are 55 described serotypes in humans
that cause respiratory tract infections (e.g., pharyngitis, pneumonia). Infection may also cause gastroenteritis, conjunctivitis,
hemorrhagic cystitis, meningoencephalitis, hepatitis, and disseminated disease. Early infected cells may display small eosinophilic inclusions. With late infection, basophilic intranuclear
inclusions eventually obscure the nucleus producing a characteristic smudge cell.
Polyomaviruses
Most people are infected with these viruses and hence are seropositive for polyomaviruses. These double-stranded DNA viruses
tend to only cause infection in immunosuppressed individuals,
and are all potentially oncogenic. They fall under the SV40
(Simian vacuolating virus 40) clade seen in monkeys, except for
Merkel cell polyomavirus.
BK virus (BKV) has a tropism for cells of the genitourinary
tract. BKV may cause nephropathy in 110% of renal transplant
Viruses
45
Poxviruses
Retroviruses
46
4. Microbiology
Miscellaneous Viruses
Bacteria
Bacteria
47
48
4. Microbiology
Mycobacteria
Bacteria
49
50
4. Microbiology
Bacteria
51
Filamentous Bacteria
Bacteria can be elongated to form filaments (e.g., Actinobacteria, Nocardia, Rhodococcus, Streptomyces, Actinomadura).
They can sometimes form complex, branched filaments that
morphologically resemble fungal mycelia (mass of branching
hyphae).
These bacteria are usually part of the normal oral flora. Most
infections are acquired by inhalation of the bacteria or via
trauma.
Actinomyces (genus) belong to the Actinobacteria (class of
bacteria). Infection (actinomycosis) with these Gram-positive
bacteria forms multiple abscesses and sinus tracts that may discharge sulfur granules. Actinomycosis is most frequently caused
by Actinomyces israelii.
Nocardia (genus) are weakly-staining Gram-positive bacteria that form partially acid-fast beaded branching filaments.
There are a total of 85 species, although Nocardia asteroides
is the species that most frequently causes infection (nocardiosis). Nocardial disease (norcardiosis) includes pneumonia,
endocarditis, encephalitis, and/or brain abscess, as well cutaneous infections such as actinomycotic mycetoma (Figs. 4.6
and 4.7).
Chlamydia
52
4. Microbiology
Bacteria
53
Fig. 4.7. Actinomyces. (Top left) Clump of long filamentous bacteria are
shown (May-Grnwald-Giemsa stain, high magnification). (Top right)
Actinomyces from the mouth contaminating a bronchoalveolar lavage
ThinPrep specimen (Pap stain, high magnification). (Bottom left) Typical dust bunny seen on a cervical Pap test (Pap stain; high magnification). (Bottom right) Sulfur granule is shown in the center of the cell block
preparation aspirated from an actinomycotic liver abscess (H&E stain,
intermediate magnification).
54
4. Microbiology
Fungi
Fungi
55
Fig. 4.9. Fungal morphology. Hyphae may be characterized as (a) pseudohyphae (e.g., Candida spp.), (b) septate (e.g., Aspergillus) or (c) coenocytic (aseptate) hyphae (e.g., Zygomycetes). Conidia (spores) develop from
asexual fruiting structures such as (d) a conidiophore or (e) enclosed in a
sac called a sporangium, in which case they are then called endospores.
Candida
Candida is a polymorphic fungus that undergoes a yeast-tomycelial transition. In clinical specimens, they produce pseudohyphae (hyphae that show distinct points of constriction
resembling sausage links), rarely true septate hyphae, and budding yeast forms (blastoconidia).
The yeast-like forms (blastoconidia) are oval and measure
35mm in diameter
56
4. Microbiology
Cryptococcus
Cryptococci are small (515 mm) pleomorphic (ovoid to spheroid) yeasts that are characterized by often having a thick gelatinlike capsule and demonstrating narrow-based (teardrop-shaped)
budding. They have thin walls and are occasionally refractile.
Their capsules may have a diameter of up to five times that of
the fungal cell, and form a halo on Diff-Quik, Pap, and India
ink stains.
Smaller (25 mm) capsule-deficient cryptococci can resemble
other organisms with similar microforms (e.g., Histoplasma,
Candida, and immature spherules of Coccidioides immitis).
In such cases, with careful examination some weakly encapsulated yeasts can still be detected. Loss of capsular material
usually elicits an intense inflammatory reaction characterized
by suppuration and granulomas.
Yeasts usually produce single buds, but multiple buds and even
chains of budding cells may rarely be present.
Fungi
57
The presence of pseudohyphae-like elements and germ tubelike structures may be detected in some cases, mimicking
Candida. However, this is rare and reported to be observed
in older lesions of cryptococcosis where aberrant forms are
frequently seen.
Infection (cryptococcosis) arises mainly in immunosuppressed
patients and may cause very little inflammation.
Cryptococcus neoformans causes most infections, such as meningitis and meningoencephalitis in HIV positive patients.
Cryptococcus gattii (formerly Cryptococcus neoformans var
gattii), endemic in tropical areas of Africa and Australia, may
cause cryptococcosis in immunocompetent individuals (Fig.4.11).
58
4. Microbiology
Aspergillus
Fungi
59
Zygomycetes
60
4. Microbiology
Zygomycota
Class
Zygomycetes
Order
Mucorales
Family
Mucoraceae
Genus
Absidia
Apophysomyces
Mucor
Rhizomucor
Rhizopus
Entomophthorales
Cunninghamellaceae
Mortierellaceae
Saksenaceae
Syncephalastraceae
Thamnidaceae
Ancylistaceae
Basidioboaceae
Fungi
61
Dimorphic Fungi
Aspergillus
Septate
Consistently thin (23mm wide)
45 angles
Absent
Present with air exposure
Morphologic feature
Pap stain appearance
Hyphal type
Hyphal width
Branching
Blastoconidia
Sporulation
Aseptate
Variable and wide (616mm wide)
90 angles
Absent
Absent
Zygomycetes
Table 4.5. Comparison between zygomycetes, Aspergillus spp., and Candida spp.
Pseudohyphae
Consistently thin (23mm wide)
Variable angles
Present
Absent
Candida
62
4. Microbiology
Fungi
63
Fig. 4.14. Zygomycetes. (Left and top right) Zygomycete hyphae are
shown characterized by broad, aseptate (coenocytic) hyphae that display wide-angle branching (Pap stain, left high magnification, top right
intermediate magnification). (Bottom right) Fungal hyphae are shown
immunoreactive with a specific immunostain for zygomycetes (high
magnification).
515
815
Oval to round
Spherical
Blastomyces
24
Cryptococcus
Yeast shape
Oval
Oval to round
Yeast appearance
Histoplasma
Fungi
Candida
No hyphae
Very rare
pseudohyphae
No hyphae
Associated elements
Pseudohyphae
Rare hyphae
Broad based
Narrow based
Narrow based
Budding
Narrow based
Mainly intracellular
Extracellular and
intracellular
Mainly intracellular
Location
Mainly extracellular
64
4. Microbiology
58
Round to
crescent
Round to
elongated
Pneumocystis
Penicilliosis
23
35
Round to elongated
Sporothrix
Yeast shape
Oval
Yeast appearance
Coccidioides
Fungi
Associated elements
Rare hyphae
No hyphae
Rare hyphae
Within spherules
Budding
None
None
Narrow based
None
Location
Mainly intracellular
Mainly extracellular
Mainly extracellular
Mainly extracellular
Fungi
65
66
4. Microbiology
Fungi
67
Fig. 4.16. Histoplasmosis. Numerous small intracellular and extracellular yeasts of H. capsulatum are shown (GMS stain, high magnification).
68
4. Microbiology
Penicillium. These fungi produce penicillin. Penicillium marneffei is the only known thermally dimorphic species. In cytology
specimens, Penicillium present in the mold phase with septate
and branched hyphae represent a contaminant. However, in
immunosuppressed patients P. marneffei is an opportunistic
infection that causes penicilliosis. There is a particularly high
incidence of penicilliosis in AIDS patients from tropical Southeast Asia. Infection after inhalation spreads from the lungs to
involve the hematopoietic system and skin. Yeast-like cells are
present within macrophages and extracellularly. They are not
true yeast cells, but rather arthroconidia. Intracellular yeasts
measure 23 mm in diameter and are round to oval. Because
they divide by binary fission, budding is not observed. The
extracellular organisms tend to be more elongated, sometimes
up to 13 mm, and can have septae (crosswalls from binary
fission).
Pneumocystis
Fungi
69
Dematiaceous Fungi
The dematiaceous (naturally pigmented) group of fungi produce melanin in their cell walls. As a result, fungal colonies
are brown when cultured and in tissue samples fungal forms are
characteristically pigmented. A Fontana-Masson stain can be
used to confirm the presence of fungal melanin pigment.
70
4. Microbiology
They cause several human infections including chromoblastomycosis (also called chromomycosis) and phaeohyphomycosis
(or phaeomycotic cyst).
Dermatophytes
Hyalohyphomycoses
Hyalohyphomycosis is the term used to group together invasive mycotic infections caused by hyaline septate hyphae. This
includes species of Aspergillus, Penicillium, Paecilomyces,
Acremonium, Beauveria, Fusarium, and Scopulariopsis. They
may represent contamination or cause invasive disease in the
immunosuppressed host.
Fusarium hyphae are similar to those of Aspergillus, with septate
hyphae that branch at acute and right angles. Sporulation may
also occur in tissue with infection (fusariosis). Their macroconidia are crescent-shaped, orangeophilic, and septate structures
that measure 8012036mm in size.
Parasites
Protozoa
Protozoa are unicellular motile organisms. They are traditionally divided according to their means of locomotion such as
amebae, flagellates, and ciliates.
Their life cycle often alternates between trophozoites (feeding
dividing stage) and cysts (dormant stage able to survive outside the
host). Their characteristics (particularly the nuclei and cytoplasmic
inclusions) help in species identification. Ingested cysts cause infection by excysting (releasing trophozoites) in the alimentary tract.
Parasites
71
72
4. Microbiology
Parasites
73
Mucocutaneous
Visceral
Pathogenic species
Old world
L. major
L. tropica
L. aethiopica
None
L. donovani
complex
New world
Geographic location
L. mexicana
L. braziliensis
None
74
4. Microbiology
Fig. 4.19. Leishmania. (Top left) Life cycle showing the transition from
a flagellated promastigote that occurs in the sandfly to small amastigotes without flagella in the human host: Promastigotes phagocytosed by
macrophages multiply within these cells and disseminate when released.
(Bottom left) Illustration of an ovoid amastigote shows a large nucleus
and prominent rod-shaped kinetoplast. (Right) This FNA sample obtained
from a Saudi Arabian child presenting with hepatosplenomegaly and
lymphadenopathy from kala-azar shows few scattered amastigotes (arrows)
among chronic inflammatory cells (Giemsa stain, high magnification).
Apicomplexans
Parasites
75
76
4. Microbiology
Helminths
Echinococcus spp.
Trematodes (flukes)
Fasciola hepatica (liver fluke)
Ascaris lumbricoides
Necator americanus (hookworm)
Ancyclostoma duodenale (hookworm)
Strongyloides stercoralis
Egg
Worm
Helminth
Cestodes (tapeworms)
Taenia saginata (beef tapeworm)
Taenia solium (pork tapeworm)
Parasites
77
78
4. Microbiology
Fig. 4.21. Parasitic eggs are shown in cytologic preparations. (Top left)
Enterobius vermicularis. (Top middle) Taenia (tapeworm). (Top right)
Trichuris trichiura. (Bottom left) Ascaris lumbricoides. (Bottom middle)
Schistosoma haematobium. (Bottom right) Pollen grain (belonging to the
Caryophyllaceae family) that may be mistaken for Toxocara eggs (images
courtesy of Dr. Pam Michelow, South Africa and Dr. Rafael Martinez
Girn, Spain).
Parasites
79
80
4. Microbiology
Parasites
81
82
4. Microbiology
and the pattern of nuclei in their tail are the main features
used to distinguish the various species. Occult filariasis has
been diagnosed by many bloody FNA procedures containing
microfilariae, worms, or even eggs. Filarial morphology is
best appreciated with a Giemsa stain. The background tissue
response in cytology aspirates may include eosinophils, neutrophils, chronic inflammation, and even granulomas.
Trematodes. The flukes are oval or worm-like helminthes that are
parasites of molluscs and vertebrates. The liver flukes include
Fasciola hepatica and Clonorchis sinensis that result in infestation of the bile ducts and subsequent biliary fibrosis. Infection
with C. sinensis is a risk factor for cholangiocarcinoma. Fasciolopis buskii is an intestinal fluke that infests both the bile ducts
and duodenum. Paragonimus westermani, the lung fluke, causes
lung infestation with pulmonitis. Also included are the schistosomes (blood flukes).
Schistosomes. Infection by these trematodes causes schistosomiasis (bilharzia). There are three human schistosome
pathogens: Schistosoma mansoni from Africa (Nile delta)
which causes intestinal schistosomiasis, S. haematobium
from Africa and the Middle East that infests the urinary bladder, and S. japonicum from China and Southeast Asia that
primarily involves the liver. S. haematobium infection can
lead to squamous cell carcinoma of the bladder. Microscopic
identification of eggs in stool or urine specimens, as well as
tissue biopsies, can provide a rapid diagnosis. The spines
present on schistosome eggs help distinguish these different
species. The egg of S. haematobium (oval) has a terminal
spine, S. mansoni (oval) has a lateral spine, and S. japonicum
(round) has a small knob-like lateral spine.
Algae
Algae
83
Fig. 4.24. Prototheca. (Left) Diagram of protothecae demonstrating variable morula formation: (Right) A sporangium of P. wickerhamii is shown
in which endospores have a moruloid (daisy-like) pattern (Pap stain, high
magnification) (image courtesy of Rafael Martinez Girn, Instituto de
Piedras Blancas-Asturias, Spain).
Suggested Reading
Ash LR, Orihel TC. Ash & Orihels atlas of human parasitology. 5th ed.
Chicago: American Society for Clinical Pathology Press; 2007.
Bayn MN, Drut R. Cytologic diagnosis of adenovirus bronchopneumonia. Acta Cytol. 1991;35:1812.
Bhambhani S, Kashyap V. Amoebiasis: diagnosis by aspiration and exfoliative cytology. Cytopathology. 2001;12:32933.
84
4. Microbiology
Gynecological Infections
Liron Pantanowitz1, R. Marshall Austin2,
and Pam Michelow3
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
2
Department of Pathology, Magee-Womens Hospital of University of
Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA 15213, USA
3
Cytology Unit, Department of Anatomical Pathology, University of the
Witwatersrand and National Health Laboratory Service, Johannesburg,
Gauteng, South Africa
1
85
Infection
Microorganisms
Vulva
Viral
Bacterial
Fungal
Parasites
Infestation
Cervix
and vagina
Viral
Bacterial
Fungal
Parasites
Upper
genital tract
Salpingitis, pelvic
inflammatory
disease (PID),
tubo-ovarian
abscess,
endometritis
Normal Flora
87
Inflammatory Changes
Normal Flora
Microbiology
88
5. Gynecological Infections
Fig. 5.1. Inflammatory cells on Pap tests. (Upper left) ThinPrep Pap
test showing several pus balls characteristic of trichomoniasis (Pap stain,
intermediate magnification). (Bottom left) Follicular cervicitis seen on a
conventional Pap smear consists of polymorphous lymphocytes and several tingible-body macrophages (Pap stain, high magnification). (Upper
right) This ThinPrep Pap test from a postmenopausal women with
follicular cervicitis shows a loose aggregate of lymphocytes in various
stages of maturation together with a tingible-body macrophage (Pap stain,
high magnification). (Bottom right) Cervix biopsy of follicular cervicitis
showing prominent subepithelial reactive lymphoid follicles with germinal
centers (H&E stain, low magnification; courtesy of Dr. Christopher Otis,
Tufts University School of Medicine, USA).
Normal Flora
89
Fig. 5.2. Lactobacilli (high magnification images). (Top left) Thin bacilli
forming part of the normal flora are shown in this routine Pap test (Pap
stain, ThinPrep). (Bottom left) Multiple lactobacilli are seen coating
these two squamous epithelial cells, not to be confused with clue cells
(Pap stain). (Right) Long slender lactobacilli are seen associated with
cytolysis and bare nuclei (Pap stain, conventional smear).
Clinical Features
Cytomorphologic Features
90
5. Gynecological Infections
Diagnostic Note
Leptothrix vaginalis
Microbiology
Clinical Features
Cytomorphologic Features
Diagnostic Note
Compared to Actinomyces, Leptothrix are much less densely clustered and are not associated with companion bacteria.
The finding of Leptothrix should encourage a thorough investigation of the specimen for associated Trichomonas.
Ancillary tests are not required (Fig.5.3).
Viral Infections
91
Viral Infections
Human Papillomavirus (HPV)
Microbiology
Papillomaviruses are DNA viruses that belong to the family Papoviridae. They selectively infect skin and mucous membranes.
Genital HPV infection is almost exclusively sexually transmitted.
HPV is the dominant causative agent in anogenital warts, SILs,
and cervical carcinoma. Most HPV infections regress spontaneously. Persistence of oncogenic HPV infection is required for
progression to carcinoma.
There are over 100 different types of HPV. The types infecting the female genital tract are divided into low- and high-risk
(HR). Low-risk (LR) HPVs are associated with condylomata
acuminata and LSIL, while the intermediate and HR oncogenic
HPV types are associated with LSIL, HSIL, and carcinoma.
92
5. Gynecological Infections
Clinical Features
Cytomorphologic Features
Viral Infections
93
Fig. 5.4. Koilocytosis (high magnification images). (Upper left) Koilocytes in a ThinPrep Pap test with LSIL. Note the striking nuclear abnormalities in the koilocytes compared to the adjacent normal appearing
squamous cells (Pap stain). (Bottom left) A group of koilocytes with
prominent perinuclear halos and enlarged nuclei are shown in a conventional Pap smear (Pap stain). (Upper right) Polka dot cells with intracytoplasmic eosinophilic hyaline globules (Pap stain). These cells more than
likely represent a degenerative process than an HPV effect associated with
condylomas as previously suggested. (Bottom right) Glycogenated squamous cells mimicking koilocytes (Pap stain).
94
5. Gynecological Infections
Diagnostic Note
Viral Infections
95
Ancillary Tests
96
5. Gynecological Infections
Fig. 5.6. p16 immunocytochemistry (high magnification images). ThinPrep Pap test with (upper left) a group of HSIL cells (top left, Pap stain)
that shows nuclear and cytoplasmic immunoreactivity for p16 (bottom
left). Nonspecific staining with p16 (clone G175-405) is demonstrated with
(upper right) Trichomonas trophozoites and (bottom right) lactobacilli.
Viral Infections
97
98
5. Gynecological Infections
Diagnostic Note
The Bethesda system interpretation is Cellular changes consistent with herpes simplex virus.
Reactive endocervical cells with multinucleation may mimic
herpetic change. Neoplastic cells with multinucleation and/or
pale vesicular nuclei may also mimic herpes (Fig. 5.8). Other
mimics of herpes may include reactive/repair change, air-drying
artifact, cell distortion, and poor cell preservation.
The differential diagnosis for large multinucleated cells on
a Pap test includes giant cell macrophages (granulomatous
Viral Infections
99
Ancillary Tests
Immunocytochemistry
HSV DNA detection by PCR or ISH
Serology (type-specific assays)
Viral culture
Cytomegalovirus (CMV)
Detection of cytomegalovirus (CMV) cytopathic effect in cervical Pap tests or biopsy is rare. CMV typically involves endocervical glandular epithelium, and less commonly squamous cells.
The characteristic viral cytopathic change includes cytomegaly
with an intranuclear inclusion surrounded by a halo (owls-eye),
which can be confirmed using immunocytochemistry if necessary.
Clinical Features
100
5. Gynecological Infections
Cytomorphologic Features
Infected squamous cells show characteristic cytoplasmic inclusions called molluscum bodies. Inclusions may be eosinophilic
or basophilic in appearance. The nuclei of infected cells are
pushed to the periphery and therefore often inconspicuous.
There is usually little or no background inflammation.
Diagnostic Note
Bacterial Infections
101
Bacterial Infections
Bacterial Vaginosis
Microbiology
Fig. 5.10. Shift in vaginal flora. (Left) Conventional Pap smear showing altered vaginal flora. The large number of bacteria in this specimen
imparts a gray color to the background smear (Pap stain, intermediate magnification). (Right) Clue cells are shown with squamous cells
coated by many small coccobacillary bacteria (Pap stain, ThinPrep,
high magnification).
102
5. Gynecological Infections
Clinical Features
Cytomorphologic Features
Diagnostic Note
Ancillary Tests
Although rarely used by cytologists, the whiff test can be performed at the bedside, whereby volatile amines are liberated when
vaginal secretions are mixed with 10% potassium hydroxide.
Bacterial Infections
103
Gram stain
Culture
Multiplex PCR for both G. vaginalis and Mobiluncus spp.
Neisseria gonorrheae
Microbiology
Clinical Features
Cytomorphologic Features
Monococci or diplococci may be seen within neutrophils. However, cytolomorphology alone is not a reliable diagnostic modality and ancillary tests are required.
Patients with chronic gonorrhea infection may show reactive
epithelial change.
Diagnostic Note
Many women are routinely screened for N. gonorrheae infection, along with C. trachomatis at the time of Pap test collection.
Concomitant testing for these microorganisms does not appear
to affect the adequacy of the Pap test, even if separate endocervical swabs are obtained before or after the Pap test. The type
of collection device (e.g., broom, brush) also does not appear to
impact the test.
Nucleic acid amplification tests (NAATs, see below) permit testing of female patients to be performed on endocervical swabs,
liquid-based Pap specimens, self-collected vaginal swabs, and
urine specimens.
104
5. Gynecological Infections
Ancillary Tests
Gram stain.
DNA for N. gonorrheae can be performed on liquid-based cytology of cervicovaginal specimens. Commercial kits are available
that employ NAAT. These offer more rapid results than culture.
Second-generation assays (e.g., APTIMA Combo 2 assay) can
simultaneously detect N. gonorrheae and C. trachomatis from
the same specimen.
Culture, which needs to be performed within 24 h or less of
specimen collection.
Also available are fluorescent antibody testing, co-agglutination,
and DNA probe.
Actinomyces
Microbiology
Actinomyces spp. are Gram-positive, nonacid-fast bacteria that exhibit branching, filamentous growth. Actinomyces israelii is the species most commonly associated with
the female genital tract. They are part of the normal flora of
the mouth and gastrointestinal tract, and less commonly the
vagina. Damage to the mucosa is required for the development of actinomycosis.
Actinomyces spp. grow as colonies that can form abscesses and
subsequent fibrosis. Yellow sulfur granules containing bacteria
may be visible macroscopically.
Actinomyces infection of the female genital tract is most often
associated with intra-uterine contraceptive device (IUD) use.
Around 25% of patients with an IUD will have Actinomyces
present in their Pap test specimens. Rare cases may develop
endometritis and/or PID.
Clinical Features
Bacterial Infections
105
Cytomorphologic Features
Diagnostic Note
The Bethesda system interpretation is Bacteria morphologically consistent with Actinomyces spp.
IUD removal and possible antibiotic treatment may be required
in symptomatic patients if actinomycosis is diagnosed.
106
5. Gynecological Infections
Ancillary Tests
Gram stain
Culture
Granuloma Venereum
This STD, also known as granuloma inguinale and Donovanosis, is caused by Klebsiella granulomatis, an intracellular Gramnegative bacteria, sometimes referred to as a Donovan body.
The organism is seen in histiocytes, enclosed within thin-walled
intracytoplasmic vacuoles. The classic safety-pin appearance
of the bacteria is not apparent in alcohol-fixed smears.
There may be a paucity of epithelial cells present due to ulceration.
As a result, the majority of the Pap test is comprised of inflammatory cells, mainly neutrophils but also macrophages. Epithelioid
histiocytes may be encountered, but giant cells are not seen. Intact
capillaries may be seen due to direct scraping of the stroma.
Various ancillary tests are available including special stains
(Romanowsky and Warthin-Starry stains), immunocytochemistry, PCR, serology, culture, and electron microscopy (Fig.5.12).
Tuberculosis
Microbiology
Clinical Features
Bacterial Infections
107
Cytomorphologic Features
The main finding is granulomatous inflammation with or without necrosis. Epithelioid histiocytes form sheets or can be seen
as single cells, along with acute and chronic inflammatory cells
in the background, as well as multinucleated giant cells.
108
5. Gynecological Infections
Diagnostic Note
Ancillary Tests
Chlamydia trachomatis
Microbiology
Chlamydia (previously called TRIC agent) are obligate intracellular Gram-negative bacteria. They require growing cells to
remain viable, forming intracellular inclusions as they grow.
C. trachomatis is transmitted via sexual contact and during vaginal child birth. This is the most common nonulcerative STD
worldwide. Coinfection with HPV, gonorrhea, syphilis, HSV-2,
and HIV is common (Fig.5.13).
Fig. 5.13. Chlamydia inclusions. (Left) Squamous cells on a Pap test are
shown with several small intracytoplasmic chlamydia inclusions (Pap stain,
high magnification). (Right) Squamous cell with a nebular body, which is
highly specific for chlamydial infection (Pap stain, high magnification).
Bacterial Infections
109
Clinical Features
Cytomorphologic Features
Diagnostic Note
Ancillary Tests
110
5. Gynecological Infections
Other nucleic acid tests (e.g., PCR, transcription-mediated amplification, strand displacement amplification, ligase chain reaction).
Immunocytochemistry.
Antigen detection (direct immunofluorescence and ELISA).
Serology, which is of limited value in adults. Detection of IgM
in neonatal infection is useful.
Culture using susceptible cells (e.g., McCoy cells). Culture is
the test of choice (gold standard) in sexual abuse cases.
Fungal Infections
Candida
Microbiology
Clinical Features
Cytolomorphogic Features
Fungal Infections
111
Fig. 5.14. Candida. (Left) Candida hyphae in this ThinPrep Pap test
appear to have skewered the surrounding squamous cells forming a shish
kebab-like structure (Pap stain, intermediate magnification). (Right)
Higher magnification shows characteristic pseudohyphae with distinct
constrictions along their length (Pap stain).
Diagnostic Note
112
5. Gynecological Infections
Fig. 5.15. Candida glabrata. With C. glabrata the only finding in a Pap test
is rare to many yeasts (left and right images Pap stain, high magnification).
Ancillary Tests
Parasitic Infections
Trichomonas vaginalis
Microbiology
Parasitic Infections
113
Fig. 5.16. Trichomoniasis. (Left). Many pear-shaped blue-gray trichomonads are shown attached to a squamous cell in a ThinPrep Pap test (Pap stain,
high magnification). (Upper right) Several trichomonads are shown in this
conventional Pap smear with prominent red cytoplasmic granules (Pap
stain, high magnification). (Middle bottom) A darker gray elliptical nucleus
can be seen within these protozoa (high magnification under oil). (Bottom
right) Trichomonads demonstrate p16 immunoreactivity. Note the thin flagella of the parasite on the right (immunocytochemistry, clone G175-405,
BD Biosciences Pharmingen, San Diego, CA; oil magnification).
Clinical Features
Patients may be asymptomatic or present with burning, pruritis, a profuse yellow-green, frothy and malodorous vaginal discharge and dysuria. Males may present with urethritis.
Trichomonas may be associated with PID, infertility, and in pregnant women premature rupture of membranes and preterm birth.
Cytomorphologic Features
114
5. Gynecological Infections
Diagnostic Note
Ancillary Tests
Parasitic Infections
115
Fig. 5.17. Schistosomiasis. (Left) Several nonviable empty ova of S. haematobium are shown in a conventional Pap smear with a bloody background (Pap stain, high magnification). (Right) A miracidium (upper
structure) and ovum (lower structure) of S. haematobium in a Pap smear
are shown. The miracidium has possibly just escaped from the ovum (Pap
stain, high magnification).
Schistosomiasis
Microbiology
Clinical Features
116
5. Gynecological Infections
Cytomorphologic Features
Viable ova are 150mm in length and 50mm in width and are surrounded by a thick shell. S. haematobium has a terminal spine
while S. mansoni has a lateral one. S. japonicum is slightly oval
with a rudimentary lateral spine. Sometimes the structure of a
miracidium within the ovum is apparent.
Nonviable ova are empty (have no internal structure) and may
exhibit a variety of forms including calcified, black, opaque,
shrunken, or collapsed eggs. Empty shells are often found in
association with multinucleated histiocytes.
Miracidia are not often seen. They usually have a pointed anterior end and round posterior end. Cilia are not seen on Pap
smear. The cytoplasm containing various structures within
the miracidia stain brightly eosinophilic while the nuclei are
basophilic.
There is usually an acute inflammatory infiltrate and multinucleated histiocytes present in the background.
Diagnostic Note
Parasitic Infections
117
Ancillary Tests
Enterobius vermicularis
Microbiology
Enterobius vermicularis (known as the pinworm or threadworm) is an intestinal parasite (nematode) that can occasionally
migrate to the vagina, uterus, and even the peritoneal cavity via
the fallopian tubes.
The finding of an adult pinworm and/or egg on a Pap test
slide likely represents contamination from perianal parasites
(gravid female worms and ova), or infrequently a true genital
infection.
Clinical Features
Cytomorphologic Features
Diagnostic Note
118
5. Gynecological Infections
Fig. 5.18. Enterobius vermicularis (Left) pinworm egg seen in a conventional pap smear, which is flat on one end (pap stain, high magnification)
(courtesy of Dr. Gladwyn Leiman, University of Vermont, USA). (Right)
Pinworm egg shown in cell block material from a cervicovaginal specimen (H&E stain, high magnification).
Ancillary Tests
Microbiology consultation
Examination of stool for parasites and/or cellulose (Scotch/
sticky) tape applied to the perianal skin for microscopic examination (Fig.5.18).
Insects
119
Insects
Phthirus pubis
Fig. 5.19. Phthirus pubis seen on a conventional Pap smear (Pap stain,
medium magnification).
120
5. Gynecological Infections
Suggested Reading
Aslan DL, McKeon DM, Stelow EB, Gulbahce HE, Kjeldahl K, Pambuccian
SE. The diagnosis of trichomonas vaginalis in liquid-based Pap tests:
morphological characteristics. Diagn Cytopathol. 2005;32:2539.
Discacciati M, Simoes J, Amaral R, Brolazo E, Rabelo-Santos S, Westin
M, etal. Presence of 20% or more clue cells: an accurate criterion for
the diagnosis of bacterial vaginosis in Papanicolaou cervical smears.
Diagn Cytopathol. 2006;34:2726.
Giacomini G. Permanent diagnosis of bacterial vaginosis: gram stain or
Papanicolaou stain? Diagn Cytopathol. 2000;23:2923.
Gupta R, Dey P, Jain V, Gupta N. Cervical tuberculosis detection in
Papanicolaou-stained smear: case report with review of literature.
Diagn Cytopathol. 2009;37:5925.
Huang JC, Naylor B. Cytomegalovirus infection of the cervix detected
by cytology and histology: a report of five cases. Cytopathology. 1993;
4:23741.
Leiman G, Markowitz S, Margolius KA. Cytologic detection of cervical
granuloma inguinale. Diagn Cytopathol. 1986;2:13843.
McMillan A. The detection of genital tract infection by Papanicolaoustained tests. Cytopathology. 2006;17:31722.
Nol JC, Engohan-Aloghe C. Morphologic criteria associated with Trichomonas vaginalis in liquid-based cytology. Acta Cytol. 2010;54:5826.
Pantanowitz L, Florence RR, Goulart RA, Otis CN. Trichomonas vaginalis p16 immunoreactivity in cervicovaginal Pap tests: a diagnostic
pitfall. Diagn Cytopathol. 2005;33:2103.
Tambouret R. Gynecologic infections. In: Kradin RL, editor. Diagnostic
pathology of infectious disease. Philadelphia: Saunders Elsevier; 2010.
p. 44363.
Pulmonary Infections
Walid E. Khalbuss1, Rodolfo Laucirica2,
and Liron Pantanowitz1
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
2
Department of Pathology and Immunology, Baylor College of Medicine,
Ben Taub General Hospital, Houston, TX, USA
1
121
122
6. Pulmonary Infections
Viral Infections
Viruses are one of the most common causes of infection of the
respiratory tract. Not all viral infections have cytopathic changes
(e.g., influenza, swine flu, severe acute respiratory syndrome/
SARS, EBV). However, in many cases the cytologic features of
viral infection are fairly specific as to the etiology (Table 6.1).
Ancillary studies such as immunohistochemistry, viral culture, and
molecular tests are often necessary to accurately identify the cause
of certain infections.
Viral Infections
123
Cytologic finding
Cowdry type A and B inclusions
Large intranuclear and small cytoplasmic
inclusions
Intranuclear inclusions (smudge cells)
and ciliocytophthoria
Syncytial giant cells
Syncytial giant cells with large cytoplasmic
inclusions and ciliocytophthoria
Multinucleated giant cells with cytoplasmic
and intranuclear Cowdry type A inclusions
Clinical Features
HSV infection of the upper respiratory tract can lead to pharyngitis, laryngotracheitis, and pneumonia. HSV infection of the
lung may cause a necrotizing pneumonia or diffuse interstitial
pneumonia.
HSV commonly infects neonates and immunocompromised
patients.
Cytomorphologic Features
124
6. Pulmonary Infections
Fig. 6.1. BAL specimen from a patient with a history of colon adenocarcinoma who presented with respiratory distress. The left photos show
characteristic of Cowdry type B herpes inclusions. The right photo shows
accompanying reactive reparative change with prominent and multiple nucleoli that mimics malignancy in this case (Pap stain, high magnification).
Differential Diagnosis
Ancillary Studies
Viral Infections
125
Fig. 6.2. Co-infection with CMV and P. jirovecii is shown in this BAL
specimen from an immunocompromised patient. Characteristic owl eye
inclusions are seen. Multinucleation is rare in CMV infection, but can
occur (see inset). Pneumocystis infection resulted in the cast of frothy
material; each circlet with a central dot is an organism (Pap stain, intermediate magnification left and high magnification right).
Cytomegalovirus (CMV)
Microbiology
CMV is one of the most common causes of opportunistic infections involving the respiratory tract. In the respiratory tract, CMV
mainly targets pulmonary macrophages, endothelial cells and
fibroblasts, but virtually any cell can be infected by this virus.
126
6. Pulmonary Infections
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Adenovirus
Microbiology
Viral Infections
127
Fig. 6.3. Adenovirus pneumonia. The images on the left are of a smear
prepared from sputum showing an infected cell (circled) with a degenerated
nucleus (top left, Pap stain, intermediate magnification) and a detached ciliary tuft (bottom left, Pap stain, high magnification). The images on the right
are of a BAL from a child with adenovirus pneumonia showing a smudgy
appearing nucleus of an infected cell (top right, Pap stain, cytospin, high
magnification) with positive immunocytochemistry confirming this is due
to adenovirus infection (bottom right, high magnification) (BAL images
courtesy of Dr.S. Ranganathan, Pittsburgh Childrens Hospital, USA).
Clinical Features
Cytomorphologic Features
128
6. Pulmonary Infections
Another finding is the presence of decapitated ciliated respiratory epithelial cells, so-called ciliocytophthoria.
There may be an associated neutrophilic pneumonia, marked
hemorrhage, or evidence of necrosis.
Differential Diagnosis
Ancillary Studies
Clinical Features
Viral Infections
129
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Parainfluenza
Microbiology
Clinical Features
Cytomorphologic Features
130
6. Pulmonary Infections
Differential Diagnosis
Ancillary Studies
Measles
Microbiology
Measles (also known as rubeola) is an infection of the respiratory system caused by the RNA rubeola virus of the genus
Morbillivirus.
Measles pneumonia is a rare and serious complication of the viral
exanthem, especially in immunocompromised patients.
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Bacterial Infections
131
Ancillary Studies
Bacterial Infections
Bacterial pneumonia may be lobar, lobular, or present in an atypical manner (e.g., mass-like or interstitial appearance). Grampositive and negative-bacteria are a common cause of pulmonary
132
6. Pulmonary Infections
infection. Most bacteria cause a nonspecific acute necroinflammatory reaction associated with a variable fibrohistiocytic response
(organization). Necrotizing pyogenic infections may result in
abscess formation. Mycobacteria may evoke a granulomatous
process. The etiology of infectious pneumonia is best established
by correlating clinical and radiologic findings with microbiology
studies.
Actinomyces
Microbiology
Clinical Features
Cytomorphologic Features
Bacterial Infections
133
Ancillary Studies
Nocardia
Microbiology
Clinical Features
Patients commonly present with slowly progressive pneumonia. In immuncompromised patients, infection may be associated with cavitary lung nodules. Infection can also spread to the
pleura or to chest wall.
134
6. Pulmonary Infections
Fig. 6.5. FNA of Nocardia pneumonia with numerous PMNs and necrotic
material (left image Pap stain, high magnification) associated with thin
filamentous branching bacteria (middle image Gram stain and right image
AFB stain, both high magnification).
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Bacterial Infections
135
Tuberculosis
Microbiology
Pulmonary tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis. Pulmonary TB may be due to primary
or reactivation (chronic) infection. Pulmonary manifestations of
TB include bronchopneumonia, caseating pneumonia, nodular
disease (tuberculoma), tracheobronchitis, milliary disease, hilar
lymphadenopathy, and pleural disease.
Individuals at risk for infection are those who are immunosuppressed, the elderly, and infants.
Nontuberculous mycobacteria (NTM), such as Mycobacterium
avium complex (MAC) and Mycobacterium kansasii, may also
cause pulmonary infections.
Infections are often associated with granulomatous inflammation.
In NTM infection, particularly in immunocompromised patients,
granulomas tend to be nonnecrotizing and incompletely formed.
Clinical Features
Cytomorphologic Features
Bacterial Infections
137
Differential Diagnosis
Ancillary Studies
Acid-fast stains (Ziehl-Neelsen or Kinyoun stains). The diagnosis of mycobacterial infection can be on the basis of the
identification of microorganisms with acid-fast (AFB) stains.
Mycobacteria with M. tuberculosis compared to NTM may be
rare and require careful and lengthy scrutiny of slides. Some
mycobacteria have a distinct morphology; for example M. kansasii
resembles a shepherds crook or candy cane and Mycobacterium
fortuitum closely resembles Nocardia spp.
Mycobacteria may be weakly Gram-positive and will stain with
GMS.
Fluorescence microscopy with fluorochrome dyes such as
auramine O or auraminerhodamine are more sensitive and
specific than AFB stains.
Autofluorescence.
PCR for diagnosis and subclassification (can be done on cell
block material).
Culture for diagnosis and subclassification, although mycobacteria are slow growing and culture can take weeks (68 weeks
with conventional Lowenstein-Jensen medium and 3 weeks with
Middlebrook liquid and solid media).
Legionella
138
6. Pulmonary Infections
Fungal Infections
Pulmonary fungal infections can be readily diagnosed by means
of exfoliative cytology or FNA. Infections are often associated
with a granulomatous or necroinflammatory reaction. Fungal morphology varies with the stage of the disease and fungal organism.
Table 6.2 summarizes the cytologic features of common fungal
pathogens that infect the respiratory tract.
Candidiasis
Microbiology
Morphology
Pseudohyphae (elongated yeasts joined together)
Narrow neck teardrop shaped budding yeast (210mm)
Narrow neck budding yeast (35mm)
Broad neck budding yeast with a thick cell wall (515mm)
Yeast with thick capsules (520mm)
Thick walled spherules (1080mm) filled with endospores
(25mm)
Regular septate hyphae with 45 branching (36mm wide)
Fruiting bodies (conidiophores)
Ribbon-like, nonseptate hyphae with 90 branching
(650mm wide)
Fungal Infections
139
Infection of the airways (laryngeal candidiasis and tracheobronchitis) may present with a sore throat, hoarseness, fever, productive cough, and possibly dyspnea. Candida pneumonia is usually
associated with disseminated candidiasis. The most common
form of infection is multiple lung abscesses.
Cytomorphologic Features
Specimens containing candida elements may contain pseudohyphae (elongated yeast joined together), true hyphae, and/or
budding yeast (blastoconidia) with/without background inflammatory cells (Fig.6.8).
140
6. Pulmonary Infections
Differential Diagnosis
Ancillary Studies
Histoplasmosis
Microbiology
Clinical Features
Pulmonary histoplasmosis can present clinically with pneumonia, lung nodule, cavitary lung disease, mediastinal or hilar
lymphadenopathy, and even superior vena cava syndrome or
obstruction of other mediastinal structures.
It is not uncommon for localized infections to mimic cancer.
Cytomorphologic Features
Differential Diagnosis
Candida
Cryptococcus neoformans (microform)
Fungal Infections
141
Blastomyces dermatitidis
P. jiroveci
Microcalcifications (especially in the cell block)
Platelets (extracellular only)
Ancillary Studies
142
6. Pulmonary Infections
Blastomycosis
Microbiology
Clinical Features
Cytomorphologic Features
One finds round large yeast (515 mm) that have a characteristic double contoured thick cell wall, and show broad-base
budding.
There is often associated granulomatous inflammation present.
Differential Diagnosis
Ancillary Studies
Cryptococcosis
Microbiology
Humans are infected with cryptococcus by inhaling basidiospores or yeast. The important human pathogens are Cryptococcus neoformans and Cryptococcus gattii.
Fungal Infections
143
Clinical Features
Cytomorphologic Features
Round to oval yeasts measuring 520mm are seen with narrowbased buds.
Yeasts are surrounded by thick capsules that are positive with mucicarmine, alcian blue, and colloidal iron stains (Figs.6.10 and 6.11).
Differential Diagnosis
Ancillary Studies
Coccidioidomycosis
Microbiology
C. immitis infection typically causes a necrotizing granulomatous inflammation. The major pulmonary manifestations include
144
6. Pulmonary Infections
Fig. 6.10. Cryptococcus pneumonia. Yeasts are round to oval and have
narrow-based buds (Pap stain left image, high magnification). Yeasts may
resemble pneumocystis cysts, but tend to be more variable and often larger
in size (left inset, DQ stain, high magnification). Encapsulated cryptococcal organisms are surrounded by a thick capsule that stains with GMS (top
right), PAS (middle right), and mucicarmine (bottom right) stains (high
magnification).
pulmonary nodules, cavities, diffuse reticulonodular pneumonia, and rarely pleural disease.
Fungemia can also produce multiple septic pulmonary emboli,
especially in patients with immune deficiency.
Clinical Features
Most people are asymptomatic following initial respiratory exposure to arthroconidia. Those who become ill typically develop respiratory symptoms, such as cough, pleurisy, fever, and weight loss.
Cytomorphologic Features
Fungal Infections
145
Differential Diagnosis
146
6. Pulmonary Infections
Ancillary Studies
Fungal Infections
147
Aspergillosis
Microbiology
Clinical Features
Cytomorphologic Features
148
6. Pulmonary Infections
Differential Diagnosis
Ancillary Studies
Fungal Infections
149
Mucormycosis (Zygomycosis)
Microbiology
150
6. Pulmonary Infections
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Pneumocystis
Microbiology
Fungal Infections
151
Clinical Features
Cytomorphologic Features
Differential Diagnosis
152
6. Pulmonary Infections
Ancillary Studies
Parasitic Infections
153
Parasitic Infections
Parasites are rare in most developed countries, but may be endemic
in other parts of the world. Pulmonary involvement often occurs
because the lungs represent a site of infection during the life cycle
of some parasites. Infection is often associated with eosinophilia
inthe blood and pulmonary tissue. Table6.3 lists parasitic organisms likely to infect the respiratory tract.
Dirofilariasis
154
6. Pulmonary Infections
Strongyloidiasis
Strongyloides stercoralis involves the respiratory tract via hematogenous spread of the infective form (filariform larvae), especially in those who are immunosuppressed.
Sputum, tracheal aspirates, and BAL samples are all useful for
establishing the diagnosis.
Filariform larvae are large (400500 mm), and possess notched
tails and a short buccal cavity. They need to be distinguished
from the larval forms of Ascaris lumbricoides and hookworms
(Fig.6.16).
Paragonimiasis
Parasitic Infections
155
Fig. 6.17. Paragonimus eggs identified in this FNA cell block from a lung
nodule. The eggs have a thick, double contour shell (H&E stain, low and
high magnification, left and right respectively).
Toxoplasma gondii
156
6. Pulmonary Infections
Entamoeba
Parasitic Infections
157
158
6. Pulmonary Infections
Fig. 6.20. Echinococcosis (hydatid disease of the lung). This lung FNA
from a 38-year-old woman yielded 20 mL of clear fluid that contained
numerous intact protoscoleces containing radially arranged hooklets
shown with a DQ stain (left, intermediate magnification) and Pap stain
(upper right, intermediate magnification). Detached hooklets resembling
sharks teeth are also seen (DQ stain, lower right, high magnification)
(images courtesy of Dr. Pawel Schubert, South Africa).
Parasitic Infections
159
Pleural (parapneumonic) effusion occurs in 2040% of hospitalized patients with bacterial pneumonia, and has three stages: exudative (early culture negative), fibrinopurulent (infected), and pleural
rind stage. Empyema is defined as pus in the pleural space.
Pleural infection can also occur following trauma, surgery,
esophageal rupture, or as a result of direct extension (from the
lung or subdiaphragmatic disease).
Infectious causes of pleural disease include bacteria (e.g., Streptococcus, H. influenza, anaerobes, actinomycosis, Legionella),
mycobacteria, fungi (Candida, Pneumocystis), and parasites
(E.histolytica).
A predominance of neutrophils indicates an acute infection,
while many mononuclear inflammatory cells usually indicate a
more indolent process (e.g., TB or fungal infection).
Pleural fluid eosinophilia (>10%) may be caused by infection
(fungal, parasitic) and noninfectious causes (e.g., air, blood, drugs).
Suggested Reading
Lemos LB, Baliga M, Taylor BD, Cason ZJ, Lucia HL. Bronchoalveolar lavage for diagnosis of fungal disease. Five years experience in a
southern United States rural area with many blastomycosis cases. Acta
Cytol. 1995;39:110111.
Moriarty AT, Darragh TM, Fatheree LA, Souers R, Wilbur DC. Performance of Candida fungal-induced atypia and proficiency testing: observations from the College of American Pathologists proficiency testing
program. Arch Pathol Lab Med. 2009;133:12725.
Naimey GL, Wuerker RB. Comparison of histologic stains in the diagnosis
of Pneumocystis carinii. Acta Cytol. 1995;39:11247.
Pisani RJ, Wright AJ. Clinical utility of bronchoalveolar lavage in immunocompromised hosts. Mayo Clin Proc. 1992;67:2217.
Raab SS, Cheville JC, Bottles K, Cohen MB. Utility of Gomori methenamine silver stains in bronchoalveolar lavage specimens. Mod Pathol.
1994;7:599604.
Saad RS, Silverman JF. Respiratory cytology: differential diagnosis and
pitfalls. Diagn Cytopathol. 2010;38:297307.
Sheehan MM, Coker R, Coleman DV. Detection of cytomegalovirus
(CMV) in HIV+ patients: comparison of cytomorphology, immunocytochemistry and in situ hybridization. Cytopathology. 1998;9:2937.
Gastrointestinal and
Hepatobiliary Infections
Robert M. Najarian and Helen H. Wang
Department of Pathology, Beth Israel Deaconess Medical Center/Harvard
Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
Gastrointestinal Infections
Fungal Esophagitis
Fungal esophagitis in both immunocompetent and immunocompromised patients results mainly from infection by Candida spp.
More rare forms of fungal esophagitis in immunocompromised
patients include those caused by dimorphic fungi, Aspergillus
spp., and the zygomycetes.
Infection typically presents in the mid to lower esophagus with
symptoms of dysphagia or odynophagia. However, patients can
be asymptomatic, especially those who are immunocompetent.
161
162
Cytomorphologic Features
Differential Diagnosis
Squamous epithelial reactive changes and an associated neutrophilic infiltrate can mimic those seen in viral esophagitis or
ulcers due to direct chemical injuries to the mucosa.
Flattened, desquamated anucleate squames, or ingested food can
approximate the appearance of fungal pseudohyphae, but can be
definitively ruled out by lack of staining of these elements with
a PAS plus diastase stain.
Oral flora in coccoid forms can be mistaken for yeast forms;
however, no budding will be demonstrated and deployment of
the brushing device in the tubular esophagus below the level of
the oral cavity should eliminate the risk of such bacterial contamination.
Filamentous (leptothrix-type) organisms may be associated with
esophageal malignancies. These may resemble actinomyces
clumps.
Ancillary Studies
Gastrointestinal Infections
163
Fig. 7.1. (Left) Brushing preparation of Candida esophagitis with bluestaining pseudohyphae and purple-staining budding yeast forms (Pap
stain, high magnification). Rare inflammatory cells are seen in the background. (Right upper) Candida esophagitis is shown in association with
reactive squamous cells (Pap stain, high magnification). (Bottom right)
Superficial esophageal mucosal biopsy showing colonization by Candida
(GMS stain, high magnification).
Fungal culture, while not time efficient for diagnosis, can help to
guide antimicrobial therapy and to identify species with resistance to standard antifungal agents.
HSV infection occurs in both immunocompromised and immunocompetent individuals, presenting clinically with acute onset
of odynophagia, fever, and atypical chest pain.
In most cases, active infection represents reactivation of latent
infection in immunocompetent individuals.
Endoscopically there may be discrete, punched-out ulcers with
an exudative base and erythematous margins. The edge of the
164
Cytomorphologic Features
Gastrointestinal Infections
165
Differential Diagnosis
Ancillary Studies
Cytomegalovirus
Cytomorphologic Features
166
single, eosinophilic, intranuclear inclusion, often with a circumferential clear halo surrounding it.
Infected cells of mesenchymal origin can also demonstrate
intracytoplasmic, basophilic granules.
Focal necrotic debris, scattered neutrophils, fibrinopurulent
exudate, and reactive squamous cells or glandular cells are often
seen in the background.
Differential Diagnosis
Gastrointestinal Infections
167
Ancillary Studies
Cytomorphologic Features
168
Differential Diagnosis
Infection with other related spiral-shaped bacteria, such as Helicobacter heilmanii can be excluded based upon morphology
alone, in that the latter bacterium is both larger in size (up to
7.5mm) and more tightly coiled.
Debris caught in the superficial gastric mucin layer can often
cause diagnostic difficulty. This can be definitively resolved
with ancillary studies.
Contamination of slides with oral flora or environmental bacteria, some of which may stain using nonspecific ancillary
methods noted below, are chiefly excluded by the presence of a
polymorphous bacterial population.
Ancillary Studies
Special stains that increase the sensitivity of Helicobacter detection such as the silver-based Steiner, Warthin-Starry, Diff-Quik,
Gastrointestinal Infections
169
Cryptosporidiosis
This gastrointestinal infection, caused by the intracellular protozoal parasite Cryptosporidium parvum, is most frequently
acquired through the ingestion of contaminated water or by
fecaloral route.
While seen as a rare, self-limited infection in immunocompetent individuals, systemic infection in those who are immunocompromised, especially patients with AIDS, may involve
the entire length of the gastrointestinal tract, including the
gallbladder.
Clinically, immunocompetent patients present with a short duration of diarrheal illness including abdominal cramps and mild
malabsorption. Those with impaired immune function may have
a protracted course with severe weight loss, cholera-like watery
diarrhea, and frequent rates of relapse (Fig.7.5).
Cytomorphologic Features
Specimens obtained via stool sampling or endoscopic brushings/mucosal biopsies demonstrate spherical organisms measuring 25mm that irregularly protrude from the apical aspect of
the surface epithelium. The microorganisms appear to be adherent to the epithelial cells.
Background inflammation is typically not present, but may be
seen in the setting of intense infections.
170
Differential Diagnosis
Gastrointestinal Infections
171
Ancillary Studies
Giardiasis
This is the most commonly diagnosed intestinal parasitic infection in both the United States and worldwide.
Infection caused by the extracellular protozoal parasite Giardia lamblia (Giardia intestinalis) is most frequently acquired
through the ingestion of contaminated water, typically untreated
water from springs or lakes or via the fecaloral route in child
care settings.
In the acute phase, a self-limited, but severe diarrheal illness can
result in volume depletion while chronic infection can result in a
severe malabsorptive state with iron and folate deficiency.
Commonly associated symptoms include abdominal pain, cramping, nausea, and vomiting with acute illness and weight loss,
malabsorption, and malnutrition in chronic illness (Fig.7.6).
Cytomorphologic Features
Differential Diagnosis
172
Ancillary Studies
Stool examination for ova and parasites, while reasonably sensitive for organism detection in the setting of active infection,
often requires multiple samples to achieve high levels of diagnostic sensitivity.
Fecal antigen detection and stool PCR tests are available for
sensitive and specific organism detection.
An immunostain for c-kit (CD117) can be used to highlight trophozoites and distinguish them from extracellular debris.
Microsporidiosis
Gastrointestinal Infections
173
Fig. 7.7. (Left and top right) Brushing from the biliary epithelium demonstrates glandular epithelial cells with an intracellular cluster (arrow) of
numerous round spores with a purple color on Papanicolaou stain. Nearby
epithelial cells display a mild increase in nuclear to cytoplasmic ratio and
prominent nucleoli (Pap stain, high magnification). (Bottom right) Microsporidia spores within an intestinal epithelial cell (arrow) are readily visible
with a Brown-Brenn Gram stain (high magnification).
Microsporidia include the obligate intracellular parasites Enterocytozoon bieneusi and Encephalitozoon intestinalis.
Despite clinical symptoms of watery diarrhea that are mild
relative to other opportunistic organisms, the propensity for
systemic dissemination is great with biliary tract, colonic, respiratory tract and pancreatic infection.
Mild infection presents with a normal endoscopic appearance,
while severe cases can have extensive ulcers (Fig.7.7).
Cytomorphologic Features
174
Differential Diagnosis
Supranuclear mucin vacuoles of oval shape can mimic microsporidia organisms. Problematic cases can be stained with mucicarmine to demonstrate intracytoplasmic mucin.
Ancillary Studies
Acid fast, silver-based, Gram, and PAS stains can all help with
organism detection, as its small size and intracellular location
can easily lead to a false negative diagnosis.
Ultrastructural examination is useful in cases in which a particular species of organism must be isolated or for confirmation of
light microscopic findings.
Extrapulmonary disseminated infection due to atypical mycobacteria occurs almost exclusively in the HIV/AIDS population,
especially those with very low CD4 cell counts. Involvement of
the gastrointestinal tract is nearly twice as common as pulmonary involvement.
Infection is mainly due to the Mycobacterium avium complex or
MAC (also called Mycobacterium avium intracellulare or MAI).
The entire tubular gastrointestinal tract may be involved in such
infections, with the small intestine being the site of most pronounced disease.
Clinical symptoms and signs are nonspecific with nausea,
chronic diarrhea, abdominal pain, and malabsorption being
most commonly reported (Fig.7.8).
Cytomorphologic Features
Specimens obtained via brushings or mucosal biopsies demonstrate organisms with a characteristic beaded rod shape
measuring 46mm in length contained either within foamy histiocytes or seen lying free in the background.
Gastrointestinal Infections
175
Fig. 7.8. Duodenal brushing specimen demonstrating infected macrophages with copious foamy cytoplasm (due to negative images of mycobacterial organisms within the cytoplasm of macrophages). Note the many free
scattered unstained mycobacteria in the background (Diff-Quik stain, high
magnification). The bottom right inset shows a macrophage stained with an
acid fast stain that demonstrates the mycobacteria (high magnification).
Differential Diagnosis
Whipples disease and histoplasmosis are diagnostic considerations, which are both Periodic acid Schiff stain positive, but acid
fast negative.
Ancillary Studies
176
PCR analysis.
Mycobacterial culture is both sensitive and specific for organism detection, but requires weeks to months to achieve adequate
organism growth.
The incidence of anal intraepithelial neoplasia (AIN) and invasive anal cancer is increasing, especially in the HIV population.
Anal Pap tests have been utilized in the HIV population for the
evaluation of HPV-related disease of the anus. The sensitivity
(4298%) and specificity (1696%) of the anal Pap test for the
detection of squamous intraepithelial lesions (SIL) are quite variable.
It is recommended that analrectal cytologic findings be reported
according to the criteria and terminology of the Bethesda System
(2001) used for reporting cervical cytology.
Cellular elements that may be encountered in an anal Pap test
include:
Squamous cells, anucleate squames, and anal transformation
zone components (metaplastic cells and/or rectal glandular
cells).
HPV-related diseases include SIL and squamous cell carcinoma. SIL tend to, but not always, exhibit prominent keratinization.
Contamination with bacteria and fecal material, which may
obscure cells, making the specimen unsatisfactory for evaluation.
Less commonly, infectious organisms other than HPV can
be detected such as Candida spp., herpes simplex virus,
trichomonas, and other parasites including ova and worms
(Fig.7.9).
Intra-Abdominal Infections
Liver Abscess
Intra-Abdominal Infections
177
Fig. 7.9. Anal Pap test showing an incidental finding (arrow) of a pathogenic ameba (higher magnification shown in the upper left inset) containing phagocytosed erythrocytes (Pap stain, high magnification) (image
courtesy of Christine Panetti CT (ASCP), Baystate Medical Center,
Springfield, MA, USA).
178
Pancreatitis
Pancreatitis (usually acute) may be caused by a variety of infections including viruses (e.g., mumps, HSV, HIV), bacteria (e.g.,
mycoplasma, salmonella), fungi (e.g., Aspergillus), and parasites
(e.g., Toxoplasma, cryptosporidium, Ascaris). FNA is typically
not performed in patients with acute pancreatitis, but if performed
will show numerous neutrophils with fat necrosis, epithelial cells
with inflammatory atypia, and a dirty background.
Microorganisms may be detected in cytology material or can be
cultured from aspirated material submitted to the microbiology
laboratory.
As pancreatitis may occur secondary to obstruction from a
neoplasm, a careful search for associated neoplastic cells is
important.
Hydatid Disease
Intra-Abdominal Infections
179
Cytomorphologic Features
180
Fig. 7.11. Fine needle aspirate of hydatid cyst fluid demonstrates a protoscolex with radial array of hooklets with a (left) Papanicolaou stain and
(top right) Diff-Quik stain (high magnification). (Lower right) Hydatid
cyst fluid is shown to contain only scattered hooklets without an associated protoscolex. Note their characteristic scimitar shape (Diff-Quik stain,
high magnification) (image courtesy of Thomas Buck, M.D., Beth Israel
Deaconess Medical Center, Boston, MA).
Differential Diagnosis
Intra-Abdominal Infections
181
Surgical excision with extensive sampling of tissue for histopathology is often required to demonstrate these components.
Ancillary Studies
182
Suggested Reading
Bean SM, Chhieng DC. Anal-rectal cytology: a review. Diagn Cytopathol.
2010;38:53846.
Huppmann AR, Orenstein JM. Opportunistic disorders of the gastrointestinal tract in the age of highly active antiretroviral therapy. Hum Pathol.
2010;41:177787.
Kotler DP, Giang TT, Garro ML, Orenstein JM. Light microscopic diagnosis of microsporidiosis in patients with AIDS. Am J Gastroenterol.
1994;89:5404.
Marshall JB, Kelley DH, Vogele KA. Giardiasis: diagnosis by endoscopic
brush biopsy of the duodenum. Am J Gastroenterol. 1984;79:5179.
Muir SW, Murray J, Farquharson MA, Wheatley DJ, MCPhaden AR.
Detection of cytomegalovirus in upper gastrointestinal biopsies from
heart transplant recipients: comparison of light microscopy, immunocytochemistry, in situ hybridization, and nested PCR. J Clin Pathol.
1998;51:80711.
Ramanathan J, Rammouni M, Baran J, Khatib R. Herpes simplex esophagitis in the immunocompetent host: an overview. Am J Gastroenterol.
2000;95:21716.
Senturk O, Canturk Z, Ercin C, etal. Comparison of five detection methods
for Helicobacter pylori. Acta Cytol. 2000;44:10104.
Kidney Infections
In general, the morphologic characteristics of infectious agents
that affect the kidney are similar to those present in other organs.
Acute Pyelonephritis
183
184
Infections in diabetic patients may be due to Klebsiella, Enterobacter, Clostridium, Candida and are rarely of viral etiology.
Risk factors include abnormal kidneys (e.g., polycystic or horseshoe kidney), vesicoureteric reflux, foreign body, instrumentation, and immunosuppression.
Infected kidneys are infiltrated with neutrophils and may result
in abscess formation, ischemic necrosis, and cystic change.
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Chronic Pyelonephritis
Kidney Infections
185
Cytomorphologic Features
Cytomorphologic Features
186
Differential Diagnosis
Kidney Infections
187
Ancillary Studies
Renal Tuberculosis
Cytomorphologic Features
Differential Diagnosis
188
XPN
Malakoplakia
Malignancy that mimics granulomas (e.g., renal cell carcinoma)
Ancillary Studies
Cytomorphologic Features
Urine usually shows nonspecific findings (e.g., neutrophils, reactive urothelial cells, RBCs). Necrotizing granulomatous inflammation is more likely to be observed in renal pelvic washings.
FNA of a fungal mass will show necrotizing granulomatous
inflammation.
Fungi including fungal casts may be seen. Depending on the
type of fungal infection specimens may include budding yeast
(e.g., narrow-based budding of Cryptococcus vs. broad-based
budding yeast diagnostic of balstomycosis), pseudohyphae
(Candida spp.), or true hyphae. Fungal organisms may be intracellular within macrophages.
Differential Diagnosis
189
Ancillary Studies
Bacterial cystitis is commonly caused by Gram-negative bacteria (E. coli, Klebsiella, Enterobacter, Serratia, Pseudomonas,
P. mirabilis) and is infrequently due to Gram-positive bacteria
(Staphylococcus aureus, Staphylococcus saprophyticus, and
Enterococci).
Infection occurs from ascending bacterial infection via the distal
urethra, and mostly affects women of reproductive age. Patients
with structural bladder abnormalities and systemic disease such
as diabetes are more susceptible to infection.
Symptoms include increased frequency, urgency, dysuria, hematuria, and suprapubic pain.
Infection typically presents with prominent acute inflammation
in the urine, and sometimes with chronic inflammatory cells in
more long-standing infections.
Cytomorphologic Features
190
Fig. 8.2. Acute bacterial cystitis. The urine specimen shows a predominance of neutrophils with bacteria and occasional red blood cells. There
were very few urothelial cells present in this case (left and upper right
images: Pap stain, ThinPrep, high magnification; bottom right image:
H&E stain, cell block, high magnification).
Differential Diagnosis
Ancillary Studies
Malakoplakia
Viral Infections
191
Fig. 8.3. (Top left image) Bacteria in urine exposed to excreted antibiotics
may assume unusual forms, such as these elongated Pseudomonas bacteria identified in this treated patient (Pap stain, high magnification). Variable numbers of bacteria in urine may be encountered (bottom left image)
due to fecal contamination or (right image) in degenerated ileal conduit
samples without associated acute inflammation (Pap stain, intermediate
magnification).
Viral Infections
Viruses are a rare cause of cystitis, but may be seen in immunosuppressed patients. Immunocytochemistry can be used for
confirmation.
192
Fig. 8.4. Follicular cystitis. This voided urine specimen shows a predominance of lymphocytes associated with bacteria (left image; Pap stain,
intermediate magnification; upper right image; high magnification, Pap
stain; lower right image, H&E stain on cell block).
Viral Infections
193
BK Polyomavirus
Microbiology
194
Fig. 8.6. HPV-related koilocytes are shown in this voided urine specimen
from a 31-year old male. He had a history of known anal condylomas (Pap
stain, high magnification).
Clinical Features
Viral Infections
195
Fig. 8.7. Decoy cells are shown with viral changes in the (top left) inclusion and (top right) postinclusion stages of BK polyomavirus infection
(Pap stain, high magnification). (Bottom left) A comet cell is shown with
an eccentrically placed glassy appearing nucleus (Pap stain, high magnification). Cells infected with polyomavirus are shown to exhibit nuclear
immunoreactivity with a BK virus immunocytochemical stain (high
magnification).
Cytomorphologic Features
The detection of decoy cells is easily identified (and even quantifiable) in routine Papanicolaou stained urine cytology specimens.
196
Fig. 8.8. Polyoma virus infection in voided urine from a renal transplant patient. Two types of inclusions in decoy cells can be appreciated
including cells with large homogenous, basophilic, glassy intranuclear
inclusions and those with vesicular nuclei containing clearing of their
chromatin. Note that these cells have no nuclear contour irregularity, an
important distinction from cells of high-grade urothelial carcinoma (Pap
stain, high magnification).
Fungal Infections
197
Differential Diagnosis
Ancillary Studies
Fungal Infections
Microbiology
198
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Parasites
199
Fig. 8.9. Acute candida cystitis. This voided urine specimen shows many
acute inflammatory cells and fungal microorganisms. The fungal organisms include budding yeasts and pseudohyphal forms characteristic of
Candida spp. (left and upper right images: Pap stain, high magnification;
bottom right image: H&E cell block, high magnification). The specimen
contains atypical urothelial cells attributed to reactive changes associated
with this fungal infection (left upper inset: Pap stain, high magnification).
Parasites
Schistosomiasis
Microbiology
Schistosomiasis (also known as bilharzia) is caused by trematodes (flukes) of the genus Schistosoma. Schistosoma hematobium causes urinary schistosomiasis.
200
Fig. 8.10. Bladder schistosomiasis. The images show the ova of Schistosoma hematobium recognized by their terminal spine (DQ left, Pap stain
right, high magnification).
Clinical Features
Cytomorphologic Features
Parasites
201
Differential Diagnosis
Ancillary Studies
Microbiology consultation
Serum antibody detection
Tissue biopsy
Trichomoniasis
202
Infections of the penis may be localized (e.g., condyloma accuminatum) or widespread (e.g., Fournier gangrene). Cytologic
diagnoses of these infections may be obtained by Tzanck preparation of ulcers, characteristic cells or organisms contaminating
urine samples, or FNA of lesions.
Epididymitis is the most common source of intrascrotal infection,
and may extend to involve the testis. Infection of the testes may
be due to viruses (e.g., mumps), bacteria (including syphilis),
malakoplakia, mycobacteria (TB orchitis and leprosy), or fungi
(Candida, Blastomyces, Aspergillus, Histoplasma capsulatum,
Trichophyton mentagrophytes, and Coccidioides immitis).
203
In general, acute bacterial infections show suppurative inflammation, whereas the cytomorphology of viral, mycobacterial,
and fungal infections as well as malakoplakia is similar to that
seen in other sites.
Urethritis
Suggested Reading
Cimbaluk D, Pitelka L, Kluskens L, Gattuso P. Update on human polyomavirus BK nephropathy. Diagn Cytopathol. 2009;37:7739.
Gupta M, Venkatesh SK, Kumar A, Pandey R. Fine-needle aspiration cytology of bilateral renal malakoplakia. Diagn Cytopathol.
2004;31:1167.
Kumar N, Jain S. Aspiration cytology of focal xanthogranulomatous pyelonephritis: a diagnostic challenge. Diagn Cytopathol. 2004;30:1114.
Pantanowitz L, Cao QJ, Goulart RA, Otis CN. Diagnostic utility of p16
immunocytochemistry for Trichomonas in urine cytology. Cytojournal.
2005;2:11.
Waugh MS, Perfect JR, Dash RC. Schistosoma haematobium in urine:
morphology with ThinPrep method. Diagn Cytopathol. 2007;35:64950.
205
206
207
Cloudy
Clear to cloudy
Clear to cloudy
Clear to cloudy
Clear to cloudy
Clear to cloudy
Clear to pink-red to
xanthochromic (yellow-orange)
Clear to cloudy, pink-red or
xanthochromic if associated
with hemorrhage
Normal
Bacterial meningitis
Viral meningitis
Fungal meningitis
Tuberculous meningitis
Neurosyphilis
Parasitic meningitis
Intracranial hemorrhage
Neoplastic
Color
Condition
Normal to low
Normal to low
Low or normal
Normal
Low
Normal
Low
5080mg/dL
Glucose
Normal
to increased
High
High
High
High
High
to very high
High
High
2045mg/dL
Protein
Leukocytes
208
9. Central Nervous System Infections
209
210
Fig. 9.1. Acute bacterial meningitis. The cytospin shows marked neutrophils
(PMNs) and cellular debris. Some lymphocytes and monocytes are also
present (Diff-Quik stain, intermediate magnification, left and high magnification right). The Gram stain (inset) shows intracellular Gram negative bacilli
(high magnification).
Clinical Features
The classic clinical trial of acute meningitis is fever, meningismus (stiff neck resistant to flexion), and a change in mental
status.
Cytomorphologic Features
211
Fig. 9.2. This cerebrospinal fluid (CSF) is from a 73 year old male with
no prior history of malignancy. His CSF specimen shows numerous neutrophils with very rare large atypical cells (see circle, right) suspicious for
carcinoma (Diff-Quik stain; low magnification, left; and high magnification, right). On follow up of this case, the patient was found to have a large
neuroendocrine carcinoma of the colon.
Differential Diagnosis
212
Ancillary Studies
Gram stain
High protein levels in CSF
Low CSF glucose level (less than 50% of the serum level)
Microbiology bacterial culture (aerobic and anaerobic)
Bacterial antigens in CSF offer rapid testing
Molecular testing: PCR assays for specific organisms; amplification of 16S rRNA gene; and ribosomal DNA assay
Viral Meningitis
Microbiology
Clinical Features
Cytomorphologic Features
Viral Meningitis
213
Fig. 9.3. This CSF is from a patient with viral meningitis showing marked
lymphocytosis. The CSF specimen shows numerous mature lymphocytes.
The microbiology cultures were negative (Diff-Quik stain, low magnification left, and high magnification right).
Differential Diagnosis
Ancillary Studies
214
Mollaret Meningitis
Microbiology
Mollaret Meningitis
215
Fig. 9.5. CSF from a 31 year old female with chronic Mollaret meningitis.
The specimen shows marked monocytosis present in a background of
scant mature lymphocytes. Monocytes exhibit a variety of nuclear morphologies (see circles) including bean shaped and bilobed nuclei, as well
as cells with nuclear clefting and cerebriform nuclear contours (Diff-Quik
stain, intermediate magnification, left; and high magnification, right).
Clinical Features
Cytomorphologic Features
216
Differential Diagnosis
Ancillary Studies
PCR assays for viral agents such as HSV-2 or West Nile virus
(not all cases test positive)
Tuberculous Meningitis
Microbiology
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Bacterial meningitis
Fungal meningitis
Lyme disease
Brain abscess
Cryptococcal Meningitis
217
Ancillary Studies
Cryptococcal Meningitis
Microbiology
Meningitis occurs following CNS infection by the fungus Cryptococcus neoformans, and less of C. gattii.
Cryptococcus is the most common mycosis of the CNS.
218
Clinical Features
Cytomorphologic Features
Blastomycosis
219
Differential Diagnosis
Ancillary Studies
Blastomycosis
Microbiology
Clinical Features
220
Fig. 9.8. Blastomycosis. The radiology image (upper left) from a 52-year-old
man shows a large posterior cerebellar brain mass due to blastomycosis infection destroying the skull bone. The Pap stained imprint cytology
specimen shows numerous large budding yeasts (right image), with broad
based buds (middle left). A GMS stain is positive (bottom left). A brain
biopsy confirmed blastomycosis infection. All images are shown with
high magnification (images courtesy of Dr. Pawel Schubert, University of
Stellenbosch, Cape Town, South Africa).
Cytomorphologic Features
Differential Diagnosis
Brain Abscess
221
Ancillary Studies
Brain Abscess
Microbiology
Clinical Features
Patients may experience symptoms related to increased intracranial pressure (e.g., headache, vomiting, confusion, coma), infection (e.g., fever) and focal tissue damage (e.g., palsy).
An untreated brain abscess may cause cerebral herniation or
rupture into the ventricles, causing severe fatal meningitis.
Cytomorphologic Features
Examination of the CSF shows no abnormalities or may be similar to acute bacterial meningitis.
222
Differential Diagnosis
Bacterial meningitis
Tuberculosis meningitis
Fungal infection
Brain tumor with acute inflammation
Leukemia
Ancillary Studies
Shunt Infections
Microbiology
Neurosyphilis
223
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Leukemoid reaction
Brain tumor with inflammation
Ancillary Studies
Neurosyphilis
Microbiology
Clinical Features
224
Fig. 9.9. Neurosyphilis. This CSF specimen from a 48 year old HIV positive male shows numerous lymphocytes and plasma cells (Diff-Quik stain,
Intermediate magnification, left; and high magnification, right). Serological testing supported a diagnosis of neurosyphilis.
Cytomorphologic Features
Differential Diagnosis
Toxoplasmosis
225
Ancillary Studies
Toxoplasmosis
Microbiology
Toxoplasmosis is caused by infection with the obligate intracellular protozoal parasite T. gondii.
Ingested oocysts transform into tachyzoites which localize in
neural and muscle tissue where they subsequently develop into
tissue cyst bradyzoites (Fig.9.10).
Clinical Features
In the CNS, toxoplasmosis may present with meningoencephalitis or with multiple small abscesses.
Toxoplasmosis infection is more common in immunosuppressed
persons, and is a common opportunistic infection in AIDS
patients. It is the most common cause of a focal brain lesion in
patients with AIDS.
Congenital infection may cause underdevelopment of the cerebrum resulting in microcephaly and mental retardation.
Ocular disease from Toxoplasma infection can result from congenital infection or infection after birth.
Cytomorphologic Features
226
Fig. 9.10. Toxoplasmosis infection. These images are from imprint cytology of a brain biopsy in an HIV+man. (Left) A small oval cyst with
intracellular parasites is shown (arrow) as well as several small scattered
parasites (circles) in the background (Pap stain, high magnification).
(Right) An immunostain confirms the presence of toxoplasmosis (high
magnification).
Differential Diagnosis
Cerebral vasculitis
CNS lymphoma
HIV encephalopathy
HIV dementia
Other (non-HIV) forms of dementia
Cerebrovascular disease
Neurosyphilis
Neurocysticercosis
227
Ancillary Studies
Neurocysticercosis
Microbiology
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Angiostrongyliasis
Schistosomiasis
Other causes of CSF eosinophilic pleocytosis
Ancillary Studies
Serology
228
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Angiostrongyliasis
229
Angiostrongyliasis
Microbiology
Angiostrongyliasis is an infection by a nematode from the Angiostrongylus genus, usually from the lungworm Angiostrongylus
cantonensis acquired after consuming certain molluscs.
Circulating larvae migrate to the meninges where they may
develop into the adult form in the brain and CSF. However, they
soon die and incite an inflammatory reaction.
It is the most common cause of eosiniphilic meningitis.
Clinical Features
Cytomorphologic Features
Differential Diagnosis
Neurocysticercosis
Other roundworm infections that present with eosinophilic meningitis (Gnathostoma spinigerum, Baylisascaris procyonis)
Other causes of CSF eosinophilic pleocytosis
230
Ancillary Studies
Suggested Reading
Brogi E, Cibas ES. Cytologic detection of Toxoplasma gondii tachyzoites
in cerebrospinal fluid. Am J Clin Pathol. 2000;114:9515.
Cajulis RS, Hayden R, Frias-Hidvegi D, Brody BA, Yu GH, Levy R. Role
of cytology in the intraoperative diagnosis of HIV-positive patients
undergoing stereotactic brain biopsy. Acta Cytol. 1997;41:4816.
Chan TY, Parwani AV, Levi AW, Ali SZ. Mollarets meningitis: cytopathologic analysis of fourteen cases. Diagn Cytopathol. 2003;28:22731.
Garges HP, Moody MA, Cotten CM, Smith PB, Tiffany KF, Lenfestey R,
etal. Neonatal meningitis: what is the correlation among cerebrospinal
fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics. 2006;117:1094100.
Gupta PK, Gupta PC, Roy S, Banerji AK. Herpes simplex encephalitis,
cerebrospinal fluid cytology studies. Two case reports. Acta Cytol.
1972;16:5635.
Silverman JF. Cytopathology of fine-needle aspiration biopsy of the brain
and spinal cord. Diagn Cytopathol. 1986;2:3129.
Teot LA, Sexton CW. Mollarets meningitis: case report with immunocytochemical and polymerase chain reaction amplification studies. Diagn
Cytopathol. 1996;15:3458.
van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired
bacterial meningitis in adults. N Engl J Med. 2006;354:4453.
Verstrepen WA, Bruynseels P, Mertens AH. Evaluation of a rapid realtime RT-PCR assay for detection of enterovirus RNA in cerebrospinal
fluid specimens. J Clin Virol. 2002;25 Suppl 1:S3943.
Weller PF, Liu LX. Eosinophilic meningitis. Semin Neurol. 1993;
13:1618.
10
Hematologic Infections
Sara E. Monaco, Walid E. Khalbuss,
and Liron Pantanowitz
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
This form of lymphadenitis is characterized by acute inflammation and possible abscess formation with pus. Typical infectious
causes include pyogenic bacterial organisms (e.g., Staphylococcus, Streptococcus spp., Gram-negative bacilli), less likely
actinomycetes (Actinomyces and Nocardia spp.) and some
fungi (Candida, Aspergillus, Zygomycetes).
231
Noninfectious
etiology
Infectious
etiology
Reactive lymphoid
hyperplasia,
dermatopathic
lymphadenitis,
low-grade lymphoma
Small polymorphous
lymphocytes
Lymphoglandular
bodies
Tingible body
macrophages
Viral, early bacterial,
or early cat scratch
infection
Predominant
cell type
Background
Macrophages
Heterogeneous
lymphocytes
Characteristic
feature
Macrophages
Granulomatous
inflammation
Inflammatory or
necrotic debris
Few
Many epithelioid
or spindle histiocytes
Bacteria, early cat
Tuberculosis,
scratch, tuberculosis,
tuberculoid leprosy,
atypical mycobacteria,
fungi, atypical
actinomyces, fungi, HSV, mycobacteria, cat
pneumocystis
scratch, LGV,
leishmania
Kikuchis, SLE-related
Foreign body,
lymphadenopathy,
sarcoidosis,
infarction
malignancy,
lipogranulomas
Inflammatory debris
Neutrophils
Suppurative
lymphadenitis
Metastatic tumor,
infarction
Mycobacteria,
fungi
Few
Necrotic debris
None
Necrosis
Lymphoma
Atypical monotonous
lymphocytes
Lymphoglandular
bodies
Tingible body
macrophages
EBV (infectious
mononucleosis),
toxoplasmosis
Homogeneous
lymphocytes
232
10. Hematologic Infections
233
Fig. 10.1. Acute suppurative lymphadentitis (Pap stain, high magnification). This lymph node FNA shows numerous neutrophils in a background
of granular inflammatory debris.
Cytomorphologic Features
Differential Diagnosis
Abscess
Cat Scratch disease
Lymphogranuloma venereum
Tularemia
234
Ancillary Studies
This acute self-limited acute necrotizing granulomatous lymphadenitis is caused by infection with the Gram-negative bacillus Bartonella henselae, and less often Bartonella quintana.
Infected patients typically develop regional (localized) lymphadenopathy 13 weeks after a bite or scratch on the nearby
skin from a cat. Low-grade fever can occur in one third of
patients. Rare cases may develop more severe systemic disease
(e.g., hepatosplenomegaly).
Lymphadenopathy has three stages. The initial phase is characterized by florid reactive lymphoid hyperplasia. The second
phase has loose granulomas and single histiocytes. A late phase
(most characteristic) has both acute suppurative and palisading
granulomatous lymphadenitis (Fig.10.2).
Cytomorphologic Features
Differential Diagnosis
235
Tularemia
Lymphogranuloma venereum
Ancillary Studies
236
Lymphogranuloma Venereum
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
237
Granulomatous Lymphadenitis
This type of chronic inflammation within a lymph node is composed of aggregates of epithelioid macrophages (granulomas).
Granulomas can occur as a result of infectious processes (e.g.,
tuberculosis, fungal infection) or noninfectious processes
(e.g., sarcoidosis, foreign body reaction), and with certain
malignancies (Figs.10.3 and 10.4).
Cytomorphologic Features
Granulomas are characterized by clusters of epithelioid macrophages. Reactive histiocytes have elongated, kidney bean or
boomerang-shaped vesicular nuclei with nucleoli, abundant
granular cytoplasm (eosinophilic on H&E and cyanophilic on
Pap stain), and ill-defined cytoplasmic cell borders sometimes
resulting in syncytial formation.
238
Differential Diagnosis
Noninfectious etiology
Background
Infection
Features
Predominant cell type
Necrotic debris
Tuberculosis, fungi, cat scratch
disease
Necrotizing granulomas
Epithelioid histiocytes
Clean
Atypical mycobacteria, histoplasmosis,
leishmaniasis, schistosomiasis
Non-necrotizing granulomas
Epithelioid histiocytes
240
Ancillary Studies
Mycobacterial Lymphadenitis
Cytomorphologic Features
241
Differential Diagnosis
242
Ancillary Studies
Fungal Lymphadenitis
Cytomorphologic Features
Granulomatous or acute inflammation with a necrotic or inflammatory background is likely to be encountered. Fungal elements
can be present in varying numbers.
C. neoformans has encapsulated yeast forms measuring 515mm.
Their thick capsule causes a clear halo with a DQ stain. The finding
of narrow based budding (tear-drop shape yeast) is very helpful.
H. capsulatum is a much smaller round to oval yeast form measuring 24mm. Abundant macrophages in these cases are usually
243
laden with intracytoplasmic yeast. One may also find narrowbased budding.
C. immitis has larger thick-walled spherules (cysts) that measure
20150 mm. When intact they contain 35 mm endospores.
Endospores may also be dispersed on the slide if the spherules
are ruptured.
Differential Diagnosis
244
Ancillary Studies
Histochemical stains for fungi include Grocott or Gomori methenamine silver (GMS) and PAS.
Cryptococcus capsule also stains positive with mucicarmine and
Alcian blue stains.
A Fontana-Masson stain can be helpful to identify capsule-deficient
Cryptococcus.
Specific immunostains may be required if available (e.g.,
Pneumocystis).
Fungal culture.
Toxoplasma Lymphadenitis
Cytomorphologic Features
Differential Diagnosis
Viral lymphadenitis
Granulomatous lymphadenitis
245
Leishmania lymphadenitis
Brucella infection (undulant fever)
Other causes of increased monocytoid B-cells (Table10.3)
Ancillary Studies
Leishmania Lymphadenitis
Cytomorphologic Features
Lymph node aspirates contain a polymorphous lymphoid background, necrotizing or non-necrotizing granulomatous inflammation, and several plasma cells. Necrosis may be suppurative.
Organisms may be detected by finding amastigotes within macrophages (Leishman-Donovan bodies), or free on the slide following rupture of cells, in routinely stained specimens. Amastigotes
are round to oval in shape and range in size from 1 to 3 mm.
246
Differential Diagnosis
Granulomatous lymphadenitis.
Histoplasma lymphadenitis: yeast forms that mimic amastigotes
can be distinguished using a GMS stain which will not stain
Leishmania organisms.
Ancillary Studies
Parasites stain with Giemsa stains, but are negative with PAS
and silver stains (GMS)
Immunostain if available
247
Serology
Culture in appropriate media
Animal inoculation
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
248
Fig. 10.8. Infectious mononucleosis (Diff-Quik stain, high magnification). This FNA is from a lymph node in an 8-year old boy with positive
EBV serology. The lymphoid cells in this aspirate are polymorphous and
include a prominent immunoblastic population and plasmacytoid cells.
Flow cytometry confirmed the absence of a monoclonal population.
Cytomorphologic Features
249
Differential Diagnosis
Viral lymphadenitis with an infectious mononucleosis-like syndrome (HIV, Cytomegaloviral [CMV], HSV, HHV6)
Toxoplasma lymphadenitis
Autoimmune disease (SLE, rheumatoid arthritis)
Lymphadenitis associated with drugs (e.g., phenytoin)
Vaccination associated lymphadenitis
Non-Hodgkin lymphoma
Hodgkin lymphoma
Ancillary Studies
250
Cytomorphologic Features
Polymorphous lymphocytes, as seen in reactive lymphoid hyperplasia, are seen with an increase of monocytoid B-cells.
Infected cells are often sparse and have characteristic CMV
intranuclear inclusions and sometimes multiple small cytoplasmic inclusions.
Differential Diagnosis
Ancillary Studies
HIV-Associated Lymphadenopathy
Lymph node enlargement occurring in a patient with HIV infection may be due to HIV infection itself and/or secondary to
co-infection (e.g., tuberculosis), an inflammatory process (e.g.,
Castleman disease or immune reconstitution inflammatory
syndrome), or malignancy (e.g., lymphoma, Kaposi sarcoma,
metastases).
An infectious mononucleosis-like syndrome may occur in acute
HIV infection that manifests with lymphadenopathy, pharyngitis,
a rash, and malaise. Chronic HIV-related lymphadenopathy
(progressive generalized lymphadenopathy) tends to present
251
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
252
Spleen Infections
Bacilliary Peliosis
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Special stains: Gram stain can be used to demonstrate Gramnegative bacilli. A Warthin-Starry stain will highlight clusters
of the Gram-negative bacilli
Immunostain for Bartonella if available
Electron microscopy in difficult cases
Serology
Culture of aspirated material
Blood culture
Spleen Infections
253
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Gram stain
Tissue culture
Blood culture
Mycobacterial Infection
Cytomorphologic Features
254
Differential Diagnosis
Fungal infection
Noninfectious granulomatous disease (e.g., sarcoidosis, chronic
granulomatous disease)
Peliosis
Felty syndrome (rheumatoid arthritis) where there is expansion
of red pulp cords and sinuses with macrophages
Proliferation of foamy macrophages due to other causes such as
ingestion of exogenous mineral oil, immune thrombocytopenic
purpura, metabolic storage disorders (Gaucher disease, NiemannPick disease, Tay-Sachs disease), thalassemia, and hyperlipidemia
For splenic spindle cell lesion the differential includes inflammatory myofibroblastic tumor, vascular neoplasms like littoral
cell angioma, and sarcoma.
Ancillary Studies
Infectious Mononucleosis
Splenomegaly in infectious mononucleosis due to EBV infection may lead to splenic rupture and death.
EBV infection results in white pulp hyperplasia without prominent germinal centers, and expansion of the red pulp sinusoids
by immunoblasts.
EBV infection may also be associated with hemophagocytic
syndrome in the spleen.
Spleen Infections
255
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
Hydatid Cyst
Cytomorphologic Features
Differential Diagnosis
Ancillary Studies
256
Suggested Reading
Caponetti G, Pantanowitz L. HIV-associated lymphadenopathy. Ear Nose
Throat J. 2008;87:3745.
Gaffey MJ, Ben-Ezra JM, Weiss LM. Herpes simplex lymphadenitis. Am
J Clin Pathol. 1991;95:70914.
Gupta SK, Kumar B, Kaur S. Aspiration cytology of lymph nodes in
leprosy. Int J Lepr Other Mycobact Dis. 1981;49:915.
Hadfield TL, Lamy Y, Wear DJ. Demonstration of Chlamydia trachomatis
in inguinal lymphadenitis of lymphogranuloma venereum: a light
microscopy, electron microscopy and polymerase chain reaction study.
Mod Pathol. 1995;8:9249.
Monaco SE, Schuchert MJ, Khalbuss WE. Diagnostic difficulties and pitfalls in rapid on-site evaluation of endobronchial ultrasound guided fine
needle aspiration. Cytojournal. 2010;7:9.
Shimizu K, Ito I, Sasaki H, Takada E, Sunagawa M, Masawa N. Fine-needle
aspiration of Toxoplasmic lymphadenitis in an intramammary lymph
node: a case report. Acta Cytol. 2001;45:25962.
Silverman JF. Fine needle aspiration cytology of cat scratch disease. Acta
Cytol. 1985;29:5427.
Solis OG, Belmonte AH, Ramaswamy G, Tchertkoff V. Pseudogaucher cells
in Mycobacterium avium intracellulare infections in acquired immune
deficiency syndrome (AIDS). Am J Clin Pathol. 1986;85:2335.
Stanley MW, Steeper TA, Horwitz CA, Burton LG, Strickler JG, Borken S.
Fine-needle aspiration of lymph nodes in patients with acute infectious
mononucleosis. Diagn Cytopathol. 1990;6:3239.
Tallada N, Ravents A, Martinez S, Compa C, Almirante B. Leishmania lymphadenitis diagnosed by fine-needle aspiration biopsy. Diagn
Cytopathol. 1993;9:6736.
11
Breast, Skin,
and Musculoskeletal Infections
Pam Michelow1, Walid E. Khalbuss2,
and Liron Pantanowitz2
Cytology Unit, Department of Anatomical Pathology,
University of the Witwatersrand and National Health Laboratory Service,
Johannesburg, Gauteng, South Africa
2
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
1
Breast Infections
Breast cytology including FNA and infrequently nipple discharge evaluation may be useful in the management of breast
infections.
Most inflammatory lesions of the breast are benign in nature
(Table11.1).
The most common microrganisms are bacteria, especially Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA).
Unusual pathogens reported to involve the breast include cat
scratch disease, mycobacteria (tuberculosis and atypical mycobacteria), actinomycosis, fungi (e.g., Cryptococcus, Aspergillus,
257
258
dimorphic fungi, chromomycosis), parasites, and maggot infestation. A rare case with herpes simplex virus cells has been
reported in a hemorrhagic nipple discharge.
Chronic infections may mimic breast cancer clinically, on imaging studies, and microscopically. They may manifest as a breast
mass, with calcifications, inflammatory skin changes, and axillary lymphadenopathy.
Unusual infections have been reported to be the initial presentation of HIV infection.
Foreign bodies (e.g., nipple piercing, breast implants) occasionally result in associated infection.
Breast Infections
259
Clinical Features
260
Fig. 11.1. Acute mastitis. (Top left) Numerous neutrophils are shown from
a breast aspirate consistent with a breast abscess (Pap stain, high magnification). (Bottom left) A group of reactive ductal epithelial cells is present
in a background of neutrophils from a case of acute mastitis (Diff-Quik
stain, high magnification). (Right) Anucleated squamous cells are shown
in a background of acute inflammation obtained from a subareolar abscess
caused by duct ectasia (top image is a Pap stain of intermediate magnification; bottom image is a Diff-Quik stain at higher magnification).
Cytomorphologic Features
Breast Infections
261
Ancillary Studies
Clinical Features
Cytomorphologic Features
Ancillary Studies
262
Skin infections can be diagnosed by Tzanck preparations, slitskin smears, and FNA of palpable lesions, vesicles, and/or cysts
(Figs.11.211.6).
Tzanck preparation. Scrapings taken from a vesicle or pustule
(ideally taken from the base of the lesion) may show herpes
simplex and varicella zoster cytopathic effect. In addition, the
waxy cytoplasmic inclusions (molluscum bodies) of Molluscum contagiosum can be seen (Fig.11.2).
Slit-skin smear. These smears are to be performed by making
an incision involving an active lesion approximately 5 mm
long and 3mm deep. Pinching the skin decreases bleeding.
The tissue is then scraped and slides prepared looking for
microorganisms such as Mycobacterium leprae in leprosy or
leishmaniasis.
A wide variety of infections may involve the skin and underlying soft tissue (Table 11.2). Deep soft tissue infections that
may be encountered include cellulitis, abscesses, necrotizing
263
fasciitis, gangrene (e.g., Clostridial gas gangrene), cryptococcoma (Fig. 11.3), protothecosis and pyomyositis (suppurative
myositis).
Skin abscesses are mostly due to Staphylococcus spp., but many
bacteria including Streptococci spp., Clostridium spp., and
actinmycoses can cause them. Purulent material comprised of
numerous neutrophils is noted.
Granulomatous inflammation can be attributed to infections
(e.g., mycobacteria) or noninfectious causes (e.g., sarcoidosis,
foreign body reaction to a ruptured epidermal inclusion cyst).
264
Fig. 11.3. Cryptococcosis. (Left) The images shown are from an HIV
positive patient that presented with a large neck mass (cryptococcoma)
suspected to be an extranodal soft tissue lymphoma based on radiological studies. There was no cervical lymphadenopathy seen. The specimen
shows granulomatous inflammation associated with extra- and intracellular fungal organisms surrounded by a clear halo due to the cryptococcal
capsules (Diff-Quik stain, high magnification). (Right) Histopathologic
image showing yeasts in macrophages and giant cells (H&E stain, high
magnification).
Tuberculosis of the skin is traditionally classified into (1) primary infection, (2) secondary disease or reinfection (which
includes lupus vulgaris, tuberculosis verrucosa, scrofuloderma,
orificial, and disseminated cutaneous tuberculosis), and (3) cutaneous reactions (tuberculids) to a distant tuberculous infection.
Scrofuloderma is involvement of the skin due to direct extension
from underlying lymphadenitis, usually due to atypical mycobacteria. Atypical mycobacteria may also result in uncommon
infections such as Buruli ulcer (Mycobacterium ulcerans) and
swimming pool granuloma (Mycobacterium marinum). Mycobacterial specimens usually show granulomatous inflammation
with/without necrosis associated with acid-fast bacilli.
265
266
Fig. 11.5. Dermatophytosis. FNA in this case was obtained from multiple
purulent neck masses caused by infection due to Trichophyton violaceum.
(Left) Pink staining fungal elements are shown at high magnification with
a Pap stain that can also be appreciated as negative images on the DiffQuik stain (top right). Branching fungal hyphae are readily visible with a
methenamine silver stain (bottom right, high magnification) (images courtesy of Dr. Pawel Schubert, Stellenbosch University, Cape Town).
Leprosy
267
Clinical Features
268
269
Cytomorphologic Features
The cytomorphology of lepromatous and borderline lepromatous leprosy include large numbers of neutrophils and foamy
macrophages (lepra cells).
Lepra cells may be multinucleated with round to oval nuclei,
finely granular chromatin, and inconspicuous nucleoli. The cells
have abundant cytoplasm containing vacuoles of various sizes.
Necrosis associated with a fatty background and epithelioid
histiocytes may be seen.
In tuberculoid and borderline tuberculoid leprosy, noncaseating
granulomas comprised of epithelioid histiocytes, Langhans-type
giant cells, and lymphocytes are seen.
Negative images of mycobacteria may be encountered on
Romanowsky-stained slides.
With acid-fast stains, the bacilli are visible both intra- and
extracellularly, 37mm in length and may be beaded, straight,
or curved.
Bacilli are readily found in lepromatous and borderline lesions,
but are scanty in borderline tuberculoid and not usually found in
tuberculoid leprosy.
Acid-fast stained smears can be used to determine a BI and
Morphological Index (MI). The BI is an index of the bacillary
load in the patient (density of bacteria is based on counting AFB
per high power fields). The MI is an index of bacilli viability.
Solid bacilli are judged to be viable while fragmented or granular bacilli are interpreted to be nonviable. At least 200 discrete
bacilli should be evaluated.
Differential Diagnosis
270
Ancillary Studies
Cutaneous Mycoses
271
Cutaneous Parasites
Parasitic infections that may involve the skin include ameba, flagellates (e.g., trypanosomes, leishmaniasis), trematodes (e.g., schistosomiasis), cestodes (e.g., cysticercosis, echinococcocis), and
nematodes (e.g., onchocerciasis, dirofilariasis, larva migrans).
Leishmaniasis. Infection due to Leishmania may manifest with
cutaneous (oriental), mucocutaneous (American) and visceral
272
273
Osteomyelitis may be caused by infection (viral, bacterial, mycobacterial, and fungal including mycetoma) and noninfectious
causes (e.g., acute fracture, sarcoidosis, histiocytic proliferation).
Bacterial osteomyelitis may result from hematogenous spread
(typically when bacteria are implicated), contiguous spread (e.g.,
diabetic foot, chronic leg ulcers) or direct inoculation (e.g., open
fracture, introduction of orthopedic hardware). Bacterial osteomyelitis is most often due to S. aureus infection, typically acute,
occurs mainly in the long bones of children, and elicits a suppurative inflammatory response that includes osteonecrosis. Osteomyelitis of the jaw may involve Actinomyces. Bacteria that may
cause a granulomatous reaction include Salmonella, Brucella,
Bartonella, Coxiella burnetii (causes Q fever), and Burkholderia pseudomallei (causes melioidosis) (Fig.11.7).
Mycobacterial osteomyelitis may be due to M. tuberculosis,
atypical mycobacteria and leprosy. Tuberculous bone infections
may be localized (e.g., Potts disease of the spine). However,
immunosuppressed patients such as those with AIDS frequently
have multifocal bone involvement. Typically these specimens
show necrotizing granulomatous inflammation.
Fungal osteomyelitis may be attributed to almost all fungi. Bone
involvement may occur from an isolated multisystem infection.
Fungi that commonly demonstrate hematogenous spread to bone
are Candida spp., Cryptococcus, and most of the dimorphic
fungi. Radiology images may indicate significant bone destruction, often with accompanying soft tissue infection.
Parasitic osteomyelitis is mainly due to infection with Echinococcus (hydatid disease).
Arthritis may be caused by infection of the joints (septic arthritis). Bacteria are the most common cause of synovial infection, including septic bursitis. Typical bacterial culprits include
Staphylococcus, Streptococci, Gonococcus, Meningococcus,
polymicrobial infections including anerobes, Lyme disease, and
mycobacteria. A wide variety of viral infections (e.g., Parvovirus B19, Hepatitis B and C, HIV, Alphavirus) can lead to joint
inflammation (rheumatic syndrome). Although less common,
fungal causes of arthritis may be due to Candida, Cryptococcus,
274
Fig. 11.7. Acute osteomyelitis. (Left) FNA of bone showing acute inflammatory cells and debris that included groups of bacterial cocci (upper left
inset) (Diff-Quik stain, high magnification). (Right) The images shown
are from a 49-year-old female who presented with a thoracic vertebral
lesion radiologically significant for osteomyelitis. (Top right) Most of the
specimen shows marked cellular debris and acute inflammatory cells (Pap
stain, high magnification). (Bottom right) The cell block in this latter case
shows similar marked acute inflammation associated with osteonecrotic
bone fragments (H&E stain, high magnification). A Gram stain on cell
block material was positive for Gram-positive cocci.
Bacillary Angiomatosis
Condition
Normal
Viral
Bacterial
Fungal
Crystals
Appearance
Clear
Cloudy
Cloudy
Variable
Cloudy
Color
Yellow
Yellow
Gray-green
Variable
White
Consistency
Viscous
Low viscosity
Low viscosity
Low viscosity
Low viscosity
Cellularity
No or rare (<25%) neutrophils
Lymphocytes and some neutrophils (>50%)
Abundant neutrophils (>75%)
Lymphocytes and some neutrophils (>50%)
Many neutrophils (<90%)
276
Cytomorphologic Features
The cytologic features are largely nonspecific including a specimen that contains blood and acute inflammatory cells.
The diagnosis is best made on cell block material and with ancillary studies. The cell block will show a proliferation of small
blood vessels, including some that are ectatic and filled with
fibrin, erythrocytes, neutrophils, and leukocytoclastic debris.
Blood vessels are lined by plump endothelial cells protruding into
the vascular lumen. These endothelial cells have round or oval
nuclei with moderate atypia, vesicular chromatin, and nuclear
membrane folding. Their cytoplasm is finely vacuolated.
Ancillary Studies
Special stain (the organisms can be detected with a WarthinStarry silver stain).
Immuncytochemistry (Bartonella antibodies are now available).
Electron microscopy (these studies will show an extracellular
aggregation of bacilli that have trilaminar walls including two
electron-dense layers separated by a less electron-dense layer).
Suggested Reading
Dabiri S, Hayes MM, Meymandi SS, Basiri M, Soleimani F, Mousavi MR.
Cytologic features of dry-type cutaneous leishmaniasis. Diagn
Cytopathol. 1998;19:1825.
EL Hag IA, Fahal AH, Gasim ET. Fine needle aspiration cytology of
mycetoma. Acta Cytol. 1996;40:4614.
277
12
Many patients present with lesions of the head and neck. These
may be congenital, infectious, cystic, reactive, inflammatory, or
neoplastic in nature. Clinical examination and radiologic imaging
may not be sufficient to render an accurate diagnosis. Cytologic
evaluation in the form of smears and fine needle aspiration (FNA)
in this anatomical region is a rapid and accurate diagnostic modality
with good sensitivity and specificity for infectious diseases. This
chapter covers several key infections likely to be encountered in
this site. Infections involving cervical lymph nodes are addressed
in Chap. 10.
279
280
Acute Sialadenitis
Cytomorphologic Features
A marked inflammatory infiltrate that consists mainly of neutrophils with associated fibrin and debris is common.
Occasional duct cells, sometimes with marked reactive changes,
can be noted. Reactive atypia may mimic a neoplasm. Restricted
numbers and limited atypia of epithelial cells in the presence of
acute inflammation suggest sialadenitis rather than a neoplasm.
Stone fragments may be seen if there is an associated sialolithiasis.
Nontyrosine (amylase type) crystalloids (5200mm) may be identified. They are nonbirefringent, geometric in shape (rectangular,
rhomboid), and typically fragment in aspirated material. They
stain orange with Pap stain and pink in H&E stained cell blocks.
Granulation tissue may be present.
281
Fig. 12.1. Acute sialadenitis. (Top left) Direct smear of a fine needle
aspiration (FNA) from a parotid gland showing numerous neutrophils and
debris consistent with acute sialadenitis. Culture revealed Staphylococcus
aureus (Pap stain, intermediate magnification). (Bottom left) Gram stain
from a salivary gland FNA showing scattered Gram-positive bacteria
(high magnification). (Right) Nontyrosine crystalloids admixed with acute
inflammatory cells in a case of acute sialadenitis (H&E stain, cell block,
high magnification).
Ancillary Studies
Chronic Sialadenitis
282
Mucoepidermoid
carcinoma
Non-Hodgkin
lymphoma
Cytomorphology
Polymorphous lymphocytes
Comment
Within or adjacent to
glands
Tingible body macrophages
Contaminating epitheLymphohistiocytic aggregates
lium can be present
Polymorphous lymphocytes
History of HIV or
Epithelial cells
Sjgren syndrome
Proteinaceous background
Increased CD8+ lymphocytes History of HIV
Polymorphous lymphocytes
Oncocytes
Cystic background
Benign squamous cells
Reactive lymphocytes
Granular debris
Malignant cells (mucinous
and/or squamous)
Background debris
Possible mucin
Monomorphic (atypical)
lymphocytes
Resembles oncocytic
metaplasia
Located outside salivary
gland
Cellular aspirate
Ancillary studies
required
Cytomorphologic Features
Ancillary Studies
283
Granulomatous Sialadenitis
Cytomorphologic Features
Ancillary Studies
284
Oropharyngeal Infections
285
Oropharyngeal Infections
286
Herpes simplex virus (HSV) is a DNA virus. HSV-1 is transmitted through infected saliva or active perioral lesions while
HSV-2 is spread by sexual contact. Both types may cause oral
lesions. Clinical lesions associated with both types are indistinguishable.
Primary HSV oral lesions occur predominantly in small children
and are associated with fever, malaise, and neck lymphadenopathy.
Painful oral lesions may extend from the mouth to the lips,
coalesce, and ulcerate.
Latent infection residing in ganglia may re-activate (e.g., following
stress or immunosuppression) causing a secondary herpetic lesion
(cold sore or fever blister), often on the lips.
A Tzanck preparation or smear (vesicle-based scraping submitted
for microscopic examination) is often done to diagnose HSV
infection (Fig.12.2).
Cytomorphologic Features
Ancillary Studies
Oropharyngeal Infections
287
Fig. 12.2. Oral herpes simplex virus (HSV) infection showing characteristic viral cytopathic changes with (left image) Pap stain, (top right)
Diff-Quik stain, and (bottom right) in H&E stained cell block material
(high magnification).
Cervicofacial Actinomycosis
288
Fig. 12.3. Oral actinomyces flora. (Left image) Filamentous bacteria are
shown without associated acute inflammatory cells (Pap stain, high magnification). Actinomyces granules without inflammation are shown in this
tonsillectomy specimen, which are frequently embedded within tonsillar
crypts (H&E stain, intermediate magnification).
Cytomorphologic Features
Ancillary Studies
Special stains (e.g., Gram, Ziehl-Neelsen, Fite). Actinomyces needs to be distinguished from Nocardia as actinomyces
responds to penicillin while Nocardia is treated with sulfa drugs.
Unlike actinomyces, Nocardia often stains with acid-fast stains.
Actinomyces also tends to stain well with GMS.
Microbiology culture.
Oropharyngeal Infections
289
Oral Candidiasis
290
Fig. 12.5. Oral candidiasis. (Left image) Oral smear showing abundant
pseudohyphae and yeasts of Candida albicans (PAS stain, intermediate
magnification) (photo courtesy of Dr. Shabnum Meer, University of the
Witwatersrand, South Africa). (Right image) Many spores can be seen
associated with debris in this case where Candida contaminated a herpetic
oral ulcer (Diff-Quik stain, high magnification).
Cytomorphologic Features
Pseudohyphae and/or yeasts are seen. Pseudohyphae are elongated and constricted along their length. Yeasts are round to oval
in shape and 24mm in size.
Candida glabrata exists only in a yeast form, with no pseudohyphae.
If yeasts are prominent, the differential includes histoplasmosis,
cryptococcosis, and blastomycosis.
If pseudohyphae predominate, they need to be distinguished
from Aspergillus (septate and branches at 45) and mucromycosis (aseptate and branches at 90), both of which do not form
budding yeasts.
Sinonasal Infections
291
Ancillary Studies
Sinonasal Infections
292
Rhinoscleroma
293
Rhinosporidiosis
294
Fig. 12.7. FNA of an infected branchial cleft cyst in a 39-year old male
shows abundant neutrophils mixed with benign squamous cells (Pap stain,
low magnification).
Eye Infections
Eye Infections
295
Fig. 12.8. Infected branchial cleft cyst. The aspirate contains mucinous
and metaplastic epithelium present with acute inflammatory cells (DiffQuik stain, left intermediate magnification, middle image high magnification). The cell block contains fragments of granulation tissue (H&E stain,
right image, intermediate magnification).
296
Eye Infections
297
Fig. 12.9. Ocular cryptococcosis. FNA of the vitreous fluid in this patient
revealed (left image) encapsulated Cryptococcal yeasts (Pap stain, high
magnification) with narrow-based budding (top right image) (H&E stain,
cell block, high magnification). (Bottom right image) Yeasts stain positively with mucicarmine stain (high magnification).
Conjunctival scrapings are useful to diagnose fly larvae, nematodes, and trematodes.
Acanthameba keratitis can occur after trauma to the cornea, and
has been reported following the use of unsterile saline contact
lens solution. Corneal scrapings are examined for characteristic
trophozoites and cysts (round to oval, 1218mm, double-walled)
on Romanowsky, calcofluor white, and trichrome stains, in
addition to fluorescent microscopy and culture. The background
contains reactive epithelium.
298
Ear Infections
While otic smears for cytologic evaluation are a useful technique used in veterinary practice, they are not utilized much in
human medicine.
Otitis externa (swimmers ear) is caused by excessive moisture
remaining in the ear canal, or disruption of the ear canal mucosa
by trauma.
The most common bacteria responsible for outer ear infections
are Staphylococcus aureus and Pseudomonas aeruginosa. Other
bacteria are less common. In a minority of cases (less than 10%),
a fungus is the cause of swimmers ear.
Confirmation of infection can be achieved by culture, rather
than cytologic examination of smears.
Suggested Reading
Braz-Silva PH, Magalhes MH, Hofman V, Ortega KL, Ilie MI, Odin G,
et al. Usefulness of oral cytopathology in the diagnosis of infectious
diseases. Cytopathology. 2010;21:28599.
Deshpande AH, Munshi MM. Rhinocerebral mucormycosis diagnosis by
aspiration cytology. Diagn Cytopathol. 2000;23:97100.
Gori S, Scasso A. Cytologic and differential diagnosis of rhinosporidiosis.
Acta Cytol. 1994;38:3616.
McQuone S. Acute viral and bacterial infections of the salivary glands.
Otolaryngol Clin North Am. 1999;32:117.
Rivasi F, Longanesi L, Casolari C, Croppo GP, Pierini G, Zunarelli E,
etal. Cytologic diagnosis of Acanthamoeba keratitis. Report of a case
with correlative study with indirect immunofluorescence and scanning
electron microscopy. Acta Cytol. 1995;39:8216.
Sah SP, Mishra A, Rani S, Ramachandran VG. Cervicofacial actinomycosis: diagnosis by fine needle aspiration cytology. Acta Cytol.
2001;45:6657.
Schnadig VJ, Rassekh CH, Gourley WK. Allergic fungal sinusitis. A report
of two cases with diagnosis by intraoperative aspiration cytology. Acta
Cytol. 1999;43:26872.
13
Immunosuppressed Host
Pam Michelow1, Sara E. Monaco2,
and Liron Pantanowitz2
Cytology Unit, Department of Anatomical Pathology,
University of the Witwatersrand and National Health Laboratory Service,
Johannesburg, Gauteng, South Africa
2
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
1
299
300
Transplantation
Transplantation
301
gastrointestinal parasites.
Late period: These transplant recipients are at stable and
often reduced levels of immunosuppression. They are at risk
for developing common infections (e.g., community-acquired
pneumonia) and/or more rare infections (e.g., disseminated
histoplasmosis).
In the transplant patient, viral coinfection may cause direct effects
(clinical infection with symptoms such as esophagitis or diarrhea)
and indirect consequences such as oncogenesis (e.g., EBV-related
posttransplant lymphoproliferative disorder or PTLD, human
herpesvirus-8 [HHV8] associated Kaposi sarcoma).
302
The hallmark of HIV infection is characterized by this retrovirus leading to selective depletion of CD4 T-lymphocytes. This
acquired immune deficiency allows for the development of
opportunistic infections and neoplasia.
The stages of HIV infection include (1) primary infection
(so-called acute seroconversion syndrome), (2) seroconversion (development of detectable antibodies), (3) clinical latent
period (with or without persistent generalized lymphadenopathy or PGL), (4) early symptomatic infection (previously called
acquired immunodeficiency syndrome [AIDS]-related complex
or ARC), (5) AIDS, and (6) advanced HIV disease (CD4 count
<50/mm3).
Normal CD4+ T-cell blood count measurements are 500cells/
mm3. CD4+ below 200cells/mm3 is indicative of AIDS. Other
conditions that may also define an AIDS diagnosis are shown
in Table13.2.
HIV may induce a direct viral cytopathic effect on host cells,
mainly lymphoid and histiocytic cells, by causing the formation
of multinucleated giant cells. These p24-positive WarthinFinkeldey-type giant cells may be observed rarely in lymph
node specimens and in abundance in fine needle aspirates of
salivary gland lymphoepithelial lesions.
Mortality and morbidity associated with HIV infection has
declined since the advent of combination antiretroviral therapy
(ART), also called highly active antiretroviral therapy (HAART).
Immune reconstitution inflammatory syndrome (IRIS) occurs
in some HIV-infected patients after commencing ART leading
to a paradoxical worsening of symptoms. Microorganisms frequently associated with IRIS include Cryptococcus, mycobacteria, varicella zoster, herpes virus, and cytomegalovirus.
Immunosuppressed individuals are at increased risk of HPVassociated malignancies including cervical, anal, penile, vulvar,
vaginal, and oropharyngeal carcinoma.
303
Cervicovaginal Disease
304
Anal Disease
Lymphadenopathy
Oropharyngeal Disease
305
Oropharyngeal Disease
Immunosuppressed patients, especially those with HIV infection, may manifest with diverse diseases of the oropharynx.
Oral candidiasis. True infection should be suspected when fungal elements (yeasts, hyphae, and pseudohyphae) are intermingled with inflammatory cells and debris. The presence of thrush
is a frequent source of Candida contamination in gastrointestinal and respiratory tract samples (e.g., bronchoalveolar lavage)
in these patients.
Oral hairy leukoplakia (OHL) (Fig.13.3). This EBV-associated
disease causes white patches on the side of the tongue, typically
with a corrugated or hairy appearance, but can also be smooth
and flat. Cytology specimens may show prominent nuclear
beading (peripheral margination and clumping of chromatin),
eosinophilic intranuclear inclusions, and ground glass nuclei.
Detection of EBV DNA can be confirmed by PCR or in situ
hybridization, as well as viral culture.
Herpes simplex virus. The diagnosis can be confirmed using a
Tzanck smear, immunohistochemical stains for HSV1/2, direct
fluorescent assay, PCR for viral DNA, and viral culture.
306
Fig. 13.2. Tuberculous lymphadenitis due to Mycobacterium tuberculosis infection. (Left) Lymph node FNA showing classic granulomatous
inflammation morphology with a Langhans type giant cell and adjacent
epithelioid histiocytes (Pap stain, high magnification). (Top right) Mycobacterial infection consisting predominantly of necrosis (Pap stain, low
magnification). (Bottom right) Mycobacterial infection presenting as an
abscess with numerous neutrophils in a necrotic background (Pap stain,
intermediate magnification).
307
Fig. 13.3. Oral hairy leukoplakia. (Top) Patient with white patches shown
on the side of the tongue. (Bottom) Oral smear showing EBV infected
epithelial cells with prominent nuclear beading (Pap stain, high magnification) (photographs courtesy of Dr. Shabnum Meer, Division of Oral
Pathology, University of the Witwatersrand, South Africa).
308
Lymphoproliferative Disorders
Posttransplant Lymphoproliferative
Disorder (PTLD)
Lymphoproliferative Disorders
309
Plasmablastic Lymphoma
310
Tumor cells are positive for plasma cell markers (CD138, CD38,
MUM1), CD79a, CD30, and EMA. They may be negative or
weakly positive for CD45 (LCA), CD20, and PAX5.
Hodgkin Lymphoma
Hodgkin lymphoma is currently among the most common nonAIDS defining cancer (NADC) encountered, particularly the
mixed cellularity and lymphocyte-depleted subtypes.
Approximately 75100% of these AIDS-associated cases have
EBV coinfection.
In HIV patients, Hodgkin lymphoma may be widely disseminated with frequent extranodal disease, but rare mediastinal
involvement.
311
312
Fig. 13.5. Algorithmic approach to HIV-associated lymphomatous effusions. BL Burkitt lymphoma; DLBCL diffuse large B-cell lymphoma;
HHV8 human herpesvirus-8; HL Hodgkin lymphoma; NHL non-Hodgkin
lymphoma; PAL pyothorax-associated lymphoma; PEL primary effusion
lymphoma (reproduced with permission from Pantanowitz L, Dezube BJ.
HIV-related lymphomas. Int Pleural Newslett. 2009;7:189).
313
314
Pulmonary Disease
Pulmonary Disease
315
316
Renal Disease
Mycobacterial spindle pseudotumor. These lesions contain spindleshaped macrophages (CD68+) that harbor numerous mycobacteria (AFB positive). They predominantly involve lymph nodes,
but may affect the skin and bone marrow. They are most often
associated with atypical mycobacteria like Mycobacterium
avium intracellulare (MAI).
Kaposi sarcoma. Aspirates procured from these lesions contain
clusters and bland spindle cells (CD34+, CD31+, D2-40+) present
in a bloody background. Nuclear immunostaining with LNA-1
for HHV8 (KSHV) is diagnostically helpful in these cases.
EBV-associated mesenchymal tumors. Leiomyoma, leiomyosarcoma, and myopericytoma present with spindle cells that
317
Fig. 13.9. HIV-associated spindle cell lesions. (Top left) FNA from a
neck lymph node showing LNA-1 negative spindle cells arranged in a
large cluster. Culture revealed Mycobacterium tuberculosis confirming
the diagnosis of Mycobacterial spindle cell pseudotumor (Pap stain, intermediate magnification). (Bottom left) Kaposi sarcoma spindle cell nuclei
stain positively with LNA-1 confirming HHV8 infection (immunostain,
high magnification). (Right) Lung FNA from an HIV+ male showing
loose aggregates of spindle cells with eosinophilic cytoplasm and nuclear
atypia in a necrotic background. Ancillary investigations confirmed the
presence of a leimyosarcoma (Pap stain, intermediate magnification).
318
Fig. 13.10. Follicular dendritic cell sarcoma showing fascicles and sheets
of atypical spindle cells with moderate amounts of cytoplasm, finely
granular chromatin, and small nucleoli (Pap stain, left intermediate magnification, right high magnification).
Suggested Reading
Ellison E, Lapuerta P, Martin S. Fine needle aspiration (FNA) in HIV+
patients: results from a series of 655 aspirates. Cytopathology.
1998;9:2229.
Gattuso P, Castelli MJ, Peng Y, Reddy VB. Posttransplant lymphoproliferative disorders: a fine-needle aspiration biopsy study. Diagn
Cytopathol. 1997;16:3925.
Hanks D, Bhargava V. Fine-needle aspiration diagnosis of HIV-related
conditions. Pathology. 1996;4:22152.
Kocjan G, Miller R. The cytology of HIV-induced immunosuppression.
Changing pattern of disease in the era of highly active antiretroviral
therapy. Cytopathology. 2001;12:28196.
Lobenthal SW, Hajdu SI. The cytopathology of bone marrow transplantation. Acta Cytol. 1990;34:55966.
Michelow P, Meyers T, Dubb M, Wright C. The utility of fine needle
aspiration in HIV positive children. Cytopathology. 2008;19:8693.
319
14
Ancillary Investigations
Pam Michelow1, Tanvier Omar2,
and Liron Pantanowitz3
Cytology Unit, Department of Anatomical Pathology,
University of the Witwatersrand and National Health Laboratory Service,
Johannesburg, Gauteng, South Africa
2
Division of Cytopathology, Department of Anatomical Pathology, School of
Pathology, National Health Laboratory Service, and University of
Witwatersrand, Johannesburg, Gauteng, South Africa
3
Department of Pathology, University of Pittsburgh Medical Center,
5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
1
321
322
The Pap stain is the most widely used routine cytologic stain
applied to alcohol-fixed material. Hematoxylin is used as a
nuclear stain and Orange G-6 (OG-6) and eosin-azure (EA) as
cytoplasmic counterstains. This stain is not entirely standardized and slight differences exist in dye composition and stain
technique.
The Pap stain provides good nuclear and cytoplasmic details
of many organisms, in addition to the hosts cellular changes
like inflammation, repair, and neoplasia that may be induced by
the infective process. Most viral changes including nuclear and
cytoplasmic inclusions are best seen in Pap-stained smears.
Romanowsky Stains
Special Stains
323
Toluidine Blue
Cell Blocks
Cell blocks are created by placing cytology material into a fixative, of which several are available such as 10% buffered formalin. The liquid specimen is centrifuged to create a cell pellet,
which is embedded for sectioning as for biopsy material.
Both conventional exfoliative and aspiration cytology have limited material available for ancillary investigations. The use of cell
block technique allows for many sections to be made and hence
multiple special stains and immunostains can be performed for
infectious diseases. Large structures floating in liquid-based
specimen vials may only be identified in cell block material.
Special Stains
324
A saline (0.85% NaCl) wet prep may be used to detect the microscopic presence of various microorganisms in liquid specimens.
The prep is observed using brightfield microscopy. Material
must usually be examined within 30min once obtained. It can
be used on vaginal secretions to diagnose motile Trichomonas
vaginalis trophozoites, clue cells, and yeast.
A wet prep with 20% potassium hydroxide (KOH) lyses epithelial cells allowing for easier visualization of certain microorganisms (e.g., Candida). Placing a drop of KOH on a slide of
the wet prep may cause a foul, fishy odor if there is anaerobic
overgrowth or infection (known as the whiff test).
Bacterial Stains
Gram Stain
Bacterial Stains
325
Fig. 14.1. Gram stained bacteria (Gram stains, high magnification). (Left)
Clusters of Gram positive Staphylococcus aureus cocci are shown in this
specimen from an infected skin wound. (Right) Numerous Gram negative
Haemophilus rods and coccobacilli are present in the background among
neutrophils and bronchial cells in this bronchoalveolar lavage specimen.
In cytology laboratories where gastric washing cytology is regularly assessed, special staining for H. pylori may be necessary.
Several staining methods can be employed:
326
Warthin-Starry Stain
This is a fastidious stain used for identifying spirochetes, Bartonella henselae and Bartonella quintana, Donovan bodies, and
H. pylori. It is also capable of demonstrating Klebsiella and
Leptospira bacteria as well as microsporidia, although this is
rarely indicated.
The stain employs a silver heat impregnation technique. Once
silver salts deposit onto the organisms, they are reduced with
hydroquinone to produce a silver metal.
Microbes appear somewhat magnified and stain black in a
golden brown background.
Stains with necrotic material or cells with intracellular debris
that show nonspecific staining are difficult to interpret. The
incubation step of this stain is critical to provide a well-stained
slide. Over- or underdeveloped sections are frustratingly difficult to interpret. Nonspecific precipitation can be removed by
rapid rinsing in 2.5% iron alum.
Fungal Stains
327
Fungal Stains
328
Action
Constituent fluorochromes
bind to cell wall
Ziehl-Neelsen
Kinyoun
Modified Fite
Triff
Result
Bacilli fluoresce orangeyellow in a black
background under
ultra-violet light
Mycobacteria stain red to
purple and are slightly
curved, rod shaped
bacilli, and occasionally beaded
Grocott methanamine
silver (GMS)
Action
Stain
McManus periodic
acid-Schiff (PAS)
Comment
Over-incubation and
uneven temperatures
result in distortion
of internal fungal
morphology
330
14. Ancillary Investigations
331
Fig. 14.4. Fungal stains (high magnification). (Upper left) PAS highlighting Cryptococcus in an FNA of a lymph node. (Bottom left) GMS
demonstrates Pneumocystis jirovecii cysts in an alveolar cast from a bronchoalveolar lavage. (Upper right) Mucicarmine highlights several encapsulated C. neoformans yeast. Note the narrow-based budding of an organism
in the upper center of the image. (Bottom right) Lactol-phenol cotton blue
stain is used to illustrate Aspergillus flavus isolated from fungal culture.
Fontana-Masson stain may demonstrate the cell wall of C. neoformans and also stains all dematiaceous (pigmented) fungi
(e.g., Phaeohyphomycosis).
Lactol-phenol cotton blue (LPCB) staining is used to examine
fungal cultures in the mycology laboratory. It is also used to
detect acid-fast parasites in stool and gastrointestinal aspirate
specimens (Fig.14.4).
332
Feulgen
Tzanck smear
Action
Basic fuchsin is differentiated with citric
acid and counterstained with methylene blue
Trichrome stain that uses hematoxylin to
stain nuclei blue, phloxine to stain viral
inclusions bright red and tartrazine to serve
as a differentiator
Shikatas Orcein
Lendrums phloxinetartrazine
Stain
Macchiavello
Positive result
Viral inclusions (e.g., Negri bodies
in rabies), rickettsia and chlamydia
Molluscum contagiosum
and measles
Comment
Organisms stain red and tissue
cells blue
Russell bodies, keratin, Paneth
cells are resistant to tartrazine differentiation and may
be a source of false-positive
interpretation
Orcein should be freshly
prepared each week
334
Immunocytochemistry
In Situ Hybridization
335
In Situ Hybridization
Localization
Bacteria
Nuclear
Fungal elements
Bacteria
Nuclear
Fungal elements
Fungal elements
Nuclear and cytoplasmic
Membranous and cytoplasmic
Nuclear
Extracellular
Bacteria
Nuclear and cytoplasmic
Cytoplasmic
Cytoplasmic
Nuclear and cytoplasmic
Nuclear
Microorganism
Actinomycetes
Adenovirus
Aspergillus
Bartonella henselae
BK virus
Candida albicans
Cryptococcus
Cytomegalovirus
EBV latent membrane protein
Epstein Barr virus
Giardia intestinalis
Helicobacter pylori
Hepatitis B core Ag
Hepatitis B surface Ag
Hepatitis C virus
Herpes simplex virus 1 and 2
Human Herpesvirus 8
Comment
Antibodies for Actinomyces genus, A. israelii and A. naeslundii
Pan-adenovirus marker; monoclonal antibody is reactive with all 41 serotypes of adenovirus
Genus specific only. Stains fungus cell wall, septa, and cytoplasm
Polyclonal antibody that does not differentiate between B. henselae and
B. quintana. There is also a monoclonal antibody specific for B. henselae
Specific for BK virus. The antibody is directed against the large T cell
antigen of SV40 virus
Does cross-react with other yeasts
Stains different Cryptococcus neoformans and serotypes
No cross-reaction with other herpes viruses or adenovirus
Monoclonal antibodies to LMP-1 or LMP-2
Acetone fixed tissue only; replicating and latent infection (EBNA2)
Stains protozoa on luminal surface of epithelia
Also cytoplasmic staining
Targets core antigen in infected cells
Targets surface antigen in infected cells (HBsAg)
Sensitivity variable
Some cross-reactivity may be observed. Polyclonal antibody does not
distinguish between HSV-1 and HSV-2
Targets latent nuclear antigen-1 (LNA-1); also called latent associated
nuclear antigen-1 (LANA)
Targets P24 protein. Not suited to tissues that have had prolonged fixation
in formalin
Table 14.4. Useful commercially available immunocytochemistry antibodies for microbe identification.
336
14. Ancillary Investigations
Nuclear
Nuclear
Cell wall of organism
Cell wall of organism
Cyst wall
Cytoplasmic
Cytoplasm and cell membrane
Parasites
Cytoplasmic
Fungal elements
Parvovirus B19
Pneumocystis jiroveci
Prion protein
Respiratory syncytial virus
Toxoplasma gondii
Major capsid protein antibody expressed in HPV type 6, 11, 16, 18, 31, 33,
42, 51, 52, 56 and 58
Majority (not all) Merkel cell tumors are positive
Raised against BCG
Species specific. With anti-BCG polyclonal antibody has shown better
sensitivity than AFB staining, except in cases where there are very few
bacilli. A polyclonal antibody against the M. tuberculosis-secreted antigen MPT64 is also useful
Recognizes an epitope common to VP1 and VP2 proteins of human Parvovirus B19
Specific to P. jiroveci (formerly P. carinii). Stained rings correspond to
individual cyst walls
Also called prion protein PrP antibody
There are multiple types and subtypes of RSV that may not be covered by
all clones
Stains bradyzoites and tachyzoites. Targets Toxoplasma gondii p30 surface
antigen
Specific for varicella zoster; does not cross-react
Genus specific only
In Situ Hybridization
337
338
Fig. 14.6. Immunocytochemistry. (Left) A CSF specimen showing immunoreactive cryptococcal yeast (high magnification). (Right) Direct smear
of a Merkel cell carcinoma showing positive staining of tumor cells with
CM2B4, a monoclonal antibody to exon 2 peptides of the Merkel cell
polyomavirus (MCPyV) T antigen (intermediate magnification).
In Situ Hybridization
339
340
Fig. 14.9. HPV-ISH of a cervix condyloma. Tissue biopsy of this condyloma shows patchy positive nuclear staining for low-risk HPV in surface
koilocytes (low magnification).
Fluorescent Stains
341
Fluorescent Stains
342
Fig. 14.12. Fluorescence of Candida from an oral smear (high magnification) (courtesy of Dr. Shabnum Meer, Division of Oral Pathology, University of the Witwatersrand, Johannesburg).
Flow Cytometry
343
Flow Cytometry
344
Serology
The nucleic acid hybridization assay is used to detect and quantify RNA or DNA targets. The assay does not require preamplification of the nucleic acid to be detected. Enzymes are used to
indicate the extent of hybridization, but unlike PCR are not used
to manipulate the nucleic acids. This technology facilitates high
throughput assays that can be used on a large number of samples
(e.g., HPV testing).
The Digene Hybrid Capture II (HC II) assay is a nucleic acid
hybridization microplate assay. It is an FDA-approved test used
to detect HPV DNA from both low- and high-risk HPV types.
There are several steps involved in the HC II assay (Fig.14.14).
345
Fig. 14.14. Hybrid Capture II assay steps. (1) Target DNA is denatured.
(2) RNA-probes hybridize with target DNA. (3) The RNA-DNA hybrids
are captured onto the microplate well surface. (4) Amplification of hybrids
with multiple antibodies conjugated to an enzyme (alkaline phosphatase).
(5) The enzyme cleaves a chemiluminescent substrate, emitting light that
gets measured.
separates into two single-stranded DNA pieces. At medium temperatures, short DNA fragments (primers) containing sequences
complementary to the target region pair up (anneal) with the single-stranded DNA together with a DNA polymerase that starts
to copy the template. The template is then coupled to the primer,
producing a double-stranded DNA molecule. As the process is
repeated, more and more copies are exponentially produced.
The copies are referred to as amplicons. Very small quantities
can be amplified and analyzed, making cytology an appropriate
medium for PCR.
In the past, traditional PCR was time consuming. Today, rapid
cycle or real-time PCR methods are quicker and easier to perform. These are carried out in a closed system in which both
amplification and detection occur, reducing the potential for
contamination and false-positive results. Monoplex assays for
the detection of a single organism and multiplex assays, whereby
several organisms can be simultaneously detected are available.
PCR is useful for the diagnosis of organisms that are slow growing, fastidious or cannot be easily cultured (e.g., M. tuberculosis, Legionella pneumophila, or P. jirovecii). PCR also permits
quantification of these organisms.
Problems related to PCR include false-positive (e.g., due to contamination) and false-negative (e.g., technical failure) results.
346
347
Fig. 14.15. Real-time PCR amplification curve for HHV-8 over 50 cycles.
The colored lines indicate different patients. Patients indicated with blue and
yellow lines are positive for HHV-8 DNA, while the samples from patients
indicated by red, purple and pink lines do not have HHV-8 DNA (courtesy
of Sharlene Naidoo, Department of Anatomical Pathology, University of
the Witwatersrand, Johannesburg).
The role of electron microscopy (EM) has been greatly diminished in recent times with the development of new techniques
described above. This holds true for the diagnosis of infectious
diseases. However, the ultrastructural features of many pathogens have been well described and EM can certainly serve as a
useful adjuvant diagnostic modality when others are unavailable
or unsuccessful.
348
Fig. 14.16. Culture plate of Nocardia spp. This photograph was taken
through a dissecting microscope and shows waxy and bumpy colonies on
culture (courtesy of Dr. Warren Lowman, Department of Microbiology,
University of the Witwatersrand, Johannesburg).
349
Suggested Reading
Armbruster C, Pokieser L, Hassl A. Diagnosis of Pneumocystis carinii
pneumonia by bronchoalveolar lavage in AIDS patients. Comparison
of Diff-Quik, fungifluor stain, direct immunofluorescence test and
polymerase chain reaction. Acta Cytol. 1995;39:108993.
Atkins KA, Powers CN. The cytopathology of infectious diseases. Adv
Anat Pathol. 2002;9:5264.
Bancroft J, Gamble M. Theory and practice of histological techniques. 6th
ed. London: Churchill Livingstone; 2008.
Bravo L, Procop G. Recent advances in diagnostic microbiology. Semin
Hematol. 2009;46:24858.
Eyzaguirre E, Haque AK. Application of immunohistochemistry to infections. Arch Pathol Lab Med. 2008;132:42431.
Hubbard RA. Human papillomavirus testing methods. Arch Pathol Lab
Med. 2003;127:9405.
Lott RL. Fungi. In: Brown RW, editor. Histologic preparations: common
problems and their solutions. Chicago: CAP Press; 2009. p. 8594.
Nuovo GJ. The surgical and cytopathology of viral infections: utility of
immunohistochemistry, in situ hybridization, and in situ polymerase
chain reaction amplification. Ann Diagn Pathol. 2006;10:11731.
Oliveira A, French C. Application of fluorescence in situ hybridization in
cytopathology. A review. Acta Cytol. 2005;49:58794.
Woods GL, Walker DH. Detection of infection or infectious agents by use
of cytologic and histologic stains. Clin Microbiol Rev. 1996;9:382404.
15
351
352
Koilocytes are squamous epithelial cells that exhibit structural changes following HPV infection. These cellular changes
include nuclear enlargement and irregularity, hyperchromasia,
and a perinuclear halo. When intracytoplasmic glycogen gets
dissolved, leaving a large clear space around the nucleus, these
cells in a Pap test may mimic koilocytes (Fig.15.1). However,
such koilocyte-like cells lack all other morphological features of
dysplasia. Nonspecific perinuclear halos within superficial and
intermediate squamous cells in Pap tests may be associated with
353
Potential mimic
Pneumocystis cast, Cryptococcus yeast
Extracellular parasites
Parasite ova and fungi
Parasite ova
Worms
Ciliated parasite and flagellated protozoa
Parasitic ova and fungal yeast
Endosporulating fungi
Worms
Exogenous structure
Pollen
Dirt
Vegetable matter
Synthetic fibers and thread
Dust and powder
Lubricant
Parasite ova
Bacteria
Viral change and worms
Worms
Parasite ova
Pneumocystis cast
354
Ancillary Studies
356
Fig. 15.4. Normal oral flora. (Upper left, high magnification) Sarcina
forms on a sputum smear, illustrating their characteristic appearance in
tetrads (buckets of eight elements). This type of bacteria is frequently
observed as a commensal flora in the mouth (Pap stain). (Bottom left, high
magnification) Leptotrichia buccalis present as a contaminant on a sputum smear (Pap stain). (Upper right, high magnification) Actinomyceslike organisms contained within a sputum smear. Their presence indicates
oral contamination and not a true infection (Pap stain). (Bottom right,
intermediate magnification) Oropharyngeal contamination composed of
anucleate squames and filamentous bacteria present within the cell block
of a bronchoalveolar lavage specimen (H&E stain).
357
Ancillary Studies
Gram stain
Bacterial culture
358
Fungal elements
Club-shaped septate conidia
Fruiting body and septate hyphae
Dark conidia with branching chains
Sickle-shaped septate conidia
Fruiting structures and septate hyphae
359
360
Fig. 15.7. Red blood cell fungal mimics. (Upper left) Acetic acid effect is
shown on erythrocytes in a Pap smear. Due to their decoloration, these red
blood cells may be misinterpreted as fungal yeast. Their size, relatively
uniform morphology, and absence of both budding and clear halos are
important keys to the differential diagnosis (Pap stain, high magnification). (Bottom left) Erythrocytes contained within a bronchoalveolar lavage
(BAL) smear mimic Pneumocystis microorganisms. Red blood cells have
irregularities and thickenings in their outlines and condensation of content
in the center (Pap stain, high magnification). (Upper right) Degenerated
erythrocytes on a cervicovaginal smear, likely due to ethanol. Because of
their appearance, they could be confused with fungal yeasts (Pap stain,
high magnification). (Bottom right) Granular bloody cast seen in a BAL
specimen resembling an alveolar cast of Pneumocystis infection. Unlike a
true cast, this blood aggregate has irregular edges (Pap stain, intermediate
magnification).
361
Yeast
36
Round-ovoid
Variable
Yes
Yes
No
Erythrocyte
57
Round
Red-orange
No
No
No
Fig. 15.8. Fungal mimics. Multiple structures are shown that resemble
fungal hyphae, as seen within several direct smear preparations (Pap and
Diff-Quik stains, high magnification).
Macrophages containing phagocytosed material within intracytoplasmic vacuoles may be mistaken for organisms such as
Histoplasma capsulatum.
Talc granules from talcum powder can mimic fungal yeast
(Fig.15.9). Talc is a mineral composed of hydrated magnesium
silicate. The granules form crystalloid, transparent, and polygonal
362
363
Fig. 15.10. Pollen grains (high magnification images). (Upper left) Pollen
grains belonging to the Betulaceae family seen within a sputum smear. In
these structures, a refractile capsule and three surface apertures (pores) are
observed (Pap stain). (Bottom left) Pollen grain belonging to the Pinaceae
family present within a sputum smear. Because their airborne sacs are
broken, the undulations on the wrinkled surface may mimic an Ascaris
lumbricoides egg (Pap stain). (Upper right) Pollen grains belonging to
the Liliaceae family detected on a sputum smear. The grains are large
(about 300150mm), ovoid in shape, with refractile capsules and notable
folds on the surface (Pap stain). (Bottom right) Pollen grains belonging to
the Caryophyllaceae family present within a sputum smear. Due to their
round shape (approximately 70mm in diameter) and evident capsule, these
structures may be mistaken for Toxocara eggs (Pap stain).
seen with a Pap stain, but fail to stain with GMS and PAS stains.
They may resemble endosporulating fungi like coccidiomycosis
and rhinosporidiosis, as well as other sporangia.
Ancillary Studies
364
Fig. 15.11. Calcification mimicking fungal (left) hyphae and (right) yeast
(H&E stain, intermediate magnification).
365
366
367
I nfections due to B. coli are rare and mainly involve the large
intestine. B. coli are much larger (40100mm) than ciliocytophthoria (1012mm). Ciliocytophthoria usually demonstrate cilia
resting on a terminal bar predominantly along one edge whereas
B. coli are uniformly covered with cilia. Also, ciliocytophthoria
368
are anucleate compared to B. coli which contain a macronucleus. Multi-flagellated protozoa show irregular insertion of
flagella, absence of a terminal bar, and prominent nuclear halos.
One may also find detached single cilia in brochoalveolar lavage specimens that mimic bacilliform structures.
Leisegang rings (or bodies) are nonpolarizable laminated ringlike structures (Fig.15.15) occasionally found in benign cysts
and abscesses. They are of variable size (3800 mm), usually
have a double-layer outer wall, faint radial striations, and an
amorphous central core. They may be confused with parasites
(especially eggs), but also with algae and psammoma bodies.
Unlike ova, they lack flattening on one side or at the poles and
show marked variation in size. They are easily observed with
Pap (green color), H&E (pink), Diff-Quik (purple) stains, and
a few other (Massons trichrome, acid-fast, Gram) stains which
accentuate their concentrically laminated morphology. They do
not stain with GMS, PAS, or von Kossa stains.
369
Fig. 15.15. Leisegang rings. These cell block specimens prepared from
fine needle aspirates of hemorrhagic cysts show laminated ring-like structures. (Left) The bodies present are of variable size and shape. Some rings
contain a distinct double-layer outer wall (H&E stain, intermediate magnification). (Right) In these two darker colored Leisegang rings, one can
see faint radial striations and an amorphous central nidus (H&E stain, high
magnification).
Ancillary Studies
370
371
372
Fig. 15.18. Algae (high magnification images). (Upper left) Diatom frustule (Navicula spp.) present within a sputum smear. Note the characteristic thick silicified cell wall, elongate shape, and presence of transversal
striations in this diatom (Pap stain). (Bottom left) The freshwater red algae
belonging to Rhodophyta was identified in this Pap smear. The round
forms are arranged as beads on a necklace (Pap stain). (Upper right) Sputum smear in which a sphere-like structure containing numerous round
cells was identified, compatible with Eudorina spp. (Pap stain). This
could be mistaken for adenocarcinoma. (Bottom right) In this cervicovaginal smear, there is an unbranched filament (Ulothrix spp.) with identical
C-shaped chloroplasts and thick cellular walls (Pap stain).
373
Ancillary Studies
374
Ancillary Studies
375
Fig. 15.20. Carpet beetle. (Left) Bottom portion of a carpet beetle larva
covered with many hairy bristles (low magnification). (Right) A carpet
beetle hair contaminant present on a cervicovaginal Pap test (Pap stain,
high magnification).
376
Fig. 15.22. Water contaminant on a sputum smear. This image shows part
of an aquatic insect (Daphnia spp.) with numerous filtering filaments (Pap
stain, high magnification).
Suggested Reading
Avrin E, Marquet E, Schwarz R, Sobel H. Plant cells resembling tumor
cells in routine cytology. Am J Clin Pathol. 1972;57:3035.
Hadziyannis E, Yen-Lieberman B, Hall G, Procop GW. Ciliocytophthoria
in clinical virology. Arch Pathol Lab Med. 2000;124:12203.
Martnez-Girn R. Sporangia, sporangium-like spherules and mimicking
structures in respiratory cytology. Diagn Cytopathol. 2010;38:8979.
Martnez-Girn R, Gonzlez-Lpez JR, Escobar-Stein J, Jou-Muoz
C, Garca-Miralles M, Ribas-Barcel A. Freshwater microorganisms
and other arthropods in Papanicolaou smears. Diagn Cytopathol.
2005;32:2225.
Martnez-Girn R, Gonzlez-Lpez JR, Esteban JG, Garca-Miralles MT,
Alvarez-de-los-Heros C, Ribas-Barcel A. Worm-like artifacts in exfoliative cytology. Diagn Cytopathol. 2006;34:6369.
Martnez-Girn R, Jodra-Fernndez O, Tormo-Molina R, Esteban JG,
Ribas-Barcel A. Uncommon structures simulating helminth eggs in
sputum. Acta Cytol. 2005;49:57880.
Martnez-Girn R, Ribas-Barcel A. Algae in cytologic smears. Acta
Cytol. 2001;45:93640.
377
Martnez-Girn R, Ribas-Barcel A, Garca-Miralles MT, LpezCabanilles D, Tamargo-Pelez ML, Torre-Bayn C, et al. Airborne
fungal spores, pollen grains, and vegetable cells in routine Papanicolaou smears. Diagn Cytopathol. 2004;30:3815.
Martnez-Girn R, Ribas-Barcel A, Garca-Miralles MT, LpezCabanilles D, Tamargo-Pelez L, Torre-Bayn C, et al. Diatoms and
rotifers in cytological smears. Cytopathology. 2003;14:702.
Rivasi F, Tosi G, Ruozi B, Curatola C. Vegetable cells in Papanicolaoustained cervical smears. Diagn Cytopathol. 2006;34:459.
Index
A
Abscess, 132
brain, 219221
breast, 259
liver, 176179
Acid-fast stains, for mycobacteria,
327, 328
Actinomyces, 51, 53
gynecological infections
ancillary tests, 106
clinical features, 104, 105
cytomorphologic features, 105
diagnosis, 105
microbiology, 104
pulmonary infections
ancillary studies, 133
clinical features, 132
cytomorphologic features,
132133
differential diagnosis, 133
microbiology, 132
Adenovirus, 44
pulmonary infections
ancillary studies, 128
clinical features, 127
cytomorphologic features,
127128
differential diagnosis, 128
pneumonia, 126, 128
urinary tract infections, 192
AIDS-related lymphomas (ARL), 309
Algae, 8283
Allergic mucin, 1516
Amebae (sarcodina), 71
Anal disease, 303304
Anal Pap test, 176, 177
Ancillary investigations
bacterial stains
acid-fast stains,
mycobacteria, 327
Gram stain, 324325
Helicobacter pylori, 325326
WarthinStarry stain,
326327
cell blocks, 323
culture and sensitivity, 347348
electron microscopy (EM), 347
flow cytometry, 343
fluorescent stains, 341343
fungal stains
characteristics, 328, 330
Fontana-Masson stain, 331
immunocytochemistry
antibodies, 335337
Aspergillus, 335, 338
Pap test, 335, 339
in situ hybridization (ISH)
advantages, 335
cervix condyloma, 339, 340
EpsteinBarr virus, 339, 341
infectious mononucleosis.,
339, 340
polymerase chain reaction (PCR)
amplicons, 345
DNA sequencing and melt
curve analysis, 346
379
380
Ancillary investigations (cont.)
microarray technology,
346, 347
postamplification
analysis and reverse
hybridization, 346
uses, 345
Rickettsial stains, 331332
routine cytology stains
H&E stain, 323
Pap stain, 322
Romanowsky stains, 322
Toluidine blue, 323
serology, 344
signal amplification
assay, 344, 345
stains, parasites, 332
viral stains, 332334
wet mount preparation, 324
Angiostrongyliasis, 229230
Animal contaminants and mimics
carpet beetles, 373, 375
dust mites, 373, 375
insects, 373, 374
invertebrates, 373
Antiretroviral therapy (ART), 302
Apicomplexa, 7476
ARL. See AIDS-related
lymphomas (ARL)
Arthritis, 273274
Aseptic meningitis. See Viruses,
meningitis
Aspergillosis
ancillary studies, 148149
clinical features, 147
cytomorphologic features,
147148
differential diagnosis, 148
microbiology, 147
paragonimus eggs, 149
in ThinPrep preparation, 148
toxoplasmosis, in BAL
specimen, 156
Aspergillus, 5860, 62
crystal formation in, 34
Asteroid bodies. See SplendoreHoeppli phenomenon
Index
B
Bacillary angiomatosis, 274276
Bacilliary peliosis, 252
Bacteria
acid-fast stains, mycobacteria
chemical property, 327, 328
modified fite stain, 327, 329
ZiehlNeelsen stain, 327, 329
acute meningitis
ancillary studies, 212
clinical and cytomorphologic
features, 210
differential diagnosis, 211
microbiology, 209
anerobic bacteria, 47
Chlamydia, 5154
conjunctivitis, 296
cystitis
acute, 190
ancillary studies, 190
cytomorphologic features, 189
differential diagnosis, 190
follicular, 192
in urine, 191
eye infection, 296
filamentous bacteria, 5153
Gram-positive and Gram-negative,
4749
Gram stain, 324325
gynecological infections
Actinomyces, 104106
bacterial vaginosis
(BV), 101103
Chlamydia trachomatis,
108110
granuloma venereum,
106, 107
Neisseria gonorrheae,
103104
tuberculosis (TB), 106108
Helicobacter pylori, stains
for, 325326
mycobacteria, 4850
osteomyelitis, 273
pulmonary infections
Actinomyces, 132133
Legionella, 137138
Index
Nocardia, 133134
tuberculosis (TB), 135137
rhinosinusitis, 291
WarthinStarry stain, 326327
Bacterial vaginosis (BV)
ancillary tests, 102103
clinical features, 102
cytomorphologic features, 102
diagnosis, 102
microbiology, 101
vaginal flora, shift in, 101
Bacteriology, 7, 8
Bartonella henselae, 326
bone and joint infections, 274
lymph node infections, 234236
spleen infections, 252
Bartonella quintana, 326
Benign lymphoepithelial cysts
(BLECs), 306308
Bilharzia. See Schistosomiasis
BK virus (BKV), 4445
ancillary studies, 197
clinical features, 194195
cytomorphologic features,
195197
decoy cells, 194, 195
differential diagnosis, 197
microbiology, 193194
polyoma virus infection, 196
Bladder schistosomiasis, 200
Blastomyces, 61, 63, 66
Blastomyces dermatitidis, 219
Blastomycosis, 142
ancillary studies, 221
clinical features, 219
cytomorphologic features, 220
differential diagnosis, 220
microbiology, 219
BLECs. See Benign lymphoepithelial
cysts (BLECs)
Bone and joint infections
arthritis, 273274
bacillary angiomatosis, 274276
bacterial osteomyelitis, 273
Cryptococcus, 273
synovial fluid characteristics,
274, 275
381
Botryomycosis, 271
Brain abscess, 219221
Breast abscess, 259
Breast infections
acute mastitis and abscess
ancillary studies, 261
clinical features and
definition, 259
cytomorphologic features,
260261
subareolar abscess, 259
chronic and granulomatous
mastitis, 261262
inflammatory lesions, 257, 258
lymphoma, 259
parasitic, 262
Staphylococcus aureus, 257
Bronchoalveolar (BAL) specimen
candidiasis in, 139
CMV and Pneumocystis
jirovecii, 127
herpes simplex virus, 124
Strongyloides stercoralis, 153
toxoplasmosis in, 156
BV. See Bacterial vaginosis (BV)
C
Calcium oxalate crystals, 33, 34
Candida, 5557, 62
Candida glabrata, 111, 112
cystitis, 199
esophagitis, 163
in gynecological infections
ancillary tests, 112
clinical features, 110
cytolomorphogic features,
110111
diagnosis, 111112
microbiology, 110
oropharyngeal infections
Candida albicans, 289
Candida glabrata, 290
Candidiasis
oral, 289291, 305
in pulmonary infections
ancillary studies, 140
382
Candidiasis (cont.)
in BAL specimen, 139
clinical features, 139
cytomorphologic features, 139
differential diagnosis, 140
microbiology, 138139
Cat scratch lymphadenitis, 234236
Cavity formation, 121, 135,
147, 157
Cell blocks, 323
Central nervous system (CNS)
infections, 11
acute bacterial meningitis
ancillary studies, 212
clinical and cytomorphologic
features, 210
differential diagnosis, 211
microbiology, 209
angiostrongyliasis, 229230
bacterial infections, 205, 206
blastomycosis
ancillary studies, 221
clinical features, 219
cytomorphologic features, 220
differential diagnosis, 220
microbiology, 219
brain abscess, 219222
cerebrospinal fluid pleocytosis,
205, 207
cryptococcal meningitis
ancillary studies, 219
clinical features, 218
cytomorphologic features,
218219
differential diagnosis, 219
microbiology, 217
CSF parameters, 206, 208
disease, in immunosuppressed
host
mass lesions, 312
meningitis, 310311
progressive multifocal
leukoencephalopathy,
313, 314
eosinophilic pleocytosis, 206
lymphocytic pleocytosis,
206, 209
Index
mollaret meningitis
ancillary studies, 216
clinical and cytomorphologic
features, 215
differential diagnosis, 216
microbiology, 214
monocytic pleocytosis, 206
neurocysticercosis, 227
neurosyphilis, 223225
neutrophilic pleocytosis, 206
primary amebic meningoencephalitis, 228
shunt infections, 222223
toxoplasmosis, 225227
tuberculous meningitis, 216217
viral meningitis
ancillary studies, 213214
clinical features, 212
cytomorphologic features,
212213
differential diagnosis, 213
microbiology, 212
Cervical carcinoma, 92
Cervicofacial actinomycosis
Actinomyces israelii, 287
oral actinomyces flora., 287, 288
Cervicovaginal disease, 303304
Cestodes (tapeworms), 7879
Charcot-Leyden crystals, 16, 33
Chlamydia
Chlamydia pneumonia, 52
Chlamydia psittaci, 53
Chlamydia trachomatis, 53, 236
ancillary tests, 109110
clinical features, 109
cytomorphologic features, 109
diagnosis, 109
microbiology, 108
forms, 51
Chlamydial eye infection, 296
Chlamydomonadales, 373
Chromomycosis, 270271
Ciliates (ciliophora), 73
Ciliocytophthoria, 2829
CMV. See Cytomegalovirus (CMV)
Coccidian diseases, 74
Coccidioides, 63, 66
Index
Coccidioidomycosis
ancillary studies, 146147
clinical features, 144
cytomorphologic features, 144145
differential diagnosis, 145
microbiology, 143144, 146
Condyloma accuminatum
(anogenital warts), 92
Conidia, 55
Contaminants and mimics
animal
carpet beetles, 373, 375
dust mites, 373, 375
insects, 373, 374
invertebrates, 373
artifacts, 351
bacterial infection, 356357
endogenous and exogenous
structures, 352, 353
fungal infection
Alternaria spp., 357, 358
ancillary studies, 363
calcification, 362, 364
cytomorphological features,
358, 361
fungal contaminants, 357,
358, 359
Histoplasma capsulatum, 361
myospherulosis, 362
pollen grains, 362, 363
red blood cell, 358, 360
spermatozoa, 360
talc granules, 361, 362
parasitic infection
(see Parasites, mimics
and contaminants)
plant
algae, 371373
ancillary studies, 373
asterosclereids, 369, 370
pollen grains, 370
sporangia, 371
trichomes, 370, 371
viral infection
ancillary studies, 354
cellular degeneration, 353
koilocytes, 352
383
potential pitfall, 354
vegetable parenchymal
cells, 353
Coronavirus, 44
Cresyl violet acetate, 326
Cryptococcal meningitis
ancillary studies, 219
clinical features, 218
cytomorphologic features,
218219
differential diagnosis, 219
microbiology, 217
Cryptococcosis, pulmonary
infections
ancillary studies, 143
clinical features, 143
cytomorphologic features, 143
microbiology, 142143
pneumonia, 144, 145
Cryptococcus, 5658
Cryptococcus neoformans
in CNS infections, 217
lymph node infections, 242, 243
Cryptosporidiosis, in gastrointestinal
infections
ancillary studies, 171
cytomorphologic features, 169
differential diagnosis, 170
gastric brushing specimen, 170
immunocompetent patients, 169
Cryptosporidium spp., 75
Crystal formation, 3334
Curschmann spirals, 364, 365
Cutaneous mycoses
botryomycosis, 271
dematiaceous fungi, 267, 270271
dermatophytosis, 266, 270
mycetoma, 271
sporotrichosis, 270
Cutaneous parasites
cysticercosis, 272
leishmaniasis, 271272
parasitic infections, 271
Cysticercosis, 272
Cytology, 5
FNA, 2
infections, diagnosis of, 2
384
Cytology (cont.)
microorganisms, 2
molecular studies, 1, 3
routine stains
H&E stain, 323
Pap stain, 322
Romanowsky stains, 322
Toluidine blue, 323
specimen
diagnosis, 2
procurement, 1
triage, 2
Cytomegalovirus (CMV), 42
clinical features, 99100
cytomorphologic features, 100
diagnosis, 100
gastrointestinal infections
ancillary studies, 167
cytomorphologic features,
165166
differential diagnosis,
166167
endothelial cells, 165, 166
esophageal brushing,
165, 166
lymphadenitis, 249250
microbiology, 99
Molluscum contagiosum,
99, 100
pulmonary infections, 125127
urinary tract infections, 193
D
Daphnia, 373
Decoy cells, in BK polyomavirus,
194, 195
Dematiaceous fungi, 6970
Demodex folliculorum, 265
Dermatophytes, 70
Dermatophytosis, 266, 270
Diatoms, 371372
Dieterle stain, 327
Diffuse infiltrative lymphocytosis
(DILS), 308
Dirofilariasis, 153154
Donovanosis, 106, 107
Index
E
Echinococcosis. See Hydatid disease
Echinococcus granulosus, 79, 80
spleen infections, 255
Emperipolesis, 2628
Empyema, pleural infections
and, 159
Entamoeba, 156157
Enterobius vermicularis, 7981
ancillary tests, 118
clinical features, 117
cytomorphologic features, 117
diagnosis, 117118
microbiology, 117
Eosinophilia
and allergic mucin
ancillary studies, 16
Charcot-Leyden crystals, 16
cytomorphologic features, 15
differential diagnosis, 15
pleocytosis, 207
EpsteinBarr virus (EBV), 42, 43
mesenchymal tumors, 316317
related lymphadenopathy (see
Infectious mononucleosis
lymphadenitis)
Eye infection
bacterial, 296
chlamydial, 296
fungal, 296297
parasitic, 297298
Pththirus pubis, 294
viral ophthalmic infections, 295
F
Female genital tract infections, 85, 86
Filamentous bacteria, 5153
Filariae, 8182
Fine needle aspiration (FNA), 2, 910
of hydatid cyst fluid, 180
of Nocardia pneumonia, 134
Flagellates (Mastigophora), 7173
Fluids, 9, 12
Flukes. See Trematodes (flukes)
Fluorescent stains
Candida, 342
Index
Mycobacterium tuberculosis,
342, 343
Pneumocystis jirovecii, 341
FNA. See Fine needle aspiration
(FNA)
Follicular (lymphocytic)
cervicitis, 87
Follicular cystitis, 192
Follicular dendritic cell sarcoma,
317, 318
Fontana-Masson stain, 331
Free-living amebae, 71
Freshwater red algae, 372, 373
Freshwater water fleas, 373
Fungi, 7, 9
Aspergillus, 5860
Candida, 5557, 110112
casts, 184, 188
conidia, 55
Cryptococcus, 5658
dematiaceous, 6970
dermatophytes, 70
dimorphic fungi, 55
Blastomyces, 61, 63, 66
Coccidioides, 63, 66
Histoplasma, 6667
morphology of, 6465
Paracoccidioides, 66
Penicillium, 68
Sporothrix, 66, 67
esophagitis
ancillary studies, 162163
Candida, 163
cytomorphologic features,
162, 163
differential diagnosis, 162
immunocompetent and
immunocompromised
patients, 161
eye infection, 296297
hyalohyphomycosis, 70
hyphae, 54
kidney infections, 188189
lymphadenitis, 242244
mimics
Alternaria spp., 357, 358
ancillary studies, 363
385
calcification, 362, 364
cytomorphological features,
358, 361
fungal contaminants, 357,
358, 359
Histoplasma capsulatum, 361
myospherulosis, 362
pollen grains, 362, 363
red blood cell, 358, 360
spermatozoa, 360
talc granules, 361, 362
morphology, 55
osteomyelitis, 273
Pneumocystis, 68, 69
pulmonary infections
aspergillosis, 147149
blastomycosis, 142
candidiasis, 138140
coccidioidomycosis, 143147
cryptococcosis, 142143
histoplasmosis, 140141
morphology of, 138
mucormycosis
(zygomycosis), 149150
pneumocystis, 150152
stains
characteristics, 328, 330
Fontana-Masson stain, 331
urinary tract infections
acute candida cystitis, 199
ancillary studies, 198199
clinical features, 198
cytomorphologic features, 198
differential diagnosis, 198
microbiology, 197
yeasts, 54, 6465
zygomycetes, 5963
G
Gastrointestinal system infections, 11
anal Pap test, 176, 177
cryptosporidiosis, 169171
cytomegalovirus, 165167
diagnosis of, 161
fungal esophagitis, 161163
giardiasis, 171172
386
Gastrointestinal system (cont.)
Helicobacter pylori gastritis,
167169
herpes simplex viruses, 163165
microsporidiosis, 172174
Mycobacterium avium complex
(MAC), 174176
Genital tract, 10
Giardia, 71
Giardiasis, 171172
Giemsa/Gimenez stain, 326, 332
Gram-positive and Gram-negative
bacteria, 4749
Gram stain, 324325
Granulomatous inflammation
ancillary studies
multinucleated foreign
body-type giant cell, 18
necrotizing granulomatous
inflammation, 19
neoplasia, 20
non-necrotizing granulomatous
inflammation, 19
cytomorphologic features, 17, 20
differential diagnosis, 1718
Granulomatous lymphadenitis
morphologic patterns, 238, 239
necrotizing, 237, 238
non-necrotizing, 237
Granulomatous mastitis, chronic,
261262
Granulomatous sialadenitis, 283
Granuloma venereum, 106, 107
Gynecological infections
acute inflammation, 87
bacterial infections
Actinomyces, 104106
bacterial vaginosis
(BV), 101103
Chlamydia trachomatis,
108110
granuloma venereum, 106, 107
Neisseria gonorrheae,
103104
tuberculosis (TB), 106108
Candida, 110112
epithelial change, 87
Index
female genital tract, 85, 86
follicular (lymphocytic)
cervicitis, 87
Leptothrix vaginalis, 9091
normal flora, 8790
Pap tests, inflammatory cells, 88
parasitic infections
Enterobius vermicularis,
117118
schistosomiasis, 115117
Trichomonas vaginalis,
112114
Phthirus pubis (insects), 119
viral infections
cytomegalovirus
(CMV), 99100
herpes simplex virus
(HSV), 9599
human papillomavirus
(HPV), 9195
H
Haemophilus influenzae, in CNS
infections, 209
Hashimotos thyroiditis, 285
Head and neck infections
ear infections, 298
eye infection
bacterial, 296
chlamydial, 296
fungal, 296297
parasitic, 297298
Pththirus pubis, 294
viral ophthalmic
infections, 295
infected embryologic cysts,
293295
oropharyngeal infections
cervicofacial actinomycosis,
287289
HPV transmission, 285
HSV, 286287
oral candidiasis, 289291
peritonsillar abscess, 285
salivary gland infections
acute sialadenitis, 280281
Index
Candida and Cryptococcus,
280
chronic sialadenitis, 281282
granulomatous sialadenitis, 283
paramyxovirus, 280
Staphylococcus aureus, 279
sinonasal infections
invasive fungal, 291
mucormycosis, 292
noninvasive fungal, 291
rhinoscleroma, 292
rhinosporidiosis, 293
thyroid gland infections
anaplastic carcinoma, 285
granulomatous thyroiditis, 285
infective thyroiditis, 283, 284
Helicobacter pylori
bacterial stains, 325326
gastritis
ancillary studies, 168169
cytomorphologic features, 167
differential diagnosis, 168
mucosal biopsy, 167, 168
Helminths (parasitic worms), 7682
Hematologic infections
cytomorphologic patterns,
231, 232
lymph node (see Lymph node
infections)
spleen
bacilliary peliosis, 252
hydatid cyst, 254255
infectious mononucleosis,
254255
mycobacterial infection,
253254
splenitis and splenic
abscess, 253
Hematoxylin and eosin (H&E)
stain, 323
Hemophagocytosis and
emperipolesis
ancillary studies, 28
cytomorphologic features, 27
differential diagnosis, 27
Hepatic amebic abscess, 178
Hepatitis viruses, 46
387
Herpes simplex virus (HSV)
gastrointestinal infections
ancillary studies, 165
cytomorphologic features, 164
differential diagnosis, 165
esophageal brushings, 164
gynecological infections
ancillary tests, 99
clinical features, 9697
cytomorphologic features, 97
diagnosis, 9899
microbiology, 9597
keratitis, 295
lymph node infections, 247
oropharyngeal disease, 305306
oropharyngeal infections, 286287
pulmonary infections
ancillary studies, 124125
BAL specimen, 124
clinical features, 123
cytomorphologic features, 123
differential diagnosis, 124
measles pneumonia, 125
types 1 and 2 (HSV1 and
HSV2), 40, 42
urinary tract infections, 192
Herpesvirues, 4043
High-grade squamous intraepithelial
lesion (HSIL), 93, 94
Highly active antiretroviral therapy
(HAART), 302
Histoplasma, 6667
Histoplasmosis, in pulmonary
infections
ancillary studies, 141
clinical features, 140
cytomorphologic features, 140
differential diagnosis, 140141
microbiology, 140
Hodgkin lymphoma, 310
Host reactions, to infection, 14
acute (purulent) inflammatory
response, 1315
ciliocytophthoria, 2829
crystal formation, 3334
eosinophilia and allergic
mucin, 1516
388
Host reactions, to infection (cont.)
granulomatous inflammation,
1620
hemophagocytosis and
emperipolesis, 2628
impaired cell-mediated
immunity, 25
inflammatory pseudotumor
reaction, 3233
IRIS, 2526
malakoplakia, 3032
necrosis, 2122
reactive epithelial and
mesenchymal repair, 2324
Splendore-Hoeppli phenomenon,
3436
viral cytopathic effect, 2223
xanthogranulomatous
inflammation, 29, 30
HPV. See Human papillomavirus
(HPV)
HSV. See Herpes simplex virus
(HSV)
Human herpesvirus8 (HHV8)associated lymphomas
HIV-associated lymphomatous
effusion, 310, 312
primary effusion lymphoma,
310, 311
Human herpesviruses (HHV),
41, 42
Human immunodeficiency virus
(HIV) infection
AIDS-defining conditions,
302, 303
lymphadenopathy, 250251,
304, 305
Human papillomavirus (HPV)
anal disease, 303304
cervicovaginal disease, 303304
gynecological infections
ancillary tests, 95
clinical features, 92
cytomorphologic features,
9294
diagnosis, 94
microbiology, 9192
Index
p16 immunocytochemistry,
95, 96
urinary tract infections, 192, 194
Hyalohyphomycosis, 70
Hybrid capture II assay, 344, 345
Hydatid cyst, 255
Hydatid disease
cytomorphologic features,
179180
differential diagnosis, 180
fine needle aspirate of, 180
pulmonary infections, 157158
Hyphae, 54
I
Immune reconstitution inflammatory
syndrome (IRIS),
2526, 302
Immunocytochemistry
antibodies, 335337
Aspergillus, 335, 338
Pap test, 335, 339
p16, for HPV, 95, 96
Immunosuppressed host
central nervous system disease
mass lesions, 312
meningitis, 310311
progressive multifocal
leukoencephalopathy,
313, 314
human immunodeficiency virus
(HIV) infection, 302
human papilloma virus
anal disease, 303304
cervicovaginal disease,
303304
lymphadenopathy, 304305
lymphoproliferative disorders
ARL, 309
Hodgkin lymphoma, 310
human herpesvirus8
(HHV8)-associated
lymphomas, 310
plasmablastic lymphoma,
309310
PTLD, 308309
Index
oropharyngeal disease
herpes simplex virus,
305306
OHL, 305, 307
oral candidiasis, 305
Penicillium marneffei infection,
299, 300
pulmonary disease
effusions, 315316
infection, 314
neoplasia, 315
renal disease, 316
salivary gland lesions, 306308
spindle cell lesions, 316318
transplantation, 300301
Impaired cell-mediated
immunity, 25
Infected branchial cleft cyst,
293295
Infectious mononucleosis
lymphadenitis, 248249
Inflammatory pseudotumor reaction
ancillary studies, 33
cytomorphologic features, 32
differential diagnosis, 33
Influenza viruses, 44
Insects, 119
In situ hybridization (ISH)
advantages, 335
cervix condyloma, 339, 340
EpsteinBarr virus, 339, 341
infectious mononucleosis.,
339, 340
Intestinal amebae, 71
Intra-abdominal infections
diagnosis of, 161
hydatid disease, 178181
liver abscesses, 176179
pancreatitis, 178
peritoneal effusion, 181
IRIS. See Immune reconstitution
inflammatory syndrome
(IRIS)
J
JC virus (JCV), 45
389
K
Kaposi sarcoma, spindle cell
lesions, 316
Kaposis sarcoma-associated herpes
virus (KSHV), 42
Kidney infections
fungal, 188189
pyelonephritis
acute, 183184
chronic, 184185
renal tuberculosis, 187188
xanthogranulomatous pyelonephritis (XPN), 185187
Klebsiella rhinoscleromatis, 292
Koilocytosis and HPV, 93
L
Lactobacilli, 8789
Lactol-phenol cotton blue (LPCB)
stain, 331
Legionella, 137138
Leishmania, 7274
Leishmania lymphadenitis, 245247
Leishmaniasis, 271272
Leprosy
ancillary studies, 270
bacteriologic index and morphologic indices, 265, 266
clinical features, 267268
cytomorphologic features, 269
differential diagnosis, 269
Mycobacterium leprae, 266
Leptothrix vaginalis, 9091
Liver abscesses, 176179
Lung infections, 121, 147. See also
Pulmonary infections
Lymph node infections
acute suppurative lymphadenitis
ancillary studies, 234
causative organisms, 231
cytomorphologic features, 233
differential diagnosis, 233234
cat scratch lymphadenitis,
234236
CMV lymphadenitis, 249250
fungal lymphadenitis, 242244
390
Lymph node infections (cont.)
granulomatous lymphadenitis,
237240
herpes simplex virus
lymphadenitis, 247
HIV-associated lymphadenopathy,
250251
infectious mononucleosis
lymphadenitis, 248249
leishmania lymphadenitis,
245247
lymphogranuloma venereum, 236
mycobacterial lymphadenitis,
240242
toxoplasma lymphadenitis,
244245
Lymphocytic pleocytosis, 206, 209
Lymphogranuloma venereum, 236
Lymphoproliferative disorders
ARL, 309
Hodgkin lymphoma, 310
human herpesvirus8 (HHV8)associated lymphomas, 310
plasmablastic lymphoma,
309310
PTLD, 308309
M
Malakoplakia, 190191, 193
ancillary studies, 32
cytomorphologic features, 31
differential diagnosis, 32
MichaelisGutmann bodies,
30, 31
Male genital tract infections,
202203
Measles, 130131
Merkel cell polyomavirus (MCV/
MCPyV), 45
MichaelisGutmann bodies, 30,
31, 193
Microbiology. See also specific
organisms
algae, 8283
bacteria, 4654
fungi, 5470
Index
parasites, 7082
viruses, 3746
Microfilariae, 8182
Microsporidia, 75
Microsporidiosis, 172174
Mikulicz cells, 292
Mimics. See Contaminants and
mimics
Mollaret meningitis
ancillary studies, 216
clinical and cytomorphologic
features, 215
differential diagnosis, 216
microbiology, 214
Molluscum contagiosum, 45,
99, 100
skin infections, 262, 263
Monocytic pleocytosis, 206
Mucormycosis (zygomycosis)
ancillary studies, 150
clinical features, 150
cytomorphologic features, 150
microbiology, 149
sputum specimen, 157
Multibacillary leprosy, 268
Multicentric Castleman disease
(MCD), 304
Musculoskeletal system infections,
11. See also Bone and
joint infections
Mycetoma, 271
Mycobacteria, 4850, 253254
lymphadenitis
Bacillus Calmette-Gurin
(BCG) vaccine, 241
granulomatous inflammation,
240, 241
tuberculous lymphadenitis, 240
osteomyelitis, 273
spindle pseudotumor, 316
Mycobacterium avium complex
(MAC)
ancillary studies, 175176
cytomorphologic features,
174175
differential diagnosis, 175
duodenal brushing specimen, 175
Index
Mycobacterium tuberculosis, 4950
CNS infections, 216
hematologic infections, 240
Mycology, 7
Myiasis, 265266
N
Naegleria fowleri, in CNS
infections, 228
Neck infections. See Head and neck
infections
Necrosis
cytomorphologic features, 2122
differential diagnosis and
ancillary studies, 22
Necrotizing granulomatous
inflammation, 19
Necrotizing granulomatous
pneumonia, 136
Neisseria gonorrheae, in
gynecological infections
ancillary tests, 104
clinical features, 103
cytomorphologic features, 103
diagnosis, 103
microbiology, 103
Neisseria meningitidis, 209
Nematodes (roundworms), 7982
Neurocysticercosis, 227
Neurosyphilis, 223225
Neutrophilic pleocytosis, 206
Nocardia, 51, 52
pulmonary infections, 133134
Nongonococcal uretheritis
(NGU), 203
Non-necrotizing granulomatous
inflammation, 19
Nontuberculous mycobacteria
(NTM), 50
Normal flora
clinical features, 89
cytomorphologic features,
8990
diagnosis, 90
lactobacilli, 89
microbiology, 8788
391
O
Ocular cryptococcosis, 297
OHL. See Oral hairy leukoplakia
(OHL)
Oral candidiasis, 289291, 305
Oral hairy leukoplakia (OHL),
305, 307
Oropharyngeal infections
cervicofacial actinomycosis,
287289
HPV transmission, 285
HSV, 286287
oral candidiasis, 289291
peritonsillar abscess, 285
Osteomyelitis, acute, 274
P
Pancreatitis, 178
Papanicolaou (Pap) test, 8
anal, 176, 177
inflammatory cells, 88
stain, 322
Papillomaviruses, 3839
Paracoccidioides, 66
Paragonimiasis, 154155
Parainfluenza virus, 44, 129130
Parasites
Apicomplexa, 7476
breast infections, 262
eye infection, 297298
gynecological infections
Enterobius vermicularis,
117118
schistosomiasis, 115117
Trichomonas vaginalis,
112114
helminths, 7682
mimics and contaminants
ancillary studies, 369
cellular degeneration,
366, 367
ciliocytophthoria, 366368
leisegang rings, 368, 369
parasite ova, 366
worms, 364, 365
osteomyelitis, 273
392
Parasites (cont.)
protozoa, 7074
pulmonary infections
dirofilariasis, 153154
echinococcosis (hydatid
disease), 157158
Entamoeba, 156157
paragonimiasis, 154155
pleural infections and
empyema, 159
strongyloidiasis, 154
Toxoplasma gondii,
155156
urinary tract infections
schistosomiasis, 199201
trichomoniasis, 201, 202
Parasitology, 7
Parvoviruses, 46
Paucibacillary leprosy, 268
Penicillium marneffei, 68
Peritoneal effusion, with
infection, 181
Peritonsillar abscess, 285
Phaeohyphomycosis, 271
Phloxine-tartrazine stain, 334
Phthirus pubis, 119
Phycomycosis, 292
p16 immunocytochemistry, for
HPV, 95, 96
Plant contaminants and mimics
algae, 371373
ancillary studies, 373
asterosclereids, 369, 370
pollen grains, 370
sporangia, 371
trichomes, 370, 371
Plasmablastic lymphoma, 309310
Pleural infections and
empyema, 159
Pneumocystis, 68, 69
ancillary studies, 152
clinical features, 151
cytomorphologic features, 151
differential diagnosis, 151152
microbiology, 150
Pneumocystis carinii, 152
Pneumocystis jirovecii, 323
Index
Pneumonia
adenovirus, 127
Cryptococcus, 144, 145
measles, 125
necrotizing granulomatous
pneumonia, 136
Nocardia, 134
tuberculosis, 136
Polymerase chain reaction (PCR)
amplicons, 345
DNA sequencing and melt curve
analysis, 346
microarray technology, 346, 347
postamplification analysis and
reverse hybridization, 346
uses, 345
Polyomaviruses, 4445, 196
Posttransplant infections, 300301
Posttransplant lymphoproliferative disorder (PTLD),
308309
Poxviruses, 45
Primary amebic meningoencephalitis, 228
Progressive multifocal leukoencephalopathy, 313, 314
Prototheca, 83
Protozoa
amebae (sarcodina), 71
ciliates (ciliophora), 73
flagellates (mastigophora), 7173
Pseudo-herpes, Pap test, 354, 355
Pseudokoilocytes, 352, 354
Pththirus pubis, 294
PTLD. See Posttransplant
lymphoproliferative
disorder (PTLD)
Pulmonary infections
bacterial infections
Actinomyces, 132133
Legionella, 137138
Nocardia, 133134
tuberculosis (TB), 135137
diagnostic method, 122
fungal infections
aspergillosis, 147149
blastomycosis, 142
Index
candidiasis, 138140
coccidioidomycosis, 143147
cryptococcosis, 142143
histoplasmosis, 140141
mucormycosis
(zygomycosis), 149150
pneumocystis, 150152
parasitic infections
dirofilariasis, 153154
echinococcosis
(hydatid disease), 157158
Entamoeba, 156157
paragonimiasis, 154155
pleural infections and
empyema, 159
strongyloidiasis, 154
Toxoplasma gondii, 155156
pneumonia, 121
viral infections
adenovirus, 126128
cytomegalovirus (CMV),
125126
herpes simplex virus (HSV),
122125
measles, 130131
parainfluenza, 129130
respiratory syncytial virus
(RSV), 128129
Purulent inflammatory response, 14
cytomorphologic features, 13
differential diagnosis, 15
Pyelonephritis
acute, 183184
chronic, 184185
xanthogranulomatous pyelonephritis (XPN), 185187
R
Reactive epithelial and mesenchymal repair, 2324
Reactive epithelial atypia, 24
Reactive lymphocytosis, 214
Renal tuberculosis, 187188
Respiratory syncytial virus (RSV),
44, 128129
Respiratory tract, 1011
393
Respiratory viruses, 44
Retroplasia, 353, 355
Retroviruses, 4546
Rhinoscleroma, 292
Rhinosporidiosis, 293
Rhinosporidium seeberi, 293
Rickettsial stains, 331332
Romanowsky stains, 322
Roundworms. See Nematodes
(roundworms)
S
Schistosomes, 82
Schistosomiasis
ancillary tests, 117
clinical features, 115116
cytomorphologic features, 116
dignosis, 116
microbiology, 115
urinary tract infections
ancillary studies, 201
clinical features, 200
cytomorphologic features,
200201
differential diagnosis, 201
microbiology, 199200
Scrofuloderma, 264
Seroconversion, 302
Sexually transmitted infection, 85,
103, 112. See also Gynecological infections
Shunt infections, 222223
Sialadenitis
acute
inflammatory infiltrate, 280
nontyrosine crystalloids,
280, 281
risk factors, 280
chronic
acinar cells, 282
differential diagnosis, 281, 282
Signal amplification assay, 344, 345
Sinonasal infections
invasive fungal, 291
mucormycosis, 292
noninvasive fungal, 291
394
Sinonasal infections (cont.)
rhinoscleroma, 292
rhinosporidiosis, 293
Skin infections, 11
cryptococcosis, 263, 264
cutaneous mycoses
botryomycosis, 271
dematiaceous fungi, 267,
270271
dermatophytosis, 266, 270
mycetoma, 271
sporotrichosis, 270
cutaneous parasites
cysticercosis, 272
leishmaniasis, 271272
parasitic infections, 271
Demodex folliculorum, 265
granulomatous inflammation, 263
leprosy (see Leprosy)
skin abscesses, 263
slit-skin smear, 262
spectrum, 262, 268
tuberculosis, 264
Tzanck preparation, 262, 263
Slit-skin smear, 262
Soft tissue infections. See Skin
infections
Specimen collection and handling
bacteriology, 7, 8
cytologic specimens, in microbiology laboratory, 8
mycology, 7
parasitology, 7
sites
central nervous system, 11
fluids, 12
gastrointestinal system, 11
genital tract, 10
musculoskeletal system, 11
respiratory tract, 1011
skin, 11
urinary tract, 10
sterile containers/tubes, aspirated
material, 6
type
fine needle aspiration
(FNA), 910
Index
fluids, 9
Pap test (smear), 8
scrapings, swabs/
impressions, 9
Tzanck test, 9
washings, brushings, and
lavage, 9
Wet prep, 9
virology, 67
Spleen infections
bacilliary peliosis, 252
hydatid cyst, 254255
infectious mononucleosis,
254255
mycobacterial infection, 253254
splenitis and splenic
abscess, 253
Splendore-Hoeppli phenomenon
cytomorphologic features, 35
differential diagnosis and
ancillary studies, 36
Splenitis and splenic abscess, 253
Sporothrix, 66, 67
Sporothrix schenckii, 270
Sporotrichosis, 270
Squamous intraepithelial lesions
(SIL), 92
Streptococcus cocci, 221
Streptococcus pneumoniae, in CNS
infections, 209
Strongyloides stercoralis, 8081, 154
Suppurative lymphadenitis, acute
ancillary studies, 234
causative organisms, 231
cytomorphologic features, 233
differential diagnosis, 233234
T
Taenia, 7879
Taenia solium, in CNS infections, 227
Tapeworms. See Cestodes
(tapeworms)
Thyroid gland infections
anaplastic carcinoma, 285
granulomatous thyroiditis, 285
infective thyroiditis, 283, 284
Index
Toluidine blue, 323, 326
Toxoplasma gondii, 75, 76,
155156
CNS infections, 221
lymph node infections, 244, 245
Toxoplasma lymphadenitis, 244245
Toxoplasmosis, 225227
Trematodes (flukes), 82
Treponema pallidum, in CNS
infections, 223
Trichomonas, 7172
Trichomonas vaginalis, 72, 366
ancillary tests, 114
clinical features, 113
cytomorphologic features,
113114
diagnosis, 114
microbiology, 112, 113
Trichomoniasis, 113, 201, 202
Tri-PAS stain, 332
Trypanosoma, 73
Tuberculosis (TB)
gynecological infections
ancillary tests, 108
clinical features, 106, 107
cytomorphologic features, 107
diagnosis, 108
microbiology, 106
pulmonary infections
ancillary studies, 137
clinical features, 135
cytomorphologic features, 135
differential diagnosis, 137
microbiology, 135, 136
pneumonia, 136
Tuberculous lymphadenitis, 240,
305, 306
Tuberculous meningitis, 216217
Tzanck test, 9
U
Urethritis, 203
Urinary bladder infections
bacterial cystitis, 189192
malakoplakia, 190191, 193
Urinary tract infections, 10
395
bladder
bacterial cystitis, 189192
malakoplakia, 190191, 193
fungal, 197199
kidney infections
acute pyelonephritis, 183184
chronic pyelonephritis,
184185
fungal, 188189
renal tuberculosis, 187188
xanthogranulomatous
pyelonephritis (XPN),
185187
male genital tract infections,
202203
parasites
schistosomiasis, 199201
trichomoniasis, 201, 202
viruses
adenovirus, 192
BK polyomavirus, 193197
herpes simplex virus
(HSV), 192
human papillomavirus
(HPV), 192
Urine trichomoniasis, 202
V
Varicella-Zoster virus (VZV), 42
Ventriculoperitoneal (VP) shunts, 222
Virology, 67
Viruses
cytopathic changes, 38, 39
cytopathic effect
cytomorphologic
features, 2223
differential diagnosis and
ancillary studies, 23
cytoplasmic inclusions, 40
gynecological infections
cytomegalovirus
(CMV), 99100
herpes simplex virus (HSV),
9599
human papillomavirus
(HPV), 9195
396
Viruses (cont.)
hepatitis viruses, 46
herpesvirues, 4043
inclusions, in culture, 7
meningitis
ancillary studies, 213214
clinical features, 212
cytomorphologic features,
212213
differential diagnosis, 213
microbiology, 212
mimics and contaminants
ancillary studies, 354
cellular degeneration, 353
koilocytes, 352
potential pitfall, 354
vegetable parenchymal
cells, 353
ophthalmic infections, 295
papillomaviruses, 3839
parvoviruses, 46
polyomaviruses, 4445
poxviruses, 45
pulmonary infections
adenovirus, 126128
cytologic features of, 123
cytomegalovirus (CMV),
125126
herpes simplex virus
(HSV), 122125
measles, 130131
parainfluenza, 129130
respiratory syncytial virus
(RSV), 128129
respiratory viruses, 44
retroviruses, 4546
stains, 332334
tumors (oncogenesis), 38
Index
urinary tract infections
adenovirus, 192
BK polyomavirus, 193197
herpes simplex virus
(HSV), 192
human papillomavirus
(HPV), 192
Volvocales algae, 373
W
WarthinStarry stain, 326327
Wet mount preparation, 324
X
Xanthogranulomatous inflammation,
29, 30
Xanthogranulomatous
pyelonephritis (XPN)
ancillary studies, 187
cytomorphologic features,
185186
differential diagnosis, 186187
histopathology, 185, 186
Y
Yeasts, 54, 6465
Z
ZiehlNeelsen stain, 327, 329
Zuska disease, 259
Zygomycetes, 5963
taxonomy, 60
Zygomycosis. See Mucormycosis
(zygomycosis)