416
Correspondence
ing 27 with Peutz-Jeghers syndrome and four with adenoma malignum of the cervix. Cancer 1982;50: 1384–402. 4. Tavassoli FA, Mooney E, Gersell DJ et al. (eds) WHO Classification of Tumours the Breast and Female Genital Organs. Lyon, France: IARC WHO Classification of Tumours; 2003: pp. 146–61. 5. Govender D, Sing Y, Chetty R. Sertoli cell nodules in the undescended testis: a histochemical, immunohistochemical, and ultrastructural study of hyaline deposits. J Clin Pathol 2004;57:802–6. 6. Davidoff MS, Breucker H, Holstein AF, Seidl K. Cellular architecture of the lamina propria of human seminiferous tubules. Cell Tissue Res 1990;262:253–61.
Fine needle aspiration cytology diagnosis of an ocular hydatid cyst DOI:10.1111/cyt.12113
Dear Editor, We report a case in which fine needle aspiration (FNA) cytology diagnosis of an ocular hydatid cyst allowed its rapid diagnosis and subsequent safe enucleation during surgery. A 35-year-old male farmer presented with a 3-month history of ‘painless left eye bulging’. It was gradual in onset and had recently been accompanied by diplopia. His past medical history and family history were insignificant. On physical examination, there was proptosis of the left eye with lateral gaze paresis and impaired visual acuity (8/10). The papillary reflex and funduscopic examination were normal and there was no relative afferent pupillary defect (Marcus Gunn pupil). The examination was otherwise normal. Laboratory studies showed mild normocytic anaemia with an increase in erythrocyte sedimentation rate (ESR) at 70 mm/ 1 hour. A Casoni test, enzyme-linked immunosorbent assay (ELISA) and indirect haemagglutination assay (IHA) test were negative. Computed tomography (CT) of the globe was performed revealing a 37 9 22 9 26-mm3, well-delineated temporal homogeneous unilocular orbit-like cyst in the left orbital cavity (Figure 1a). Differential diagnoses included teratoma, dermoid cyst, hydatid cyst, haematocoele, mucocoele, encephalocoele, inclusion cyst, schwannoma and paraganglioma. Correspondence: Y. Daneshbod, Department of Pathology, Dr Daneshbod Laboratory, Shiraz 7134777118, Iran Tel.: +98 917 308 7930; Fax: +98 711 234 6325; E-mails: [email protected]; [email protected]
FNA of the cystic mass was performed. Cytological examination of the air-dried smear and cell block prepared from the cyst fluid sediment showed hooklets (Figure 1b) and typical protoscolices (Figure 1c). Rapid diagnosis of hydatid cyst (Echinococcus) was made without surgery at the time. Complete enucleation of the cyst was performed later without rupture. The diagnosis of ocular hydatid cyst was confirmed histologically. Further investigations, including lung and liver, did not show any other organ involvement. The patient underwent treatment with albendazole and was referred to the infectious unit for treatment. Follow-up was uneventful, with no recurrence. Hydatidosis is a parasitic infection caused by the larval stage of tapeworm (Echinococcus granulosus and Echinococcus vogeli). Although the lung and liver are the organs most commonly involved, hydatid infection of the orbit comprises about 1% of the total incidence.1 Most ocular cysts are seen in the superior temporal area, which corresponds to the location of involvement in our patient. This predilection may be a result of the rich blood supply to this area.2 Although immunodiagnosis and imaging techniques, such as ultrasonography and CT, can aid in diagnosis, most hydatid cysts are diagnosed clinically. Hydatid cysts grow an average of 1.5 cm per year; because of the limited space in the orbital cavity, patients usually show compressive symptoms before 2 years.2 Most cases are unilateral with findings such as exophthalmia, chemosis, lid oedema, visual impairment and restriction of extraocular motility.2,3 Immunological tests are less useful because, in contrast with liver or lung involvement, orbital hydatid cyst proteins are confined to the orbital space and have less exposure to the immune system.3 The lesion on CT and magnetic resonance imaging (MRI) manifests as a hypodense cystic space with well-defined borders and a thin, homogeneous, hyperdense wall. The absorptive value of the cyst content on CT is similar to vitreous or cerebrospinal fluid.1,3 A fertile (mature) cyst is bilayered (germinal and laminated) and contains brood capsules with protoscolices. Although cyst enucleation is considered to be the treatment of choice, the injection of cysticidal agents and cryoextraction have also been postulated.1–3 ‘Immediate diagnosis’ of hydatid cyst pre-operatively and during surgery, in which cytological samples of the mass are prepared, can be performed easily. Immediate diagnosis in this way requires a clinical suspicion of the diagnosis as well as the attendance © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
Correspondence
(a)
(b)
(c)
Figure 1. (a) Axial and coronal computed tomography scan of the hydatid cyst showing a well-delineated temporal homogeneous unilocular orbit-like cyst in the left orbital cavity. (b) Air-dried smears of the fluid show many hooklets (Wright 9400). (c) Cell block of the sediment of the fluid shows typical protoscolices (haematoxylin and eosin 9400).
of a cytologist.4 Aspiration of hydatid cysts is now thought to be a useful procedure and, furthermore, allows enucleation to be performed safely because the diagnosis is known pre-operatively.5 Cytological findings in aspiration hydatid fluid show classic cytomorphology and allow an unquestionable diagnosis.4–6 The fluid aspirated from a hydatid cyst is usually clear and contains debris, a few inflammatory cells and numerous scolices. In old cysts, the scolices may be difficult to find in FNA preparations, but hooklets in a ring-like arrangement remain. The finding of hooklets or scolices is diagnostic of hydatid disease.4–6 Although albendazole (which is considered as the preferred medical treatment because of improved intestinal absorption and lower dosage) is used in extraocular infection, it also decreases orbital cyst size and is useful pre- and postoperatively.5,6 Intraoperative cytological evaluation of any cystic mass is a rapid, reliable method for the diagnosis of hydatid disease. Cytologists must therefore be familiar with the cytological features, as fluid from the cyst may be aspirated or submitted intraoperatively.
3.
4.
5.
6.
report of two cases and review of the literature. Orbit 2010;29:51–6. Kiratli H, Bilgicß S, Ozt€ urkmen C, Aydin O. Intramuscular hydatid cyst of the medial rectus muscle. Am J Ophthalmol 2003;135:98–9. Majumdar K, Saran RK, Sakhuja P, Jagetia A, Sinha S. Intact protoscolices and hooklets in cytospin preparation of intra-operative cyst fluid allow rapid confirmation of rare cerebral intraventricular hydatid infestation. Cytopathology 2013;24:277–9. Powers CN. Diagnosis of infectious diseases: a cytopathologist’s perspective. Clin Microbiol Rev 1998;11: 341–65. Daneshbod Y. A flower-like parasite with bladed petals. Arch Pathol Lab Med 2004;128:939–40.
Termite hindgut flagellates in a sputum cytology smear DOI:10.1111/cyt.12114
References
Dear Editor, Certain types of insects, such as lower termites, harbour symbiotic microflora inside their intestines that play important roles in their digestive process. Among these microorganisms, the flagellate protozoa are essential for the digestion of cellulose and other plant materials in the hindgut of lower termites. The symbiotic flagellates have been classified by their morphology and they belong to the orders Hypermastigida, Oxymonadida and Trichomonadida (class Zoomastigophorea). The first two are unique in nature, as their occurrence has been doc-
1. Turgut AT, Altin L, Topcßu S et al. Unusual imaging characteristics of complicated hydatid disease. Eur J Radiol 2007;63:84–93. 2. Bagheri A, Fallahi MR, Yazdani S, Rezaee Kanavi M. Two different presentations of orbital echinococcosis: a
Correspondence: Dr R. Martınez-Gir on, Fundaci on INCLINICA, Calvo Sotelo, 16. 33007-Oviedo, Spain Tel.: +34-985532306; Fax: +34-985507192 E-mail: [email protected]
H. Mirfazaelian*, B. Bagheri† and Y. Daneshbod‡ *Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, †Department of Ophthalmology, Dr Bagheri Ophthalmology Clinic, and ‡Department of Cytopathology, Dr Daneshbod Pathology Laboratory, Shiraz, Iran
© 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
417
Copyright of Cytopathology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Correspondence
ing 27 with Peutz-Jeghers syndrome and four with adenoma malignum of the cervix. Cancer 1982;50: 1384–402. 4. Tavassoli FA, Mooney E, Gersell DJ et al. (eds) WHO Classification of Tumours the Breast and Female Genital Organs. Lyon, France: IARC WHO Classification of Tumours; 2003: pp. 146–61. 5. Govender D, Sing Y, Chetty R. Sertoli cell nodules in the undescended testis: a histochemical, immunohistochemical, and ultrastructural study of hyaline deposits. J Clin Pathol 2004;57:802–6. 6. Davidoff MS, Breucker H, Holstein AF, Seidl K. Cellular architecture of the lamina propria of human seminiferous tubules. Cell Tissue Res 1990;262:253–61.
Fine needle aspiration cytology diagnosis of an ocular hydatid cyst DOI:10.1111/cyt.12113
Dear Editor, We report a case in which fine needle aspiration (FNA) cytology diagnosis of an ocular hydatid cyst allowed its rapid diagnosis and subsequent safe enucleation during surgery. A 35-year-old male farmer presented with a 3-month history of ‘painless left eye bulging’. It was gradual in onset and had recently been accompanied by diplopia. His past medical history and family history were insignificant. On physical examination, there was proptosis of the left eye with lateral gaze paresis and impaired visual acuity (8/10). The papillary reflex and funduscopic examination were normal and there was no relative afferent pupillary defect (Marcus Gunn pupil). The examination was otherwise normal. Laboratory studies showed mild normocytic anaemia with an increase in erythrocyte sedimentation rate (ESR) at 70 mm/ 1 hour. A Casoni test, enzyme-linked immunosorbent assay (ELISA) and indirect haemagglutination assay (IHA) test were negative. Computed tomography (CT) of the globe was performed revealing a 37 9 22 9 26-mm3, well-delineated temporal homogeneous unilocular orbit-like cyst in the left orbital cavity (Figure 1a). Differential diagnoses included teratoma, dermoid cyst, hydatid cyst, haematocoele, mucocoele, encephalocoele, inclusion cyst, schwannoma and paraganglioma. Correspondence: Y. Daneshbod, Department of Pathology, Dr Daneshbod Laboratory, Shiraz 7134777118, Iran Tel.: +98 917 308 7930; Fax: +98 711 234 6325; E-mails: [email protected]; [email protected]
FNA of the cystic mass was performed. Cytological examination of the air-dried smear and cell block prepared from the cyst fluid sediment showed hooklets (Figure 1b) and typical protoscolices (Figure 1c). Rapid diagnosis of hydatid cyst (Echinococcus) was made without surgery at the time. Complete enucleation of the cyst was performed later without rupture. The diagnosis of ocular hydatid cyst was confirmed histologically. Further investigations, including lung and liver, did not show any other organ involvement. The patient underwent treatment with albendazole and was referred to the infectious unit for treatment. Follow-up was uneventful, with no recurrence. Hydatidosis is a parasitic infection caused by the larval stage of tapeworm (Echinococcus granulosus and Echinococcus vogeli). Although the lung and liver are the organs most commonly involved, hydatid infection of the orbit comprises about 1% of the total incidence.1 Most ocular cysts are seen in the superior temporal area, which corresponds to the location of involvement in our patient. This predilection may be a result of the rich blood supply to this area.2 Although immunodiagnosis and imaging techniques, such as ultrasonography and CT, can aid in diagnosis, most hydatid cysts are diagnosed clinically. Hydatid cysts grow an average of 1.5 cm per year; because of the limited space in the orbital cavity, patients usually show compressive symptoms before 2 years.2 Most cases are unilateral with findings such as exophthalmia, chemosis, lid oedema, visual impairment and restriction of extraocular motility.2,3 Immunological tests are less useful because, in contrast with liver or lung involvement, orbital hydatid cyst proteins are confined to the orbital space and have less exposure to the immune system.3 The lesion on CT and magnetic resonance imaging (MRI) manifests as a hypodense cystic space with well-defined borders and a thin, homogeneous, hyperdense wall. The absorptive value of the cyst content on CT is similar to vitreous or cerebrospinal fluid.1,3 A fertile (mature) cyst is bilayered (germinal and laminated) and contains brood capsules with protoscolices. Although cyst enucleation is considered to be the treatment of choice, the injection of cysticidal agents and cryoextraction have also been postulated.1–3 ‘Immediate diagnosis’ of hydatid cyst pre-operatively and during surgery, in which cytological samples of the mass are prepared, can be performed easily. Immediate diagnosis in this way requires a clinical suspicion of the diagnosis as well as the attendance © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
Correspondence
(a)
(b)
(c)
Figure 1. (a) Axial and coronal computed tomography scan of the hydatid cyst showing a well-delineated temporal homogeneous unilocular orbit-like cyst in the left orbital cavity. (b) Air-dried smears of the fluid show many hooklets (Wright 9400). (c) Cell block of the sediment of the fluid shows typical protoscolices (haematoxylin and eosin 9400).
of a cytologist.4 Aspiration of hydatid cysts is now thought to be a useful procedure and, furthermore, allows enucleation to be performed safely because the diagnosis is known pre-operatively.5 Cytological findings in aspiration hydatid fluid show classic cytomorphology and allow an unquestionable diagnosis.4–6 The fluid aspirated from a hydatid cyst is usually clear and contains debris, a few inflammatory cells and numerous scolices. In old cysts, the scolices may be difficult to find in FNA preparations, but hooklets in a ring-like arrangement remain. The finding of hooklets or scolices is diagnostic of hydatid disease.4–6 Although albendazole (which is considered as the preferred medical treatment because of improved intestinal absorption and lower dosage) is used in extraocular infection, it also decreases orbital cyst size and is useful pre- and postoperatively.5,6 Intraoperative cytological evaluation of any cystic mass is a rapid, reliable method for the diagnosis of hydatid disease. Cytologists must therefore be familiar with the cytological features, as fluid from the cyst may be aspirated or submitted intraoperatively.
3.
4.
5.
6.
report of two cases and review of the literature. Orbit 2010;29:51–6. Kiratli H, Bilgicß S, Ozt€ urkmen C, Aydin O. Intramuscular hydatid cyst of the medial rectus muscle. Am J Ophthalmol 2003;135:98–9. Majumdar K, Saran RK, Sakhuja P, Jagetia A, Sinha S. Intact protoscolices and hooklets in cytospin preparation of intra-operative cyst fluid allow rapid confirmation of rare cerebral intraventricular hydatid infestation. Cytopathology 2013;24:277–9. Powers CN. Diagnosis of infectious diseases: a cytopathologist’s perspective. Clin Microbiol Rev 1998;11: 341–65. Daneshbod Y. A flower-like parasite with bladed petals. Arch Pathol Lab Med 2004;128:939–40.
Termite hindgut flagellates in a sputum cytology smear DOI:10.1111/cyt.12114
References
Dear Editor, Certain types of insects, such as lower termites, harbour symbiotic microflora inside their intestines that play important roles in their digestive process. Among these microorganisms, the flagellate protozoa are essential for the digestion of cellulose and other plant materials in the hindgut of lower termites. The symbiotic flagellates have been classified by their morphology and they belong to the orders Hypermastigida, Oxymonadida and Trichomonadida (class Zoomastigophorea). The first two are unique in nature, as their occurrence has been doc-
1. Turgut AT, Altin L, Topcßu S et al. Unusual imaging characteristics of complicated hydatid disease. Eur J Radiol 2007;63:84–93. 2. Bagheri A, Fallahi MR, Yazdani S, Rezaee Kanavi M. Two different presentations of orbital echinococcosis: a
Correspondence: Dr R. Martınez-Gir on, Fundaci on INCLINICA, Calvo Sotelo, 16. 33007-Oviedo, Spain Tel.: +34-985532306; Fax: +34-985507192 E-mail: [email protected]
H. Mirfazaelian*, B. Bagheri† and Y. Daneshbod‡ *Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, †Department of Ophthalmology, Dr Bagheri Ophthalmology Clinic, and ‡Department of Cytopathology, Dr Daneshbod Pathology Laboratory, Shiraz, Iran
© 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
417
Copyright of Cytopathology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
