HEMATOPATHOLOGY Original Article
Herpes Simplex Lymphadenitis MICHAEL J. GAFFEY, M.D., JONATHAN M. BEN-EZRA, M.D., AND LAWRENCE M. WEISS, M.D.
inclusions were stromal, not lymphoid, cells. Combining the current two cases with the six well-documented cases previously reported in the literature, seven of the eight cases of HSV lymphadenitis have developed in inguinal lymph nodes, with four occurring in patients with previously or subsequently diagnosed hematopoietic malignancies, including both patients in the current series. (Key words: Herpesviridae; Herpes simplex virus; Necrotizing lymphadenitis; Malignant lymphoma) Am J Clin Pathol 1991;95:709-714
Herpes simplex virus (HSV) infection of immunocompetent patients usually is a self-limited vesicular disease confined to mucocutaneous areas. Immunocompromised patients may develop severe, chronic, or progressive infection with contiguous involvement of the esophagus and lower respiratory tract. Lymph node involvement by HSV is uncommon and usually occurs in patients with disseminated infection. Localized herpetic lymphadenitis without synchronous visceral involvement is rare, with only six well-documented cases previously reported. 1-4 We now report two additional patients with localized herpetic lymphadenitis documented by light and electron microscopy and in situ hybridization.
cervical, axillary, and inguinal adenopathy with roentgenographic evidence of hilar, retroperitoneal, and portal lymph node enlargement. Right cervical and axillary lymph node biopsies were positive for monocytoid B-cell lymphoma (MBCL)5 bearing kappa light chains and IgM heavy chains. Subsequent studies revealed involvement of the bone marrow and peripheral blood by MBCL. The patient received M-BACOD, ProMACE/MOPP, DHAP chemotherapy and alpha interferon without appreciable clinical response. The patient was admitted in August 1989 for evaluation of fever, nodular pulmonary infiltrates and tender, erythematous left inguinal lymph nodes. Fine-needle aspiration of a pulmonary nodule showed septate hyphae consistent with Aspergillus, and a left inguinal lymph node biopsy showed involvement by MBCL and herpetic lymphadenitis. Tissue cultures of the lymph node were negative for bacteria, acid fast bacilli, and fungi: viral cultures were not performed. The patient was re-evaluated, and multiple perineal lesions consistent with HSV were discovered. The patient was treated with intravenous amphotericin B and acyclovir with resolution of her fever and pulmonary lesions in three weeks. At last follow-up, 20 months after presentation, the patient was undergoing outpatient Cytoxan chemotherapy for MBCL without detectable clinical response.
REPORTS OF CASES Case 1 A 35-year-old Asian woman presented in January 1989 complaining of fatigability and a mass in the right side of her neck. Work-up revealed
Case 2
An asymptomatic 37-year-old white woman was evaluated in October 1986 for a left inguinal mass thought to represent an inguinal hernia. Surgical exploration revealed multiple, enlarged lymph nodes: biopsy of From the Division of Pathology. City ofHope National Medical Center. one of the lymph nodes was positive for herpetic lymphadenitis. Viral Duarte. California. cultures were not performed. The patient was re-evaluated and found Received July 16, 1990; received revised manuscript and accepted for free of additional adenopathy and mucocutaneous herpetic lesions. Labpublication September 7, 1990. oratory studies, including a CBC. were normal. Routine follow-up five Dr. Ben-Ezra is a member of the City of Hope Cancer Research Center, months later revealed an enlarged spleen, thrombocythemia. and leusupported by Public Health Service Grant CA-33572, and is a recipient kocytosis with 12.3 gm/dL hemoglobin, 1,620,000 platelets, and 15.000 of an American Cancer Society Clinical Oncology Career Development leukocytes; the differential count was 60 neutrophils, 11 bands, 21 lymAward. phocytes, and 8 nucleated red cells. Bone marrow examination demThe current address for Dr. Gaffey is Department of Pathology, Unionstrated a myeloproliferative disorder with marked granulocytic and versity of Virginia Medical School, Charlottesville, Virginia. megakaryocyte hyperplasia and dyserythropoiesis. In the ensuing months, Address reprint requests to Dr. Weiss: Division of Pathology, City of the patient developed progressive myelofibrosis, thrombocythemia. and Hope National Medical Center, 1500 East Duarte Road, Duarte, Calicirculating immature granulocytes; Philadelphia-chromosome-positive fornia 91010.
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Localized herpetic lymphadenitis is an extremely uncommon complication of herpes simplex virus (HSV) infection. The authors report two cases of localized herpetic lymphadenitis, both showing well-circumscribed areas of necrosis containing cells with diagnostic intranuclear inclusions. Electron microscopic studies in both cases revealed characteristic viral particles, and in situ hybridization studies using a herpes simplex genomic probe demonstrated HSV DNA in both specimens. Immunohistochemical studies demonstrated that the cells containing the
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HEMATOPATHOLOGY
Article chronic myelogenous leukemia in megakaryoblastic transformation was diagnosed in February 1988. Despite chemotherapeutic intervention, the patient never achieved complete remission, and after repeated episodes of cellulitis, osteomyelitis, and perineal herpes, she died from gastrointestinal exsanguination 25 months after presentation. Permission for autopsy was denied. MATERIALS A N D METHODS
Immunologic
Studies
Immunohistochemical studies on formalin-fixed, paraffin-embedded material were performed using the ABC method as previously described.6 Antibodies used were all murine monoclonal preparations, including Factor VHI-related antigen (DAKO, Carpinteria, CA; 1:20), KP1 (CD68) (DAKO; 1:50), LCA (CD45) (leukocyte common antigen, DAKO; 1:50), Leu-22 (CD43) (Becton Dickinson, Mountain View, CA; 1:20), L-26 (CD20) (DAKO; 1:100), and vimentin (DAKO; 1:100). The Ulex europaeus lectin (Vector Laboratories, Burlingame, CA; 1:200) also was employed. Electron Microscopic Studies Tissue for electron microscopy was retrieved from the paraffin blocks, deparaffinized in xylene, rehydrated in graded ethanol/water solutions, postfixed in 5% phosphate-buffered glutaraldehyde and osmium tetroxide, dehydrated in graded ethanol/water solutions and xylene, and embedded in Epon 812. Sections 1 nm thick were stained with toluidine blue and examined by light microscopy. Appropriate sections were selected for ultrastructural study, stained with uranyl acetate and lead citrate, and examined on a Zeiss EM-9 electron microscope. In Situ
Hybridization
Tissue in situ hybridization studies were performed on paraffin-embedded tissue using previously described methods.7'8 The HSV probe, a mixture of HSV type 1 and 2 probes (obtained from Enzo Biochem, New York, NY), was used in the hybridization solution at a concentration of 37.5 ng/mL. The probe was radiolabeled with a-35S-dCTP by the random hexamer priming technique.9
The lymph node biopsy from case 1 was received as seven irregular fragments of tan lymphoid tissue, the largest of which measured 1.0 cm in diameter. Histologic examination showed predominantly necrotic tissue fragments with peripheral rims of viable lymphoid tissue (Fig. 1). The infarct-like necrotic areas contained amorphous eosinophilic material with occasional acute and chronic inflammatory cells and a peripheral transition zone composed of granulation tissue. Cells with nuclear enlargement, peripheral chromatin, and eosinophilic, groundglass intranuclear inclusions with clear halos were seen within the necrotic debris (Fig. 1). Infected cells were numerous and evenly distributed, with virtually every viable cell within the necrotic area showing diagnostic inclusions. Multinucleated giant cells were not seen. The remaining lymphoid tissue showed architectural effacement by monomorphic sheets of small lymphocytes consistent with involvement by monocytoid B-cell lymphoma. Immunologic studies performed on paraffin-embedded tissue showed the lymphoid cells to be positive for L-26 and negative for Leu-22, an immunophenotype consistent with a B-cell lineage. In case 2, a gross description of the lymph node biopsy specimen was not available. Histologically the lymph node demonstrated multiple, sharply demarcated, punched-out necrotic areas simulating microabscesses with "ghost" cells, nuclear debris, fibrin, and numerous neutrophils (Fig. 2). Infected cells with diagnostic intranuclear inclusions were relatively infrequent and were concentrated around the edges of the necrotic foci; multinucleated giant cells were absent. The non-necrotic lymph node was diffusely hyperplastic with the paracortex expanded by small lymphocytes, immunoblasts, and occasional plasma cells (Fig. 2). In both cases, immunologic studies showed that the cells containing the inclusions were positive for vimentin but negative for the lymphoid markers LCA, L26, and Leu-22, the vascular markers Factor VHI-related antigen and Ulex europeus lectin, and the macrophage marker KP1 (Fig. 3). The efficacy of the latter six antibodies was confirmed by the labeling of the appropriate internal control cells. Electron microscopic examination of both cases revealed numerous intranuclear and intracytoplasmic particles consistent with herpes virus (Fig. AA). However, because of relatively poor tissue preservation, it was not possible to identify the infected cell type. The presence of HSV DNA in both cases was confirmed by in situ hybridization studies that showed the deposition of silver grains over the infected cells after hybridization with the HSV DNA probe (Fig. 4B). Positive cells were seen only
A.J.C.P. May 1991
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Formalin-fixed, paraffin-embedded tissue and hematoxylin and eosin-stained slides were available in both cases. One case was retrieved from the files of the Sylvia Cowen Laboratory, Department of Pathology, City of Hope National Medical Center, whereas the other case was received in consultation by one of the authors (LMW). Clinical information was obtained from the hospital chart or the referring pathologist.
RESULTS
GAFFEY, BEN-EZRA, AND WEISS
711
Herpes Simplex Lymphadenitis
FIG. 1 (upper). Case 1. A necrotic area seen at top, while viable lymphoid tissue is seen at bottom. A transitional zone of granlation tissue is seen between the two areas. Insel. Intranuclear nclusions consistent with HSV are shown. Hematoxylin and cosin (X200). (Inset) (X400).
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FIG. 2 (lower). Case 2. A. A "punched out" area of necrosis is seen that directly interfaces with the viable lymphoid tissue. Inset. igh-power magnification in the area of necrosis shows cells with intranuclear inclusions interspersed with neutrophils. B. The viable lymphoid tissue shows a mixed, reactive lymphoid infiltrate. Hematoxylin and eosin (A) X200. (B) X200, (Inset) X1,000.
712
HEMATOPATHOLOGY Original Article
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V-**/*. FIG. 3 (upper). Case 1. A Herpes inclusion-bearing cells are seen to be positive for vimentin (at arrows). B. The herpes inclusion-bearing cells are negative for LCA (at arrows), while lymphoid cells within the samefieldshow the appropriate membrane staining. A. Immunoperoxidase for vimentin (X 1,000). B. Immunoperoxidase for LCA (X 1,000). FIG. 4 (lower). Case 1. A. Ultrastructural examination shows an intranuclear grouping of viral particles typical of HSV. B. In situ hybridization studies using an HSV DNA probe labels numerous cells within the necrotic area. A. Uranyl acetate and lead citrate (X80,000). B. Hematoxylin and eosin counterstain (X400).
GAFFEY, BEN-EZRA, AND WEISS Herpes SimplexLymphadenitis in the necrotic areas, with no evidence of increased hybridization levels above background in the surrounding lymphoid tissue. DISCUSSION
to histiocytic necrotizing lymphadenitis (Kikuchi's disease) or other infectious agents such as bacteria, fungi, or other viruses.22 However, because all reported cases of localized HSV lymphadenitis have shown characteristic intranuclear inclusions, differentiation from most of the former entities is easily accomplished by careful histologic examination of the necrotic foci. Since some other viruses, such as cytomegalovirus and varicella-zoster, may show similar intranuclear inclusions, DNA hybridization techniques may sometimes be helpful in resolving cases in which the specific etiologic viral agent is of importance.15,16 In a recent report of two cases of herpetic lymphadenitis, Tamaru and colleagues3 claimed that the herpes-infected cells were T immunoblasts in the background of T-zone hyperplasia with focal necrosis. Although they demonstrated that the herpes-infected cells were found in areas rich in T cells, the authors did not illustrate inclusionbearing cells with reactivity for T-cell antigens, and they did not perform double-labeling studies to specifically identify the infected cells as T cells. Furthermore, their electron microscopic studies failed to demonstrate the nature of the cells containing the inclusions. In our two cases, cells with diagnostic inclusions were positive for vimentin, but negative for LCA, Leu-22, KP1, Factor VHI-related antigen, and Ulex europaeus lectin. The negativity for LCA and Leu-22 indicates that the infected cells were not T cells, and they probably were not endothelial cells or macrophages, based on the negative staining for Factor VHI-related antigen, Ulex europeaus lectin and KP1. The positivity for vimentin suggests that the cells containing the inclusions may be stromal cells, possibly fibroblasts. Of interest is that four of the eight cases of herpetic lymphadenitis reported in the literature occurred in patients with lymphoproliferative disease (well-differentiated lymphocytic lymphoma, chronic lymphocytic leukemia with nodal involvement, nodular sclerosing Hodgkin's disease, and monocytoid B-cell lymphoma). The patient described here in the second case report developed myeloproliferative disease progressing to chronic myelogenous leukemia within five months after presentation. While the association between herpetic lymphadenitis and lymphoproliferative disease may reflect only the immunocompromised state of the patients, these results suggest that the occurrence of herpetic lymphadenitis in an otherwise clinically unremarkable patient, particularly in the absence of a demonstrable genital lesion, may be a harbinger for the development of a hematopoietic malignancy. REFERENCES 1. Audouin J, Tourneau AL, Aubert J-P, Diebold J. Herpes simplex lymphadenitis mimicking tumoral relapse in a patient with Hodgkin's disease in remission. Virchows Arch (Pathol Anat) 1985;408:313-321.
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Herpes simplex virus (HSV) is an icosahedral, enveloped virus with a linear, double-strand segment of DNA.10 Two closely related serologic types for which man is the only natural host are recognized. Primary infection in the immunocompetent host usually is asymptomatic, and both types establish latent infection in local sensory ganglia, which may repetitively reactivate after any of a variety of stimuli. Primary or reactivated infection in the immunocompromised host often is severe and may involve the esophagus or lower respiratory tract by contiguous spread; systemic dissemination also may occur."" 14 Lymphadenitis due to other Herpesviridae, such as Epstein-Barr virus, cytomegalovirus, and varicella-zoster virus, is well described,1516 but published accounts of Herpes simplex lymphadenitis are rare. Occasional cases have been reported from patients with systemic HSV infect i o n , " ' 4 ' 7 but only six well-documented cases of isolated HSV lymphadenitis have been described previously,1-4 with the presence of HSV confirmed by immunohistochemical, ultrastructural, or DNA hybridization techniques. The two cases reported here are histologically similar to those previously described, showing circumscribed areas of necrosis-containing cells with characteristic intranuclear inclusions. An additional case was reported by Lapsley and colleagues,18 wherein paracortical immunoblastic and histiocytic proliferation was described in a lymph node biopsy specimen from a patient with serologic evidence of HSV infection. The histologic appearance of the lymph node in that case, however, was not unlike that of varicella-zoster lymphadenitis, the patient's children were concurrently diagnosed as having varicella-zoster, and the patient also was afflicted with a generalized rash. Therefore, we must view that case as suspect. While the origins of infection in the current cases are uncertain, the localization to inguinal lymph nodes of seven of the eight acceptable cases reported thus far suggests lymphatic spread from the urogenital tract.1'2,4 The development of perineal herpes in both of the current patients and in two of those previously reported around the time of biopsy and the frequent occurrence of regional lymphadenopathy in HSV-infected patients lends credence to this hypothesis.19 Because primary and recurrent HSV infection may be subclinical,20,21 a similar mechanism may be operative for the other patients as well. Herpetic lymphadenitis must be distinguished from necrotizing lymphadenitis of other types, such as that due
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HEMATOPATHOLOGY Original Article 12. Muller SA, Herrmann EC Jr, Winkelmann RK. Herpes simplex infections in hematologic malignancies. Am J Med 1972;52:102— 104. 13. Naraqi S, Jackson GG, Jonasson OM. Viremia with herpes simplex type 1 in adults. Four nonfatal cases, one with features of chickenpox. Ann Intern Med 1976;85:165-169. 14. Sutton AL, Smithwick EM, Seligman SJ, Kim D-S. Fatal disseminated herpesvirus hominis type 2 infection in an adult with associated thymic dysplasia. Am J Med 1974;56:545-553. 15. Ioachim HL. Lymph node biopsy. Philadelphia: J.B. Lippincott Co., 1982;42. 16. Schnitzer B. Reactive lymphoid hyperplasia. In: Jaffe ES, eds. Surgical pathology of the lymph nodes and related organs. Philadelphia: W.B. Saunders Co., 1985:22-56. 17. Ramsey PG, Fife KH, Hackman RC, Meyers JD, Corey L. Herpes simplex pneumonia: clinical, virologic, and pathologic features in 20 patients. Ann Intern Med 1982;97:813-820. 18. Lapsley M, Kettle P, Sloan JM. Herpes simplex lymphadenitis: a case report and review of the published work. J Clin Pathol 1984;37:1119-1122. 19. Hirsch MS. Herpes simplex virus. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases, 3rd ed. New York: Churchill Livingstone, 1990:1144-1153. 20. Josey WE, Nahmias AJ, Naib ZM. Genital herpes simplex infection in the female. Am J Obstet Gynecol 1966;96:493-501. 21. Yen SSC, Reagan JW, Rosenthal MS. Herpes simplex infection in the female genital tract. Obstet Gynecol 1965;25:479-492. 22. Turner RR, Martin J, Dorfman RF. Necrotizing lymphadenitis: a study of 30 cases. Am J Surg Pathol 1983;7:115-123.
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2. Epstein JI, Ambinder RF, Kuhajda FP, Pearlman SH, Reuter VE, Mann RB. Localized herpes simplex lymphadenitis. Am J Clin Pathol 1986;86:444-448. 3. Tamaru J-I, Mikata A, Horie H, et al. Herpes simplex lymphadenitis: report of two cases with review of the literature. Am J Surg Pathol 1990;14:571-577. 4. Taxy JB, Tillawi I, Goldman PM. Herpes simplex lymphadenitis: an unusual presentation with necrosis and viral particles. Arch Pathol Lab Med 1985;109:1043-1044. 5. Sheibani K, Burke JS, Swartz WG, Nademanee A, Winberg CD. Monocytoid B cell lymphoma: clinicopathologic study of 21 cases of a unique type of low-grade lymphoma. Cancer 1988;62:1531 — 1538. 6. Sheibani K, Tubbs RR. Enzyme immunohistochemistry: technical aspects. Semin Diagn Pathol 1984;1:235-250. 7. Weiss LM, Movahed LA, Warnke RA, Sklar J. Localization of Epstein-Barr virus genomes to Reed-Sternberg cells in Hodgkin's disease. N Engl J Med 1989;320:502-506. 8. Weiss LM, Movahed LA. In situ demonstration of Epstein-Barr viral genomes in viral-associated B cell lymphoproliferations. Am J Pathol 1989;134:651-659. 9. Feinberg AP, Vogelstein B. A technique for radiolabeling DNA restriction endonuclease fragments to high specific activity. Anal Biochem 1983;132:6-13. 10. Drew WL, Rawls WE. Herpes simplex viruses. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ, eds. Manual of clinical microbiology, 4th ed. Washington, DC: American Society for Microbiology, 1985:705-710. 11. Abraham AA, Manko MA. Disseminated herpesvirus hominus 2 infection following drug overdose. Arch Intern Med 1977; 137: 1198-1200.
Herpes Simplex Lymphadenitis MICHAEL J. GAFFEY, M.D., JONATHAN M. BEN-EZRA, M.D., AND LAWRENCE M. WEISS, M.D.
inclusions were stromal, not lymphoid, cells. Combining the current two cases with the six well-documented cases previously reported in the literature, seven of the eight cases of HSV lymphadenitis have developed in inguinal lymph nodes, with four occurring in patients with previously or subsequently diagnosed hematopoietic malignancies, including both patients in the current series. (Key words: Herpesviridae; Herpes simplex virus; Necrotizing lymphadenitis; Malignant lymphoma) Am J Clin Pathol 1991;95:709-714
Herpes simplex virus (HSV) infection of immunocompetent patients usually is a self-limited vesicular disease confined to mucocutaneous areas. Immunocompromised patients may develop severe, chronic, or progressive infection with contiguous involvement of the esophagus and lower respiratory tract. Lymph node involvement by HSV is uncommon and usually occurs in patients with disseminated infection. Localized herpetic lymphadenitis without synchronous visceral involvement is rare, with only six well-documented cases previously reported. 1-4 We now report two additional patients with localized herpetic lymphadenitis documented by light and electron microscopy and in situ hybridization.
cervical, axillary, and inguinal adenopathy with roentgenographic evidence of hilar, retroperitoneal, and portal lymph node enlargement. Right cervical and axillary lymph node biopsies were positive for monocytoid B-cell lymphoma (MBCL)5 bearing kappa light chains and IgM heavy chains. Subsequent studies revealed involvement of the bone marrow and peripheral blood by MBCL. The patient received M-BACOD, ProMACE/MOPP, DHAP chemotherapy and alpha interferon without appreciable clinical response. The patient was admitted in August 1989 for evaluation of fever, nodular pulmonary infiltrates and tender, erythematous left inguinal lymph nodes. Fine-needle aspiration of a pulmonary nodule showed septate hyphae consistent with Aspergillus, and a left inguinal lymph node biopsy showed involvement by MBCL and herpetic lymphadenitis. Tissue cultures of the lymph node were negative for bacteria, acid fast bacilli, and fungi: viral cultures were not performed. The patient was re-evaluated, and multiple perineal lesions consistent with HSV were discovered. The patient was treated with intravenous amphotericin B and acyclovir with resolution of her fever and pulmonary lesions in three weeks. At last follow-up, 20 months after presentation, the patient was undergoing outpatient Cytoxan chemotherapy for MBCL without detectable clinical response.
REPORTS OF CASES Case 1 A 35-year-old Asian woman presented in January 1989 complaining of fatigability and a mass in the right side of her neck. Work-up revealed
Case 2
An asymptomatic 37-year-old white woman was evaluated in October 1986 for a left inguinal mass thought to represent an inguinal hernia. Surgical exploration revealed multiple, enlarged lymph nodes: biopsy of From the Division of Pathology. City ofHope National Medical Center. one of the lymph nodes was positive for herpetic lymphadenitis. Viral Duarte. California. cultures were not performed. The patient was re-evaluated and found Received July 16, 1990; received revised manuscript and accepted for free of additional adenopathy and mucocutaneous herpetic lesions. Labpublication September 7, 1990. oratory studies, including a CBC. were normal. Routine follow-up five Dr. Ben-Ezra is a member of the City of Hope Cancer Research Center, months later revealed an enlarged spleen, thrombocythemia. and leusupported by Public Health Service Grant CA-33572, and is a recipient kocytosis with 12.3 gm/dL hemoglobin, 1,620,000 platelets, and 15.000 of an American Cancer Society Clinical Oncology Career Development leukocytes; the differential count was 60 neutrophils, 11 bands, 21 lymAward. phocytes, and 8 nucleated red cells. Bone marrow examination demThe current address for Dr. Gaffey is Department of Pathology, Unionstrated a myeloproliferative disorder with marked granulocytic and versity of Virginia Medical School, Charlottesville, Virginia. megakaryocyte hyperplasia and dyserythropoiesis. In the ensuing months, Address reprint requests to Dr. Weiss: Division of Pathology, City of the patient developed progressive myelofibrosis, thrombocythemia. and Hope National Medical Center, 1500 East Duarte Road, Duarte, Calicirculating immature granulocytes; Philadelphia-chromosome-positive fornia 91010.
709
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Localized herpetic lymphadenitis is an extremely uncommon complication of herpes simplex virus (HSV) infection. The authors report two cases of localized herpetic lymphadenitis, both showing well-circumscribed areas of necrosis containing cells with diagnostic intranuclear inclusions. Electron microscopic studies in both cases revealed characteristic viral particles, and in situ hybridization studies using a herpes simplex genomic probe demonstrated HSV DNA in both specimens. Immunohistochemical studies demonstrated that the cells containing the
710
HEMATOPATHOLOGY
Article chronic myelogenous leukemia in megakaryoblastic transformation was diagnosed in February 1988. Despite chemotherapeutic intervention, the patient never achieved complete remission, and after repeated episodes of cellulitis, osteomyelitis, and perineal herpes, she died from gastrointestinal exsanguination 25 months after presentation. Permission for autopsy was denied. MATERIALS A N D METHODS
Immunologic
Studies
Immunohistochemical studies on formalin-fixed, paraffin-embedded material were performed using the ABC method as previously described.6 Antibodies used were all murine monoclonal preparations, including Factor VHI-related antigen (DAKO, Carpinteria, CA; 1:20), KP1 (CD68) (DAKO; 1:50), LCA (CD45) (leukocyte common antigen, DAKO; 1:50), Leu-22 (CD43) (Becton Dickinson, Mountain View, CA; 1:20), L-26 (CD20) (DAKO; 1:100), and vimentin (DAKO; 1:100). The Ulex europaeus lectin (Vector Laboratories, Burlingame, CA; 1:200) also was employed. Electron Microscopic Studies Tissue for electron microscopy was retrieved from the paraffin blocks, deparaffinized in xylene, rehydrated in graded ethanol/water solutions, postfixed in 5% phosphate-buffered glutaraldehyde and osmium tetroxide, dehydrated in graded ethanol/water solutions and xylene, and embedded in Epon 812. Sections 1 nm thick were stained with toluidine blue and examined by light microscopy. Appropriate sections were selected for ultrastructural study, stained with uranyl acetate and lead citrate, and examined on a Zeiss EM-9 electron microscope. In Situ
Hybridization
Tissue in situ hybridization studies were performed on paraffin-embedded tissue using previously described methods.7'8 The HSV probe, a mixture of HSV type 1 and 2 probes (obtained from Enzo Biochem, New York, NY), was used in the hybridization solution at a concentration of 37.5 ng/mL. The probe was radiolabeled with a-35S-dCTP by the random hexamer priming technique.9
The lymph node biopsy from case 1 was received as seven irregular fragments of tan lymphoid tissue, the largest of which measured 1.0 cm in diameter. Histologic examination showed predominantly necrotic tissue fragments with peripheral rims of viable lymphoid tissue (Fig. 1). The infarct-like necrotic areas contained amorphous eosinophilic material with occasional acute and chronic inflammatory cells and a peripheral transition zone composed of granulation tissue. Cells with nuclear enlargement, peripheral chromatin, and eosinophilic, groundglass intranuclear inclusions with clear halos were seen within the necrotic debris (Fig. 1). Infected cells were numerous and evenly distributed, with virtually every viable cell within the necrotic area showing diagnostic inclusions. Multinucleated giant cells were not seen. The remaining lymphoid tissue showed architectural effacement by monomorphic sheets of small lymphocytes consistent with involvement by monocytoid B-cell lymphoma. Immunologic studies performed on paraffin-embedded tissue showed the lymphoid cells to be positive for L-26 and negative for Leu-22, an immunophenotype consistent with a B-cell lineage. In case 2, a gross description of the lymph node biopsy specimen was not available. Histologically the lymph node demonstrated multiple, sharply demarcated, punched-out necrotic areas simulating microabscesses with "ghost" cells, nuclear debris, fibrin, and numerous neutrophils (Fig. 2). Infected cells with diagnostic intranuclear inclusions were relatively infrequent and were concentrated around the edges of the necrotic foci; multinucleated giant cells were absent. The non-necrotic lymph node was diffusely hyperplastic with the paracortex expanded by small lymphocytes, immunoblasts, and occasional plasma cells (Fig. 2). In both cases, immunologic studies showed that the cells containing the inclusions were positive for vimentin but negative for the lymphoid markers LCA, L26, and Leu-22, the vascular markers Factor VHI-related antigen and Ulex europeus lectin, and the macrophage marker KP1 (Fig. 3). The efficacy of the latter six antibodies was confirmed by the labeling of the appropriate internal control cells. Electron microscopic examination of both cases revealed numerous intranuclear and intracytoplasmic particles consistent with herpes virus (Fig. AA). However, because of relatively poor tissue preservation, it was not possible to identify the infected cell type. The presence of HSV DNA in both cases was confirmed by in situ hybridization studies that showed the deposition of silver grains over the infected cells after hybridization with the HSV DNA probe (Fig. 4B). Positive cells were seen only
A.J.C.P. May 1991
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Formalin-fixed, paraffin-embedded tissue and hematoxylin and eosin-stained slides were available in both cases. One case was retrieved from the files of the Sylvia Cowen Laboratory, Department of Pathology, City of Hope National Medical Center, whereas the other case was received in consultation by one of the authors (LMW). Clinical information was obtained from the hospital chart or the referring pathologist.
RESULTS
GAFFEY, BEN-EZRA, AND WEISS
711
Herpes Simplex Lymphadenitis
FIG. 1 (upper). Case 1. A necrotic area seen at top, while viable lymphoid tissue is seen at bottom. A transitional zone of granlation tissue is seen between the two areas. Insel. Intranuclear nclusions consistent with HSV are shown. Hematoxylin and cosin (X200). (Inset) (X400).
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FIG. 2 (lower). Case 2. A. A "punched out" area of necrosis is seen that directly interfaces with the viable lymphoid tissue. Inset. igh-power magnification in the area of necrosis shows cells with intranuclear inclusions interspersed with neutrophils. B. The viable lymphoid tissue shows a mixed, reactive lymphoid infiltrate. Hematoxylin and eosin (A) X200. (B) X200, (Inset) X1,000.
712
HEMATOPATHOLOGY Original Article
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if
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V-**/*. FIG. 3 (upper). Case 1. A Herpes inclusion-bearing cells are seen to be positive for vimentin (at arrows). B. The herpes inclusion-bearing cells are negative for LCA (at arrows), while lymphoid cells within the samefieldshow the appropriate membrane staining. A. Immunoperoxidase for vimentin (X 1,000). B. Immunoperoxidase for LCA (X 1,000). FIG. 4 (lower). Case 1. A. Ultrastructural examination shows an intranuclear grouping of viral particles typical of HSV. B. In situ hybridization studies using an HSV DNA probe labels numerous cells within the necrotic area. A. Uranyl acetate and lead citrate (X80,000). B. Hematoxylin and eosin counterstain (X400).
GAFFEY, BEN-EZRA, AND WEISS Herpes SimplexLymphadenitis in the necrotic areas, with no evidence of increased hybridization levels above background in the surrounding lymphoid tissue. DISCUSSION
to histiocytic necrotizing lymphadenitis (Kikuchi's disease) or other infectious agents such as bacteria, fungi, or other viruses.22 However, because all reported cases of localized HSV lymphadenitis have shown characteristic intranuclear inclusions, differentiation from most of the former entities is easily accomplished by careful histologic examination of the necrotic foci. Since some other viruses, such as cytomegalovirus and varicella-zoster, may show similar intranuclear inclusions, DNA hybridization techniques may sometimes be helpful in resolving cases in which the specific etiologic viral agent is of importance.15,16 In a recent report of two cases of herpetic lymphadenitis, Tamaru and colleagues3 claimed that the herpes-infected cells were T immunoblasts in the background of T-zone hyperplasia with focal necrosis. Although they demonstrated that the herpes-infected cells were found in areas rich in T cells, the authors did not illustrate inclusionbearing cells with reactivity for T-cell antigens, and they did not perform double-labeling studies to specifically identify the infected cells as T cells. Furthermore, their electron microscopic studies failed to demonstrate the nature of the cells containing the inclusions. In our two cases, cells with diagnostic inclusions were positive for vimentin, but negative for LCA, Leu-22, KP1, Factor VHI-related antigen, and Ulex europaeus lectin. The negativity for LCA and Leu-22 indicates that the infected cells were not T cells, and they probably were not endothelial cells or macrophages, based on the negative staining for Factor VHI-related antigen, Ulex europeaus lectin and KP1. The positivity for vimentin suggests that the cells containing the inclusions may be stromal cells, possibly fibroblasts. Of interest is that four of the eight cases of herpetic lymphadenitis reported in the literature occurred in patients with lymphoproliferative disease (well-differentiated lymphocytic lymphoma, chronic lymphocytic leukemia with nodal involvement, nodular sclerosing Hodgkin's disease, and monocytoid B-cell lymphoma). The patient described here in the second case report developed myeloproliferative disease progressing to chronic myelogenous leukemia within five months after presentation. While the association between herpetic lymphadenitis and lymphoproliferative disease may reflect only the immunocompromised state of the patients, these results suggest that the occurrence of herpetic lymphadenitis in an otherwise clinically unremarkable patient, particularly in the absence of a demonstrable genital lesion, may be a harbinger for the development of a hematopoietic malignancy. REFERENCES 1. Audouin J, Tourneau AL, Aubert J-P, Diebold J. Herpes simplex lymphadenitis mimicking tumoral relapse in a patient with Hodgkin's disease in remission. Virchows Arch (Pathol Anat) 1985;408:313-321.
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Herpes simplex virus (HSV) is an icosahedral, enveloped virus with a linear, double-strand segment of DNA.10 Two closely related serologic types for which man is the only natural host are recognized. Primary infection in the immunocompetent host usually is asymptomatic, and both types establish latent infection in local sensory ganglia, which may repetitively reactivate after any of a variety of stimuli. Primary or reactivated infection in the immunocompromised host often is severe and may involve the esophagus or lower respiratory tract by contiguous spread; systemic dissemination also may occur."" 14 Lymphadenitis due to other Herpesviridae, such as Epstein-Barr virus, cytomegalovirus, and varicella-zoster virus, is well described,1516 but published accounts of Herpes simplex lymphadenitis are rare. Occasional cases have been reported from patients with systemic HSV infect i o n , " ' 4 ' 7 but only six well-documented cases of isolated HSV lymphadenitis have been described previously,1-4 with the presence of HSV confirmed by immunohistochemical, ultrastructural, or DNA hybridization techniques. The two cases reported here are histologically similar to those previously described, showing circumscribed areas of necrosis-containing cells with characteristic intranuclear inclusions. An additional case was reported by Lapsley and colleagues,18 wherein paracortical immunoblastic and histiocytic proliferation was described in a lymph node biopsy specimen from a patient with serologic evidence of HSV infection. The histologic appearance of the lymph node in that case, however, was not unlike that of varicella-zoster lymphadenitis, the patient's children were concurrently diagnosed as having varicella-zoster, and the patient also was afflicted with a generalized rash. Therefore, we must view that case as suspect. While the origins of infection in the current cases are uncertain, the localization to inguinal lymph nodes of seven of the eight acceptable cases reported thus far suggests lymphatic spread from the urogenital tract.1'2,4 The development of perineal herpes in both of the current patients and in two of those previously reported around the time of biopsy and the frequent occurrence of regional lymphadenopathy in HSV-infected patients lends credence to this hypothesis.19 Because primary and recurrent HSV infection may be subclinical,20,21 a similar mechanism may be operative for the other patients as well. Herpetic lymphadenitis must be distinguished from necrotizing lymphadenitis of other types, such as that due
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HEMATOPATHOLOGY Original Article 12. Muller SA, Herrmann EC Jr, Winkelmann RK. Herpes simplex infections in hematologic malignancies. Am J Med 1972;52:102— 104. 13. Naraqi S, Jackson GG, Jonasson OM. Viremia with herpes simplex type 1 in adults. Four nonfatal cases, one with features of chickenpox. Ann Intern Med 1976;85:165-169. 14. Sutton AL, Smithwick EM, Seligman SJ, Kim D-S. Fatal disseminated herpesvirus hominis type 2 infection in an adult with associated thymic dysplasia. Am J Med 1974;56:545-553. 15. Ioachim HL. Lymph node biopsy. Philadelphia: J.B. Lippincott Co., 1982;42. 16. Schnitzer B. Reactive lymphoid hyperplasia. In: Jaffe ES, eds. Surgical pathology of the lymph nodes and related organs. Philadelphia: W.B. Saunders Co., 1985:22-56. 17. Ramsey PG, Fife KH, Hackman RC, Meyers JD, Corey L. Herpes simplex pneumonia: clinical, virologic, and pathologic features in 20 patients. Ann Intern Med 1982;97:813-820. 18. Lapsley M, Kettle P, Sloan JM. Herpes simplex lymphadenitis: a case report and review of the published work. J Clin Pathol 1984;37:1119-1122. 19. Hirsch MS. Herpes simplex virus. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases, 3rd ed. New York: Churchill Livingstone, 1990:1144-1153. 20. Josey WE, Nahmias AJ, Naib ZM. Genital herpes simplex infection in the female. Am J Obstet Gynecol 1966;96:493-501. 21. Yen SSC, Reagan JW, Rosenthal MS. Herpes simplex infection in the female genital tract. Obstet Gynecol 1965;25:479-492. 22. Turner RR, Martin J, Dorfman RF. Necrotizing lymphadenitis: a study of 30 cases. Am J Surg Pathol 1983;7:115-123.
A.J.C.P.-May 1991
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2. Epstein JI, Ambinder RF, Kuhajda FP, Pearlman SH, Reuter VE, Mann RB. Localized herpes simplex lymphadenitis. Am J Clin Pathol 1986;86:444-448. 3. Tamaru J-I, Mikata A, Horie H, et al. Herpes simplex lymphadenitis: report of two cases with review of the literature. Am J Surg Pathol 1990;14:571-577. 4. Taxy JB, Tillawi I, Goldman PM. Herpes simplex lymphadenitis: an unusual presentation with necrosis and viral particles. Arch Pathol Lab Med 1985;109:1043-1044. 5. Sheibani K, Burke JS, Swartz WG, Nademanee A, Winberg CD. Monocytoid B cell lymphoma: clinicopathologic study of 21 cases of a unique type of low-grade lymphoma. Cancer 1988;62:1531 — 1538. 6. Sheibani K, Tubbs RR. Enzyme immunohistochemistry: technical aspects. Semin Diagn Pathol 1984;1:235-250. 7. Weiss LM, Movahed LA, Warnke RA, Sklar J. Localization of Epstein-Barr virus genomes to Reed-Sternberg cells in Hodgkin's disease. N Engl J Med 1989;320:502-506. 8. Weiss LM, Movahed LA. In situ demonstration of Epstein-Barr viral genomes in viral-associated B cell lymphoproliferations. Am J Pathol 1989;134:651-659. 9. Feinberg AP, Vogelstein B. A technique for radiolabeling DNA restriction endonuclease fragments to high specific activity. Anal Biochem 1983;132:6-13. 10. Drew WL, Rawls WE. Herpes simplex viruses. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ, eds. Manual of clinical microbiology, 4th ed. Washington, DC: American Society for Microbiology, 1985:705-710. 11. Abraham AA, Manko MA. Disseminated herpesvirus hominus 2 infection following drug overdose. Arch Intern Med 1977; 137: 1198-1200.
