L etters to Editor
Pulmonary echinococcosis with Actinomycetes-like organisms mimicking malignancy: Diagnosed by fine needle aspiration cytology Sir, Superimposed fungal or bacterial infections are known to occur in pre-existing lung cavities secondary to tuberculosis, bronchial cysts and bullae, pulmonary tumors or infarction. Fungal infections such as Aspergillosis have been described previously in a hydatid cyst. We here describe the rare occurrence of Actinomycetes-like organisms growing in a hydatid cyst diagnosed on fine needle aspiration cytology in an immunocompetent patient. A 50-year-old female patient presented with a history of cough and expectoration associated with hemoptysis for 3 months. Human immunodeficiency virus serology was negative. Contrast enhancing computed tomography chest revealed a 3 cm diameter well-defined heterogeneous peripherally enhancing lesion with irregular borders in the right lower lobe of lung [Figure 1a]. The differential diagnoses considered on imaging were bronchogenic carcinoma or a pulmonary abscess. Computed tomography guided fine-needle aspiration was performed, which yielded about 1.5 mL of thin necrotic pus-like material. The sediment as well as direct smears were prepared. The smears were stained with May-Grünwald-Geimsa (MGG), H and E, Papanicolaou, Periodic acid-Schiff ’s (PAS) and Ziehl-Neelsen stains. Smears revealed multiple fragments of amorphous lamellated hyaline acellular PAS positive membranes [Figure 1b-d] and hooklets of Echinococcus granulosus [Figure 1d, Inset]. In addition, numerous thin delicate filamentous organisms were seen growing over the lamellated membranes. One of the MGG stained smear was destained and stained with the Gram stain. These filamentous organisms were Gram-positive consistent with morphology of Actinomycetes-like organisms. Sheets of acute inflammatory cells and foamy macrophages were seen in the background of the smear; however, no epithelioid cell granulomas were noted. Part of the pus like material was also processed with SurePathTM liquid based cytology technique [Figure 1d]. The cytologic diagnosis offered was pulmonary echinococcosis with superadded Actinomycetes-like organisms. Culture was not sent as the possibility of malignancy was high clinico-radiologically at the time of aspiration. Patient was given a high dose of sulfamethoxazole and trimethoprim, therapy for 6 weeks and albendazole therapy 400 mg twice daily and later was subjected to surgery of the hydatid disease. The histopathology revealed 216
only hydatid cyst and Actinomycetes-like organisms were not seen as histopathology was done after treatment. At present, the patient is doing well. Lung is the most common site of involvement by hydatid disease. Pulmonary hydatid cyst may rupture into the bronchial tree and produce cough, chest pain, or hemoptysis. At this stage, it is difficult to diagnose on imaging due to atypical features.[1] Pulmonary actinomycosis is a rare bacterial disease and it occurs due to poor oral hygiene, which allows the normal flora to proliferate. Aspiration of the infected material is the presumptive mechanism that leads to thoraco-pulmonary infection.[2] Diagnosis of dual or multiple infections of the respiratory tract by fine needle aspiration cytology (FNAC) has been documented in a few case reports especially in immunocompromised patients.[3,4] There is only one previous case report of diagnosis of these two dual infections/ infestations diagnosed on FNAC.[5] We report a rare case of pulmonary hydatid disease complicated with Actinomycetes-like organisms diagnosed on FNAC, radiologically mimicking bronchogenic carcinoma. Although FNAC is contraindicated in suspected hydatid disease, this case highlights the role of
a
b
c
d
Figure 1: (a) Contrast enhancing computed tomography chest showing a well-defined heterogeneous peripherally enhancing 3 cm lesion with irregular borders in right lower lobe of lung with in-situ fine needle aspiration needle; (b) Hyaline membrane of hydatid cyst with dense acute inflammatory infiltrate ( MGG, x200); (c) Amorphous acellular hydatid membrane with filamentous bacteria (MGG ×400); (d) Liquid based cytology smear showing hyaline laminated hydatid membranes (MGG ×40), Inset-Hooklet of hydatid (Pap, x400)
Journal of Cytology / July 2013 / Volume 30 / Issue 3
Letters to Editor
FNAC in the diagnosis of two rare lung infections in this case, prompting an early and sucessful treatment.
2.
3.
Nalini Gupta, Sangeeta Verma, Pinaki Dutta1, Diveyesh Mahajan2, Naveen Kalra2 Departments of Cytology and Gynecological Pathology, Endocrinology, and 2Radiodiagnosis, Postgraduate Institute of
1
Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Nalini Gupta, Department of Cytology and Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: [email protected]
5.
Access this article online Quick Response Code Website: www.jcytol.org
References 1.
4.
Paksoy N, Ozer D, Tuneli IÖ. Diagnosis of pulmonary hydatid disease presenting with solid nodule and mimicking malignancy by fine needle aspiration cytology. Cytojournal 2012;9:13. Gupta N, Arora J, Nijhawan R, Aggarwal R, Lal A. Aspergillosis with pulmonary echinococcosis. Cytojournal 2006;3:7. Duggal R, Rajwanshi A, Gupta N, Lal A, Singhal M. Polymicrobial lung infection in postrenal transplant recipient diagnosed by fine-needle aspiration cytology. Diagn Cytopathol 2010;38:294-6. Sodhani P, Gupta S. Pulmonary echinococcosis complicated with actinomycotic abscess: A rare fine needle aspiration diagnosis. Acta Cytol 2006;50:359-60.
Kilinç O, Döskaya M, Sakar A, Yorgancioğlu A, Halilçolar H, Caner A, et al. Three atypical pulmonary hydatidosis lesions mimicking bronchial cancer from Turkey. New Microbiol 2009;32:229-33.
DOI: 10.4103/0970-9371.117637
Donovanosis: An incidental finding on Pap test Sir, Pap test has been an effective way to screen women for squamous dysplasia and carcinoma of the uterine cervix. Although the Pap test is primarily used for detecting cellular and epithelial abnormalities, certain infections are detected on the Pap test too e.g., donovanosis, tuberculosis, coccidioidomycosis, schistosomiasis, teniasis, molluscum contagiosum.[1] These rare entities pose challenges due to the infrequent occurrence of these entities in the daily practice of cytology. These conditions may also give rise to diagnostic pitfalls to be aware of in Pap tests. We are reporting an incidental finding of Calymmatobacterium granulomatis/ Donovan bodies on Pap test. A 27-year-old married woman presented with chief complaint of recurrent seropurulent vaginal discharge. She was treated with anti-fungals repeatedly but got only symptomatic relief for some time. Her spouse was also counseled and treated. A complete history and examination was sought in the Indian Council of Medical Research (ICMR) clinic Mandi, Himachal Pradesh. There was a history of seropurulent discharge and itchy ulcerations on the vulva for past one year. There was no promiscuous sexual behavior. Both partners were non reactive for human immunodeficiency virus and Veneral Diseases Research Laboratory test. A Pap test was taken. Pap smears were satisfactory and negative for intraepithelial lesion/malignancy. In addition, smears showed acute inflammatory cell infiltrate
with numerous macrophages. The macrophages contained numerous safety pin shaped structures with polar thickening (donovan bodies) and a halo around them [Figure 1]. Pap smears was reported positive for Calymmatobacterium granulomatis/ Donovanosis. It was an incidental finding in a patient who was given erroneous treatment for an intractable infection in an on-going cancer control project in Himachal Pradesh. Donovanosis is another name for granuloma inguinale. It is a bacterial sexually transmitted disease (STD) caused by a gram negative, intracellular, non-motile, non-sporing cocco-bacillus
Figure 1: Macrophages show numerous safety pin shaped structures with polar thickening of chromatin (donovan bodies) and a halo around them (circle) (Pap, ×100)
Journal of Cytology / July 2013 / Volume 30 / Issue 3
217
Copyright of Journal of Cytology is the property of Medknow Publications & Media Pvt. Ltd. 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.
Pulmonary echinococcosis with Actinomycetes-like organisms mimicking malignancy: Diagnosed by fine needle aspiration cytology Sir, Superimposed fungal or bacterial infections are known to occur in pre-existing lung cavities secondary to tuberculosis, bronchial cysts and bullae, pulmonary tumors or infarction. Fungal infections such as Aspergillosis have been described previously in a hydatid cyst. We here describe the rare occurrence of Actinomycetes-like organisms growing in a hydatid cyst diagnosed on fine needle aspiration cytology in an immunocompetent patient. A 50-year-old female patient presented with a history of cough and expectoration associated with hemoptysis for 3 months. Human immunodeficiency virus serology was negative. Contrast enhancing computed tomography chest revealed a 3 cm diameter well-defined heterogeneous peripherally enhancing lesion with irregular borders in the right lower lobe of lung [Figure 1a]. The differential diagnoses considered on imaging were bronchogenic carcinoma or a pulmonary abscess. Computed tomography guided fine-needle aspiration was performed, which yielded about 1.5 mL of thin necrotic pus-like material. The sediment as well as direct smears were prepared. The smears were stained with May-Grünwald-Geimsa (MGG), H and E, Papanicolaou, Periodic acid-Schiff ’s (PAS) and Ziehl-Neelsen stains. Smears revealed multiple fragments of amorphous lamellated hyaline acellular PAS positive membranes [Figure 1b-d] and hooklets of Echinococcus granulosus [Figure 1d, Inset]. In addition, numerous thin delicate filamentous organisms were seen growing over the lamellated membranes. One of the MGG stained smear was destained and stained with the Gram stain. These filamentous organisms were Gram-positive consistent with morphology of Actinomycetes-like organisms. Sheets of acute inflammatory cells and foamy macrophages were seen in the background of the smear; however, no epithelioid cell granulomas were noted. Part of the pus like material was also processed with SurePathTM liquid based cytology technique [Figure 1d]. The cytologic diagnosis offered was pulmonary echinococcosis with superadded Actinomycetes-like organisms. Culture was not sent as the possibility of malignancy was high clinico-radiologically at the time of aspiration. Patient was given a high dose of sulfamethoxazole and trimethoprim, therapy for 6 weeks and albendazole therapy 400 mg twice daily and later was subjected to surgery of the hydatid disease. The histopathology revealed 216
only hydatid cyst and Actinomycetes-like organisms were not seen as histopathology was done after treatment. At present, the patient is doing well. Lung is the most common site of involvement by hydatid disease. Pulmonary hydatid cyst may rupture into the bronchial tree and produce cough, chest pain, or hemoptysis. At this stage, it is difficult to diagnose on imaging due to atypical features.[1] Pulmonary actinomycosis is a rare bacterial disease and it occurs due to poor oral hygiene, which allows the normal flora to proliferate. Aspiration of the infected material is the presumptive mechanism that leads to thoraco-pulmonary infection.[2] Diagnosis of dual or multiple infections of the respiratory tract by fine needle aspiration cytology (FNAC) has been documented in a few case reports especially in immunocompromised patients.[3,4] There is only one previous case report of diagnosis of these two dual infections/ infestations diagnosed on FNAC.[5] We report a rare case of pulmonary hydatid disease complicated with Actinomycetes-like organisms diagnosed on FNAC, radiologically mimicking bronchogenic carcinoma. Although FNAC is contraindicated in suspected hydatid disease, this case highlights the role of
a
b
c
d
Figure 1: (a) Contrast enhancing computed tomography chest showing a well-defined heterogeneous peripherally enhancing 3 cm lesion with irregular borders in right lower lobe of lung with in-situ fine needle aspiration needle; (b) Hyaline membrane of hydatid cyst with dense acute inflammatory infiltrate ( MGG, x200); (c) Amorphous acellular hydatid membrane with filamentous bacteria (MGG ×400); (d) Liquid based cytology smear showing hyaline laminated hydatid membranes (MGG ×40), Inset-Hooklet of hydatid (Pap, x400)
Journal of Cytology / July 2013 / Volume 30 / Issue 3
Letters to Editor
FNAC in the diagnosis of two rare lung infections in this case, prompting an early and sucessful treatment.
2.
3.
Nalini Gupta, Sangeeta Verma, Pinaki Dutta1, Diveyesh Mahajan2, Naveen Kalra2 Departments of Cytology and Gynecological Pathology, Endocrinology, and 2Radiodiagnosis, Postgraduate Institute of
1
Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Nalini Gupta, Department of Cytology and Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: [email protected]
5.
Access this article online Quick Response Code Website: www.jcytol.org
References 1.
4.
Paksoy N, Ozer D, Tuneli IÖ. Diagnosis of pulmonary hydatid disease presenting with solid nodule and mimicking malignancy by fine needle aspiration cytology. Cytojournal 2012;9:13. Gupta N, Arora J, Nijhawan R, Aggarwal R, Lal A. Aspergillosis with pulmonary echinococcosis. Cytojournal 2006;3:7. Duggal R, Rajwanshi A, Gupta N, Lal A, Singhal M. Polymicrobial lung infection in postrenal transplant recipient diagnosed by fine-needle aspiration cytology. Diagn Cytopathol 2010;38:294-6. Sodhani P, Gupta S. Pulmonary echinococcosis complicated with actinomycotic abscess: A rare fine needle aspiration diagnosis. Acta Cytol 2006;50:359-60.
Kilinç O, Döskaya M, Sakar A, Yorgancioğlu A, Halilçolar H, Caner A, et al. Three atypical pulmonary hydatidosis lesions mimicking bronchial cancer from Turkey. New Microbiol 2009;32:229-33.
DOI: 10.4103/0970-9371.117637
Donovanosis: An incidental finding on Pap test Sir, Pap test has been an effective way to screen women for squamous dysplasia and carcinoma of the uterine cervix. Although the Pap test is primarily used for detecting cellular and epithelial abnormalities, certain infections are detected on the Pap test too e.g., donovanosis, tuberculosis, coccidioidomycosis, schistosomiasis, teniasis, molluscum contagiosum.[1] These rare entities pose challenges due to the infrequent occurrence of these entities in the daily practice of cytology. These conditions may also give rise to diagnostic pitfalls to be aware of in Pap tests. We are reporting an incidental finding of Calymmatobacterium granulomatis/ Donovan bodies on Pap test. A 27-year-old married woman presented with chief complaint of recurrent seropurulent vaginal discharge. She was treated with anti-fungals repeatedly but got only symptomatic relief for some time. Her spouse was also counseled and treated. A complete history and examination was sought in the Indian Council of Medical Research (ICMR) clinic Mandi, Himachal Pradesh. There was a history of seropurulent discharge and itchy ulcerations on the vulva for past one year. There was no promiscuous sexual behavior. Both partners were non reactive for human immunodeficiency virus and Veneral Diseases Research Laboratory test. A Pap test was taken. Pap smears were satisfactory and negative for intraepithelial lesion/malignancy. In addition, smears showed acute inflammatory cell infiltrate
with numerous macrophages. The macrophages contained numerous safety pin shaped structures with polar thickening (donovan bodies) and a halo around them [Figure 1]. Pap smears was reported positive for Calymmatobacterium granulomatis/ Donovanosis. It was an incidental finding in a patient who was given erroneous treatment for an intractable infection in an on-going cancer control project in Himachal Pradesh. Donovanosis is another name for granuloma inguinale. It is a bacterial sexually transmitted disease (STD) caused by a gram negative, intracellular, non-motile, non-sporing cocco-bacillus
Figure 1: Macrophages show numerous safety pin shaped structures with polar thickening of chromatin (donovan bodies) and a halo around them (circle) (Pap, ×100)
Journal of Cytology / July 2013 / Volume 30 / Issue 3
217
Copyright of Journal of Cytology is the property of Medknow Publications & Media Pvt. Ltd. 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.
