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
418
Correspondence
umented specifically in termites and wood-eating cockroaches.1 The purpose of this letter is to report, using light microscope, the observation of unusual form elements that were present in an expectoration from a 42-year-old female asthmatic patient. The sample was obtained via spontaneous expectoration of sputum and stained using the Papanicolaou method. Figure 1 shows, in the smear from the spontaneous expectoration, the presence of several enlarged structures (30–50 9 3–7 lm) with a granular appearance and irregular outlines. At the cephalic end (arrow) a protrusion is visible (the so-called ‘rostrum’). Numerous flagella are inserted over the entire body surface. On the basis of these morphological features and the resemblance to some of the anaerobic flagellate symbionts seen in the intestinal extracts of termites, these structures were tentatively catalogued as multiflagellate protozoa belonging to the order Hypermastigida. One of the main morphological features of these protozoa is the presence of numerous flagella alongside the entire cytoplasmic surface. This conclusion was reached after the establishment of the differential diagnosis with degenerate released bronchial-ciliated cells (in them, unidirectional cilia inserted in a terminal bar located at the apical end of the cytoplasm were observed). Through meticulous examination of numerous sputa corresponding to bronchopulmonary diseases, especially from asthmatic patients, we have acquired a level of experience in the recognition of uncommon flagellate protozoa, distinguishing them also from degenerate bronchial-ciliated cells (the ‘Ciliocytophthoria’ phenomena).2 At this point, it is necessary to ask the following question: how do these protozoa, which are restricted to the hindgut of termites, appear in expectorated secretions from the human respiratory tract? Certain species of termites, such as Kalotermes flavicollis and Cryptotermes brevis, which live in humid areas, form colonies inside wood (furniture, frames, doors, balks, etc.). A characteristic of these termites are the small faecal balls that may fall to the ground from the attacked elements or tunnels filling their galleries. Young and newly moulted termites are not born with microorganisms in their guts. Therefore, they acquire flagellate protozoa through the excreted faeces that they eat directly. Hypermastigida flagellates and termites form an obligate symbiotic association where each is dependent on the other. Outside of the host,
Figure 1. Multiflagellate protozoa in a sputum smear from spontaneous expectoration (Papanicolaou stain, 91000. Scale bar = 10 lm).
these anaerobic flagellates die unless they are enclosed in protective cysts.3 The physiology of encystment in the Hypermastigida flagellates preclude their transfer via cysts in other hosts. Protozoan cysts of flagellates have been isolated as airborne contaminants in the atmosphere,4 and consequently may be inhaled by humans or other animals. Once introduced into the human respiratory tract, the inhaled cysts under favourable conditions such as an adequate pH, humidity, temperature, and the anaerobiosis provoked by hypoxic inspissated mucopurulent secretions, have the potential to produce an excystation with a subsequent liberation of the flagellate protozoa. With regard to asthma, another uncommon anaerobic flagellate protozoa, observed in sputum smears from asthmatic patients, has been reported;5 as well as in a case–control study demonstrating an association between flagellate protozoa in induced sputum samples and asthma.6 This is an intriguing dilemma that, until now, has not been solved. With regard to this interesting topic, in my opinion, I suggest that proteolitic enzymes, secreted by these uncommon multiflagellated protozoa, could break the bonds between bronchial epithelial cells (tight junctions, desmosomes and adherence junctions) compromising the integrity of the respiratory epithelium and increasing paracellular permeability so as to facilitate the delivery of allergens to underlying tissues. Moreover, a marked increase in the shedding of bronchial epithelial cells is found on examination of sputum from asthmatic patients, signalling that the epithelial barrier of the airways © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
Correspondence
could be damaged by this protozoal proteolitic activity. Because the majority of these flagellate protozoa are un-cultivable and molecular studies are costly, with the need for specialized personnel that are within reach of all laboratories, the observation under light microscope based on morphological features continues to be a simple, practical and inexpensive procedure in order to identify these eukaryotic microorganisms in respiratory secretions. R. Martınez-Gir on Protozoal Respiratory Pathology Research Unit, INCLI NICA Foundation, Oviedo, Spain References 1. Ohkuma M, Hongoh Y, Kudo T. Diversity and molecular analyses of yet-uncultivated microorganisms. In: Intestinal Microorganisms of Termites and Other Invertebrates. K€ onig H, Varma A (eds). Berlin, Heidelberg: SpringerVerlag; 2006: pp. 304. 2. Martınez-Giron R, Doganci L, Ribas A. From the 19th century to the 21st, an old dilemma: ciliocytophthoria, multiflagellated protozoa, or both? Diagn Cytopathol 2008;36:609–11. 3. Nisbert B. Nutrition and Feeding Strategies in Protozoa. Manuka, Australia: Croom Helm Ltd.; 1984. 4. Rogerson A, Detwiler A. Abundance of airborne heterotrophic protists in ground level air of South Dakota. Atmos Res 1999;51:35–44. 5. Martınez-Gir on R. Oxymonad and Spirotrichonympha: two anaerobic flagellated protozoa on sputum smears related to asthma. Diagn Cytopathol 2011;39:311–2. 6. van Woerden HC, Ratier-Cruz A, Aleshinloye OB et al. Association between protozoa in sputum and asthma: a case–control study. Respir Med 2011;105:877–84.
Metastatic retinoblastoma of mandible diagnosed on fine needle aspiration cytology DOI:10.1111/cyt.12115
Dear Editor, Retinoblastoma (RB) is one of the commonest tumours of childhood. Lymphatic and haematogenous dissemination usually occurs if there is scleral invasion.1 Metastasis to the mandible is Correspondence: Dr D. Jain, Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Tel.: +91-11-26594774; Fax: +91-11-2658863; E-mail: [email protected] © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
rare.2 Herein we report cytology features of RB and emphasize the utility of fine needle aspiration (FNA) in diagnosing this tumour at an uncommon site especially when clinical and radiological diagnoses are misleading and immunocytochemistry can be done. A 3-year-old girl was brought to the cytology clinic for aspiration of a large swelling in the left parotid region, which had been present for 2– 3 weeks, with a clinical diagnosis of parotid neoplasm. Her right eye had been enucleated at 1.9 years of age and histopathological examination revealed features of RB. The tumour showed large areas of necrosis and calcification. There was massive choroidal and scleral invasion with involvement of the retrolaminar portion of the optic nerve head. The resected end of the optic nerve, iris, ciliary body and anterior chamber were tumour free. The child was under regular follow-up with the paediatric oncology unit and received 10 cycles of chemotherapy (vincristine, etoposide and carboplatin) along with radiotherapy. Cerebrospinal fluid (CSF) cytology and bone marrow examination were performed at regular intervals and were negative for tumour. The patient had been tumour free for more than a year when the parents noticed a swelling in the left parotid region. The swelling was large (6 9 6 cm), non-tender and firm in consistency. A computed tomography (CT) scan of the head and neck revealed a soft tissue mass in the left masticator space with sunburst type of aggressive periosteal reaction of the left half of the mandibular body and ramus extending to involve the condyle and coronoid process (Figure 1a). The fat plane with the left parotid was preserved. The radiological appearance suggested an osteosarcoma. FNA of the swelling was performed. Air-dried and alcohol-fixed aspiration smears were stained with May-Gr€ unwald–Giemsa and Papanicolaou stains, respectively. The smears showed a malignant small round cell tumour (MSRCT). The cells were round with scant cytoplasm and hyperchromatic nuclei. Focal necrosis, nuclear molding and mitotic figures were identified (Figure 1b). Attempted pseudorosettes were seen focally. Immunostaining was carried out on a spare unstained alcohol-fixed smear and showed the tumour cells to be strongly immunopositive for synaptophysin (1 : 200; Thermo Scientific, Waltham, MA, USA) confirming metastasis of retinoblastoma (Figure 1c). Later staining of de-stained smears showed focal staining for CD56 (1 : 50; Novocastra, Newcastle upon Tyne, UK); the S-100
419
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.
(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
418
Correspondence
umented specifically in termites and wood-eating cockroaches.1 The purpose of this letter is to report, using light microscope, the observation of unusual form elements that were present in an expectoration from a 42-year-old female asthmatic patient. The sample was obtained via spontaneous expectoration of sputum and stained using the Papanicolaou method. Figure 1 shows, in the smear from the spontaneous expectoration, the presence of several enlarged structures (30–50 9 3–7 lm) with a granular appearance and irregular outlines. At the cephalic end (arrow) a protrusion is visible (the so-called ‘rostrum’). Numerous flagella are inserted over the entire body surface. On the basis of these morphological features and the resemblance to some of the anaerobic flagellate symbionts seen in the intestinal extracts of termites, these structures were tentatively catalogued as multiflagellate protozoa belonging to the order Hypermastigida. One of the main morphological features of these protozoa is the presence of numerous flagella alongside the entire cytoplasmic surface. This conclusion was reached after the establishment of the differential diagnosis with degenerate released bronchial-ciliated cells (in them, unidirectional cilia inserted in a terminal bar located at the apical end of the cytoplasm were observed). Through meticulous examination of numerous sputa corresponding to bronchopulmonary diseases, especially from asthmatic patients, we have acquired a level of experience in the recognition of uncommon flagellate protozoa, distinguishing them also from degenerate bronchial-ciliated cells (the ‘Ciliocytophthoria’ phenomena).2 At this point, it is necessary to ask the following question: how do these protozoa, which are restricted to the hindgut of termites, appear in expectorated secretions from the human respiratory tract? Certain species of termites, such as Kalotermes flavicollis and Cryptotermes brevis, which live in humid areas, form colonies inside wood (furniture, frames, doors, balks, etc.). A characteristic of these termites are the small faecal balls that may fall to the ground from the attacked elements or tunnels filling their galleries. Young and newly moulted termites are not born with microorganisms in their guts. Therefore, they acquire flagellate protozoa through the excreted faeces that they eat directly. Hypermastigida flagellates and termites form an obligate symbiotic association where each is dependent on the other. Outside of the host,
Figure 1. Multiflagellate protozoa in a sputum smear from spontaneous expectoration (Papanicolaou stain, 91000. Scale bar = 10 lm).
these anaerobic flagellates die unless they are enclosed in protective cysts.3 The physiology of encystment in the Hypermastigida flagellates preclude their transfer via cysts in other hosts. Protozoan cysts of flagellates have been isolated as airborne contaminants in the atmosphere,4 and consequently may be inhaled by humans or other animals. Once introduced into the human respiratory tract, the inhaled cysts under favourable conditions such as an adequate pH, humidity, temperature, and the anaerobiosis provoked by hypoxic inspissated mucopurulent secretions, have the potential to produce an excystation with a subsequent liberation of the flagellate protozoa. With regard to asthma, another uncommon anaerobic flagellate protozoa, observed in sputum smears from asthmatic patients, has been reported;5 as well as in a case–control study demonstrating an association between flagellate protozoa in induced sputum samples and asthma.6 This is an intriguing dilemma that, until now, has not been solved. With regard to this interesting topic, in my opinion, I suggest that proteolitic enzymes, secreted by these uncommon multiflagellated protozoa, could break the bonds between bronchial epithelial cells (tight junctions, desmosomes and adherence junctions) compromising the integrity of the respiratory epithelium and increasing paracellular permeability so as to facilitate the delivery of allergens to underlying tissues. Moreover, a marked increase in the shedding of bronchial epithelial cells is found on examination of sputum from asthmatic patients, signalling that the epithelial barrier of the airways © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
Correspondence
could be damaged by this protozoal proteolitic activity. Because the majority of these flagellate protozoa are un-cultivable and molecular studies are costly, with the need for specialized personnel that are within reach of all laboratories, the observation under light microscope based on morphological features continues to be a simple, practical and inexpensive procedure in order to identify these eukaryotic microorganisms in respiratory secretions. R. Martınez-Gir on Protozoal Respiratory Pathology Research Unit, INCLI NICA Foundation, Oviedo, Spain References 1. Ohkuma M, Hongoh Y, Kudo T. Diversity and molecular analyses of yet-uncultivated microorganisms. In: Intestinal Microorganisms of Termites and Other Invertebrates. K€ onig H, Varma A (eds). Berlin, Heidelberg: SpringerVerlag; 2006: pp. 304. 2. Martınez-Giron R, Doganci L, Ribas A. From the 19th century to the 21st, an old dilemma: ciliocytophthoria, multiflagellated protozoa, or both? Diagn Cytopathol 2008;36:609–11. 3. Nisbert B. Nutrition and Feeding Strategies in Protozoa. Manuka, Australia: Croom Helm Ltd.; 1984. 4. Rogerson A, Detwiler A. Abundance of airborne heterotrophic protists in ground level air of South Dakota. Atmos Res 1999;51:35–44. 5. Martınez-Gir on R. Oxymonad and Spirotrichonympha: two anaerobic flagellated protozoa on sputum smears related to asthma. Diagn Cytopathol 2011;39:311–2. 6. van Woerden HC, Ratier-Cruz A, Aleshinloye OB et al. Association between protozoa in sputum and asthma: a case–control study. Respir Med 2011;105:877–84.
Metastatic retinoblastoma of mandible diagnosed on fine needle aspiration cytology DOI:10.1111/cyt.12115
Dear Editor, Retinoblastoma (RB) is one of the commonest tumours of childhood. Lymphatic and haematogenous dissemination usually occurs if there is scleral invasion.1 Metastasis to the mandible is Correspondence: Dr D. Jain, Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India Tel.: +91-11-26594774; Fax: +91-11-2658863; E-mail: [email protected] © 2013 John Wiley & Sons Ltd Cytopathology 2014, 25, 412–421
rare.2 Herein we report cytology features of RB and emphasize the utility of fine needle aspiration (FNA) in diagnosing this tumour at an uncommon site especially when clinical and radiological diagnoses are misleading and immunocytochemistry can be done. A 3-year-old girl was brought to the cytology clinic for aspiration of a large swelling in the left parotid region, which had been present for 2– 3 weeks, with a clinical diagnosis of parotid neoplasm. Her right eye had been enucleated at 1.9 years of age and histopathological examination revealed features of RB. The tumour showed large areas of necrosis and calcification. There was massive choroidal and scleral invasion with involvement of the retrolaminar portion of the optic nerve head. The resected end of the optic nerve, iris, ciliary body and anterior chamber were tumour free. The child was under regular follow-up with the paediatric oncology unit and received 10 cycles of chemotherapy (vincristine, etoposide and carboplatin) along with radiotherapy. Cerebrospinal fluid (CSF) cytology and bone marrow examination were performed at regular intervals and were negative for tumour. The patient had been tumour free for more than a year when the parents noticed a swelling in the left parotid region. The swelling was large (6 9 6 cm), non-tender and firm in consistency. A computed tomography (CT) scan of the head and neck revealed a soft tissue mass in the left masticator space with sunburst type of aggressive periosteal reaction of the left half of the mandibular body and ramus extending to involve the condyle and coronoid process (Figure 1a). The fat plane with the left parotid was preserved. The radiological appearance suggested an osteosarcoma. FNA of the swelling was performed. Air-dried and alcohol-fixed aspiration smears were stained with May-Gr€ unwald–Giemsa and Papanicolaou stains, respectively. The smears showed a malignant small round cell tumour (MSRCT). The cells were round with scant cytoplasm and hyperchromatic nuclei. Focal necrosis, nuclear molding and mitotic figures were identified (Figure 1b). Attempted pseudorosettes were seen focally. Immunostaining was carried out on a spare unstained alcohol-fixed smear and showed the tumour cells to be strongly immunopositive for synaptophysin (1 : 200; Thermo Scientific, Waltham, MA, USA) confirming metastasis of retinoblastoma (Figure 1c). Later staining of de-stained smears showed focal staining for CD56 (1 : 50; Novocastra, Newcastle upon Tyne, UK); the S-100
419
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.
