Le Infezioni in Medicina, Suppl. 3, 12-15, 2012 fine needle cytology in the diagnosis of infectious diseases: clinical settings Citologia per ago sottile dei linfonodi nella diagnosi delle malattie infettive: aspetti clinici

Valentina Natella, Immacolata Cozzolino, Laura Virginia Sosa Fernandez, Elena Vigliar Dipartimento di Scienze Biomorfologiche e Funzionali, Università degli Studi di Napoli “Federico II”, Napoli, Italy

n BACKGROUND performed under ultrasound (US) or computed tomography (CT) control; in both cases, rapid ine needle cytology (FNC) is widely used on-site evaluation (ROSE) of the smears should in the diagnosis of different organs and be performed. ROSE ensures the adequacy of Fpathologies [1-18]. Lymph nodes are also the sample for cellularity and an initial diag - being more and more used to diagnose benign nostic orientation in order to perform addition - reactive conditions in non-surgical diseases, al passes, when needed, and to address specific such as infections or other benign conditions. ancillary techniques. For example, if an infec - Coupled with an accurate clinical history, phys - tion is suspected additional material may be ob - ical examination and ancillary techniques, tained for culture. when needed, FNC of enlarged nodes provides sufficient information to allow keeping the Cytological features lymph node, clinical surveillance and medical Smears are generally air dried and alcohol fixed treatment, when needed. for specific stains; air dried smear are immedi - , in both adults and chil - ately stained by Diff-Quik. This latter stain is a dren, are a common problem in the clinical Romanowsky modified stain that is performed practice and may be due to different causes. in a couple of minutes. The most common cause is represented by a ROSE of these smears is able to confirm the ad - non-specific reactive hyperplasia probably due equacy of the smear and an initial diagnostic to an asymptomatic inflammatory process or orientation. by specific infectious agents that disappear be - At low magnification cellularity, cell patterns fore they can be clinically or radiologically de - and background material (e.g. necrosis, inflam - tected. Infectious agents include pyogenic bac - matory debris) are generally evaluated. In case teria, mycobacteria, fungi, cat-scratch disease, of reactive hyperplasia, the presence of epithe - toxoplasmosis, HIV and infectious mononucle - liod cells or lympho-histiocytic aggregates con - osis [19-23]. taining dendritic cells are helpful in the diagno - sis of reactive hyperplasia. Technical aspects At high magnification, nuclear and cytoplasmic FNC lymph node of palpable lymph nodes features are evaluated; this allows to identify should be performed by the cytopathologist af - specific cell subtypes such as follicular centre ter the clinical evaluation and after a detailed cells, reticular cells, granulocytes, small lym - anamnesis of the patient, as reported in another phocytes and macrophages, as well as their article of the issue. In case of impalpable size, shape, chromatin pattern and nucleoli. Be - and/or deep located lymph node, FNC will be nign processes caused by infectious agents tend

12 2012 Figure 1 - Cytological features of reactive follicular Figure 2 - Cytological features of a reactive granulo - hyperplasia. Numerous follicular centre cells are matous lymph node; note small groups of epithe - present intermingled with mature lymphocytes. lioid cells and mature lymphocytes in the back- These cases are indistinguishable from ground (Diff-Quik stain 270X). on the sole cytological presentations and need an - cillary techniques to be correctly diagnosed (Diff Quik stain 430X). to be more polymorphous, showing a predom - pect to smears. Chronic lymphadenitis are gen - inance of small lymphoid cells, and a variable erally classified into non-granulomatous amount of macrophages. (Figure 2) and granulomatous; in this latter, the A quite polymorphous smear, in a proper clini - structure of the lymph node may be partially or cal and imaging setting may be sufficient to di - completely subverted by confluent granulomas agnose a reactive hyperplasia in much of the with or without necrosis. cases. When the smear is relatively monomor - Corresponding smears will reflect these aspects phous, with large centrofolicular cells (Figure 1) showing necrotizing (necrotic/dirty back - and/or does not match with clinical data and ground) or non-necrotizing (clean background) imaging, immunophenotyping of the cells by smears. flow cytometry (FC) is performed to assess cell When a granulomatous pattern is observed, at - polyclonality. The presence of a heterogeneous tention should be paid to the detection of population of lymphoid cells allows morpho - eosinophils and atypical mono or binucleated logically to hypothesize the etiology of a benign cells that may reveal an unsuspected Hodgkin evaluating the presence of . an increased proportion of plasma cells, Necrotic background may be purulent as in tu - macrophages or eosinophils in a clean or laremia, linfogranulomatosis venereal groin necrotic and granulomatous or non-granuloma - (LVG), cat-disease, Kikuchi disease and lym - tous background. phadenitis of Maschoff-Knopp; it can be Lymphadenitis are clinically classified as acute caseous in cases of typical and atypical my - and chronic, and cytological presentations of - cobacteria infections. ten reflects the clinical one. Acute lymphadeni - Among the non-necrotizing granulomatous tis generally shows polymorphous smears with lymphadenitis, the most common are tubercu - prevalence of one of the above reported cell loid leprosy, fungal infection and atypical my - types; when the lymphadenitis is maintained cobacteria. by pyogenic bacteria a variable amount of gran - Chronic non-granulomatous lymphadenopathy ulocytes is detected. Granulocytes generally in - can be systematized according to clean or filtrate the sinuses and the lymph node stroma, necrotic/dirty background. A heterogeneous and are associated to follicular hyperplasia. In lymphoid population with clean background corresponding smears, a variable amount may may be a viral infection, such as mononucleo - be detected ranging between a definite amount sis, lymphadenitis post-vaccination, and intermingled between all other cells and a com - syphilis; instead, if a heterogeneous lymphoid plete prevalence, conferring a suppurative as - population is accompanied by eosinophils,

13 2012 with presence of eosinophilia, this may be a n CONCLUSIONS parasite infection. When there are numerous in a polymorphic framework, whip - FNC of lymph nodes is a simple and useful tool ple disease, atypical mycobacteria, leproma - in the assessment of enlarged lymph node, pro - tous-histiocitoid leprosy, histoplasma, and viding that an expert cytopathologist performs atypical mycobacteria are taken into considera - the FNC, evaluates the smears by ROSE and re - tion. quires ancillary techniques, when needed, on Moreover, in the case of lymphadenitis with a the basis of the specific clinical context and cy - heterogeneous lymphoid population and a topathological features. When these conditions necrotic background (necrotizing lymphadeni - are met, reactive lymph nodes FNC may be use - tis) with , early cat scratch disease, ful because, excluding possible lymphomas or , atypical mycobacteria, filaria, and metastases, it allows to avoid useless biopsies HSV are taken into consideration. Instead, and appropriate therapies. Kikuchi lymphoadenitis and pneumocystis in - fection are characterized by a polymorphous Keywords: lymph lode, fine needle cytology, in - population without neutrophils [19, 22]. These fectious diseases, clinical setting. cytological presentations may suggest a possi - ble etiology but are specific and diagnostic of a Conflict of interest disclosure: The authors declare specific agent. Additional passes and residual that the article has not been sponsored, that no fi - material may be used for microbiological or nancial support has been given and finally that there molecular testing for specific antigens. is no conflict of interest.

SUMMARY

Lymph node reactive hyperplasia, caused by spe - provides information about the cell population cific infectious etiologic factors, represents the and the nature of the process. FNC can also pro - most frequent cause of enlarged peripheral lymph vide suitable material for ancillary techniques, nodes. The main infectious agents are viruses, pyo - such as flow cytometry, immunocytochemistry, genic bacteria, mycobacteria, fungi and protozoa molecular biology and microbiological examina - that may determine unspecific or specific patho - tions. logical entities, such as cat-scratch disease, toxo - This study focuses on the cytological features of plasmosis or infectious mononucleosis. Lymph benign lymphadenopathy of infectious origin and node fine needle cytology (FNC) is a safe, simple, their possible contribution to the clinical setting cost-effective and efficient technique that quickly definition of corresponding patients.

RIASSUNTO

Le iperplasie reattive linfonodali causate da diversi che essere utilizzata per acquisire materiale utile per tec - agenti microbiologici rappresentano la prima causa di niche ancillari applicate quali citometria a flusso, im - ingrandimento linfonodale. Gli agenti infettivi respon - munocitochimica e tecniche microbiologiche e molecola - sabili sono rappresentati da virus, batteri piogeni, mico - ri. Queste metodiche sono spesso indispensabili per dia - batteri, funghi e protozoi che possono determinare entità gnosticare la natura del processo stesso e possibilmente patologiche specifiche quali la malattia da graffio di gat - gli eventuali agenti biologici. Questo studio è focalizza - to, la toxoplasmosi, la mononucleosi o entità non speci - to sugli aspetti citologi delle linfoadenopatie benigne, fiche. La citologia per ago sottile (FNC) è una metodica reattive, sulle possibili relazioni con i corrispondenti semplice, economica ed efficace che può fornire informa - agenti microbiologici e sul contributo che la metodica zioni rapide sui costituenti cellulari del linfonodo e sul - può fornire alla definizione del contesto clinico e delle la natura della corrispondente iperplasia. FNC può an - strategie terapeutiche.

14 2012 n REFERENCES [13] Malapelle U., Bellevicine C., Zeppa P., Palombi - ni L., Troncone G. Cytology-based gene mutation [1] Zeppa P. Haematocytopathology: why? Cy - tests to predict response to anti-epidermal growth topathology. 2, 73-75, 2012. factor receptor therapy: a review. Diagn. Cytopathol. [2] Petruzziello F., Zeppa P., Ciancia G., et al. Cyto - 9, 703-710, 2011. logical and histological detection of amyloid de - [14] Bellevicine C., Malapelle U., Iaccarino A., et al. posits in bone marrow of patients affected by multi - Foamy gland pancreatic ductal adenocarcinoma di - ple myeloma. Leuk Lymphoma . 12, 2304-2307, 2011. agnosed on EUS-FNA: A histochemical, immunohis - [3] Zeppa P., Varone V., Cozzolino I., Salvatore D., tochemical, and molecular report. Diagn. Cytopathol . Vetrani A., Palombini L. Fine needle cytology and 2012. (In press). flow cytometry of ectopic cervical : a case [15] D’Antonio A., Paolella G., Zeppa P. Rapidly report. Acta Cytol . Suppl 5, 998-1002, 2010. growing intraparotid mass in a young child. J. Cran - [4] Zeppa P ., Vigliar E ., Cozzolino I ., et al. Fine nee - iofac. Surg . 4, 305-306, 2012. dle aspiration cytology and flow cytometry im - [16] Zeppa P., Sosa Fernandez L.V., Cozzolino I., et munophenotyping of non-Hodgkin lymphoma: can al. Immunoglobulin heavy-chain fluorescence in situ we do better? Cytopathology. 5, 300-310, 2010. hybridization-chromogenic in situ hybridization [5] Zeppa P., Barra E., Napolitano V., et al. Impact of DNA probe split signal in the clonality assessment of endoscopic ultrasound-guided fine needle aspiration lymphoproliferative processes on cytological sam - (EUS-FNA) in lymph nodal and mediastinal lesions: ples. Cancer Cytopathol . 2012 (in press). a multicenter experience. Diagn. Cytopathol . 10, 723- [17 ] Cozzolino I ., Zeppa R ., Zeppa P. Lymph nodal 729, 2011. Merkel cell carcinoma: primary tumor or metastasis [6] Troncone G., Guerriero E., Pallante P., et al. UbcH10 from unknown primary site? J. Cutan. Pathol. 10, 836- expression in human lymphomas. Histopathology 54, 837, 2011 . 6,731-740, 2009. [18] Cozzolino I., Nappa S., Picardi M., et al. P. Clon - [7] Zeppa P., Cozzolino I., Peluso A.L., et al. Cyto - al B-cell population in a reactive lymph node in ac - logic, flow cytometry, and molecular assessment of quired immunodeficiency syndrome. Diagn. Cyto - lymphoid infiltrate in fine-needle cytology samples pathol. 12, 910-914, 2009 of Hashimoto thyroiditis. Cancer 3, 174-184, 2009. [19] Monaco S.E., Khalbuss W.E., Pantanowitz L. Be - [8] Schmitt F., Vielh P., Zeppa P. Cytology for pathol - nign non-infectious causes of lymphadenopathy: a ogists: two sides of the same coin or different views review of cytomorphology and differential diagno - of the same side? Cytopathology 5, 345-346. 2012. sis. Diagn. Cytopathol . 40, 925-38, 2012. [9] Vigliar E., Bellevicine C., Cozzolino I., Zeppa P. [20] Lioe T.F., Elliott H., Allen D.C., Spence R.A. The Histological and fine needle aspiration cytological role of fine needle aspiration cytology (FNAC) in the features of Hashimoto thyroditis-associated ‘an - investigation of superficial lymphadenopathy; uses giomatoid’ papillary thyroid carcinoma. Cytopatholo - and limitations of the technique. Cytopathology . 10, gy . 2012. (In press). 291-71, 1999. [10] Vigliar E., Cozzolino I., Fernandez L.V., et al. [21] Schafernak K.T., Kluskens L.F., Ariga R., Reddy Fine-needle cytology and flow cytometry assessment V.B., Gattuso P. Fineneedle aspiration of superficial of reactive and lymphoproliferative processes of the and deeply seated lymph nodes on patients with and breast. Acta Cytol. 2, 130-138, 2012. without a history of malignancy: review of 439 cases. [11] Stanzione B., Cozzolino I., Arpino G., Vigliar E., Diagn. Cytopathol . 29, 315-319, 2003. Virginia S.F., Zeppa P. Multiple metachronus prolif - [22] Miliauskas J. Lymph nodes. In: Orell & Sterrett’s erative fasciitis occurring in different anatomic re - Fine needle aspiration cytology (Orell S.R. and Ster - gions: a case report and review of the literature. rett G.F., 5 th Ed) 2012, 77-112. Churchill-Livigstone. Pathol. Res. Pract. 2, 126-130, 2012. [23] Cozzolino I., Vigliar E., Sosa Fernandez L.V., et [12] D’Antonio A., Baldi C., Memoli D., Caleo A., Ro - al. Non lymphomatous clonal B-cell population in samilio R., Zeppa P. Fine needle aspiration biopsy of enlarged lymph nodes in acquired immunodefi - intraparotid spindle cell lipoma: A case report. Di - ciency syndrome. Infez. Med. 20, 35-42, 2012. agn. Cytopathol . 2011 (in press).

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