Jebmh.com Original Research Article

Staging of Cytological Smears in HIV Lymphadenitis and Correlation with Histopathology

Hemalatha A. N.1

1Professor, Department of , Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

ABSTRACT

BACKGROUND Corresponding Author: nodes from HIV positive patients with progressive generalized Dr. Hemalatha A. N, th undergo morphological changes associated with progression of 8 Cross, RMV Extension, 1st Stage, Sadashiva Nagar, disease. These changes can be categorized cytologically with correlation of Bangalore- 560080, Karnataka. histopathological findings. FNA cytology although unable to differentiate between E-mail: [email protected] the three histological stages, can establish in most instances a reactive lymphoid DOI: 10.18410/jebmh/2019/611 process. Lymphadenitis is a common finding which includes numerous infectious and noninfectious conditions. In this study I have included only patients who are Financial or Other Competing Interests: confirmed and diagnosed as HIV positive, and presented with generalized None. lymphadenopathy. How to Cite This Article: Hemalatha AN. Staging of cytological METHODS smears in HIV lymphadenitis and FNAC was performed smears were air dried, few preserved in 90% methanol correlation with histopathology. J. Evid. Based Med. Healthc. 2019; 6(46), 2931- simultaneously was done on these patients for histopathological 2934. DOI: 10.18410/jebmh/2019/611 examination. Smears are stained by pap and Leishman stains. Submission 24-10-2019, RESULTS Peer Review 04-11-2019, Acceptance 11-11-2019, One hundred HIV positive patients were studied who presented with generalized Published 14-11-2019. lymphadenopathy. Cases of Reactive Lymphadenitis, which were diagnosed on Fine Needle aspiration, were studied and correlated with histopathological sections in following stages-

Type I pattern - Follicular with or without paracortical hyperplasia.

Type II pattern - Diffuse with loss of Germinal centers.

Type III pattern - Marked lymphocytic depletion.

CONCLUSIONS Patterns 1 & 2 are associated with persistent generalised lymphadenopathy type 11 is rarer. Hence one should be very cautious to study this staging, because it mimics various forms of on FNA smears. Immunocytochemistry is helpful to confirm benign nature of the process by demonstrating polyclonality.

KEYWORDS HIV, , reactive process

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Jebmh.com Original Research Article

BACKGROUND histological findings in the hyperplastic phase in lymph nodes

in AIDS or ARC, with some emphasizing certain features that Lymphadenopathy in HIV positive patient is a common others have not considered important. Based on their studies occurrence where the spectrum of pathological changes and cases, one set of authors believe that only two features ranges from the more common non lymphoid proliferations characterize this stage: florid reactive follicular hyperplasia (HIV lymphadenitis) to involvement with non - Hodgkin’s and and monocytoid cells, associated with a small number of Hodgkin’s lymphoma, Kaposi’s sarcoma, and opportunistic neutrophils, in the para follicular sinuses. O Murchadha et al infections. These changes are related to the HIV virus itself. confirm that the histologic changes alone are not diagnostic, FNA is a Powerful tool that may be used to differentiate to they fail to recognize foci of mononuclear cells, associated HIV lymphadenitis from these malignant conditions. Stage I with neutrophils in para follicular sinuses in many of their is characterized by follicular hyperplasia. Stage II by cases the failure to define the extent of follicular hyperplasia follicular involution Stage III by depletion of follicles with and failure to take into account the extent and duration of development of a diffuse pattern. FNA cytology although lymph node enlargement. unable to differentiate between the three, histologic stages They say that these findings are characteristic and can establish in most instances a reactive lymphoid process. warrant testing for HIV infection. The sinusoidal FNA smears usually demonstrates polymorphous population mononuclear cells, also designated immature histiocytes, of cells which predominates small lymphoid cells admixed have been identified as monocytoid B cells. Why small with larger transformed () in a number of neutrophils are found in association mononuclear 6 background of tingible body , plasma cells and cells, irrespective of etiology, is unclear. The known mitotic figures. In some cases, corresponding to stage I HIV etiologic factors of florid reactive hyperplasia in lymph nodes lymphadenitis large cells (centroblasts or transformed include , , and plasma cell variant follicular center cells) may predominate in the smear. Care of angiofollicular hyperplasia (castlemans dieasease or giant should be taken not to diagnose this appearance as large lymph node hyperplasia) An example of this is cell lymphoma.1,2,3,4 which, in addition to reactive follicular hyperplasia, usually shows epithelioidalclusters of histiocytes often impinging on reactive follicles, and clusters of mononuclear cells within nodal sinusoids. Cat scratch disease, lymhopathia venereum, and tularemia characteristically show necrotizing granulomatous lymphadenitis in addition to a component of Figure 1. 10x Leishman Stain Stage I Showing reactive follicular hyperplasia. Similarly, the lymph nodes of Prominent Germinal rheumatoid arthritis and plasma cell variant of angiofollicular Centre lymph node hyperplasia show marked interfollicular plasmacytosis in addition to reactive follicular hyperplasia. Reactive follicular hyperplasia extremely difficult to differentiate from follicular lympohma. This processes is termed as giant follicular hyperplasia, usually results in

Figure 2. 45x Leishman painless enlargement of one or more lymph nodes of cervical Stain Showing Tangible chain, particularly in the parotid or submandibular location. Body Macrophages The histological features of varying sized follicles set off by rim of small round lymphocytes, the presence of numerous

tangible body macrophages, a high mitotic rate and the

heterogeneous population of cells within the often

Figure 3. 45 x HPE Type serpentine giant follicles, and preservation of sinuses are all 1 Pattern- Follicular in favor of benign reactive processes. However there were Hyperplasia with some features present which generally are accepted as Paracortical Hyperplasia favoring a diagnosis of lymphoma. These are complete

involvement of the lymph node surface area by these

frequently coalescent giant follicles, the focal compression Lymphadenopathy is common finding in patients with of sinuses and the capsular infiltration, although in all cases acquired immunodeficiency syndrome (AIDS) and related this was focal process with few small lymphocytes and conditions which includes benign follicular hyperplasia, non plasma cells, without significant capsular thickening. Thus Hodgkins lymphoma, Hodgkins disease, lympadenopathic because of presence of contradictory features, it is kaposis sarcoma, disseminated mycobacterial infection, and reasonable to consider in the differential diagnosis both the less commonly, metastatic tumor.5 The lymph node changes etiologies of follicular hyperplasia and .7,8 described in patients with AIDS and AIDS related complex We wanted to study staging in reactive process in (ARS) present three broad stages: the exuberant cytological smears and also to correlate with histopathology. hyperplastic stage initially, the depleted phase at the other end of the spectrum, an intermediate phase between these two. The majority of investigators have described similar

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Jebmh.com Original Research Article

METHODS No Cases Cytology HPE Type 1 50 50 45 Type 2 20 20 14 One hundred HIV positive cases were selected aspiration Type 3 30 30 20 done in OPD patients presented with generalized Total 100 100 79 Table 2 lymphadenopathy. All aseptic precautions was taken prior to aspiration and thereafter. This study was carried out in Dr. Out of one hundred cases only 79 had histopathological BRAMCH, KCG, T. B Sanitorium & Elbit diagnosis Bengaluru. correlation. Another 21 cases we could not fallow up. Typing Excision biopsy was done simultaneously for correlation with was made only on cytological background. histopathology.

Inclusion Criteria

Cytologically reported as Reactive lymphadenitis associated RESULTS

with AIDS lymphadenopathy.

Cytomorphological features reveling reactive lymphadenitis Exclusion Criteria were analysed in and tabulated as fallows. AIDS associated reactive lymphadenitis with infectious diseases eg: Tuberculosis or any other parasitic or fungal Type 1 50 infections or neoplastic conditions. Type 2 20 Type 3 30 Total 100

Table 1 DISCUSSION

Type I & II patterns are associated with persistent Lymphadenopathy is a common finding in patients with genralised lymphadenopathy of the two patterns, type II is acquired immunodeficiency syndrome .Which is probably of rarer and because of large number of immunoblasts in the viral etiology is often preceded by a prodromal phase. This paracortex can be mistaken for AILD. Type III pattern is phase is characterized by superficial polyadenopathy either seen with fully developed AIDS and is characterized by an isolated, corresponding to the lymphadenopathic syndrome absence of lymphoid follicles, a marked depletion of both T (LAS) or associated with other clinical and biological signs and B cells and prominent sinus histiocytosis. IHC and characterizing the AIDS related complex.9 Routine electron microscopic was performed in few cases where histological examination alone or preferably with immune staging could not be made on both cyto and HPE. labeling is often sufficient for the diagnosis of

lymphadenopathic syndrome of AIDS; such an aspect

Figure 4. 5x Leishman associated with anti LAV and/or anti-HTLV III in Stain Type II Pattern- serum, affirms the presence of a viral infection. Diffuse Lymphoid Although lymphadenopathy has limited differential Hyperplasia with Loss of diagnosis the precise cause of the enlarged lymph nodes is Germinal Centers often difficult to establish by history radiographic studies and laboratory tests Fine needle aspiration biopsy is a useful test to evaluate Figure 5. Type 2 HPE 45X lymphadenopathy in the AIDS outpatient clinic.10 Follicular Type II: Lymphocytes labyrinthine foci consisting of an expanded dendritic reticular Present in Diffuse Sheets ( trapping) cells has been described in lymph nodes with Loss of Germinal Centres from four immune deficient homosexual men with unexplained persistent lymphadenopathy. These findings support a role for routine electron microscopy as an a aid to diagnostic evaluation of nodal tissue from patients with Figure 6. 45x Leishman suspected AIDS. Viral non lymphoid cell trophism may be a Stain Type 111 Pattern- significant factor in the pathogenesis of the disease.11 The Marked Lymphocytic Depletion histological finding of follicular lysis and hyperplasia with depletion in HIV infected group although not

diagnostic, is a common finding in this disease and may be

used as a marker for HIV infection. The fine needle aspiration is been evaluated in many studies, where Figure 7. 45 x HPE Type III. adequate samples were obtained and very good correlation Revealing Follicular Lysis with excision biopsy was seen, indicating reliable and Depletion of the microscopic interpretation.12 FNAC is a highly accurate, cost Lymphoid Cells effective method of diagnosis. In our study staging could be done on FNA smears in known HIV positive cases, where

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Jebmh.com Original Research Article cytomorpholgical features were well appreciated and clarity [2] Palleshn G, Gerstoft J, Mathiesen L. Stages in of the smears was excellent to interpret and well correlated LAV/HTLV‐III lymphadenitis: histological and with histological findings. Stage I and III was ease with immunohistological classification. Scand J Immunol clinical and microscopic findings. Stage II was done with 1987;25(1):83-91. further ancillary tests which included IHC and even [3] Diebold J, Audouin J, Le Tourneau A. Lymphoid tissue electronic microscopy. Light microscopy revealed changes in HIV-infected patients. Lymphology pronounced follicular hyperplasia with wide follicles 1988;21(1):22-27. composed of germinal centers. These findings were classical [4] Shabb N, Katz R, Ordonez N, et al. Fine-needle which was easily readable on cytology and it was evident on aspiration evaluation of lymphoproliferative lesions in scanner view. In stage II discrete or semi-confluent human deficiency virus-positive patients. A aggregates of expanded non lymphoid dendritic reticular multiparameter approach. 1991;67(4):1008- cells were a notable feature. 1018. [5] Bottles K, McPhaul LW, Volberding P. Fine needle aspiration biopsy of patients with the acquired immunodeficiency syndrome (AIDS): experience in an

outpatient clinic. Ann Intern Med 1988;108(1):42-45.

[6] Butler JJ, Osborne BM. Lymph node enlargement in patients with unsuspected human immunodeficiency Figure 8. 45X virus infections. Hum Pathol 1988;19(7):849-854. [7] Butler JJ. Non- neoplastic lesions of lymph nodes of man

to be differentiated from . Natl cancer Inst

Monogr 1969;32:233-255. Germainal centre revealing dendritic cells, [8] Osborne BM, Butler JJ, Variakojis D, et al. Reactive immunoblasts centrocytes and small lymphocytes which lymph node hyperplasia with giant follicles. Am J Clin adhere to syncytial cytoplasm with pale grey violet granules. Pathol 1982;78(4):493-499.

[9] Le Tourneau A, Audouin J, Diebold J, et al. LAV like

particles in lymph node germinal centers in patients with CONCLUSIONS

the persistent lymphadenopathy syndrome and the acquired immunodeficiency syndrome related complex: This study concludes that aspiration smears can evaluate an ultrastructural study of 30 cases. Hum Pathol typing in HIV Lymphadenopathy. Although type II is rare or 1986;17(10):1047-1053. difficult to diagnosis, one can approach on [10] Bottles K, Cohen MB, Brodie H, et al. Fine-needle cytomorphological features. aspiration cytology of lymphadenopathy in homosexual

males. Diag Cytopathol 1986;2(1):31-35.

[11] Armstrong JA, Horne R. Follicular dendritic cells and REFERENCES virus like particles in AIDS related lymphadenopathy. Lancet 1984;2(8399):370-372. [1] Ewing EP, Chandler FW, Spira TJ, et al. Primary lymph [12] Jeena PM, Coovadia HM, Hadley LG, et al. Lymph node node pathology in AIDS and AIDS-related in HIV infected and non-infected children with lymphadenopathy. Arch Pathol Lab Med persistent lung disease. Int J Tuberc Lung Dis 1985;109(11):977-981. 2000;4(2):139-146.

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