结核性淋巴结炎的“结节病”样变型

对１２例经病理学专家会诊、从病变上认定的淋巴结“结节病”石蜡包埋组织，应用结核杆菌ＤＮＡ特异性序列片段的聚合酶链反应（Ｍ．ＴＢ－ＰＣＲ）技术、ＢＣＧ免疫组化（ＢＣＧ－ＩＨＣ）技术和抗酸染色（ＡＦ）进行了分支杆菌／结核杆菌检测。在这１２例考虑为“结节病”的病例中：有１例呈ＢＣＧ－ＩＨＣ和Ｍ。ＴＢ－ＰＣＲ两项阳性；另１例呈ＡＦ、ＢＣＧ－ＩＨＣ和Ｍ．ＴＢ－ＰＣＲ三项阳性。研究结果提示：（１）某些结核性淋巴结炎可呈结节病样病变；（２）淋巴结结节病很可能与分支杆菌／结核杆菌感染有关。     

Mycobacterial cervical lymphadenitis: the histological features of non-tuberculous mycobacterial infection

AIMS: The distinction between nontuberculous mycobacterial (NTM) lymphadenitis and other causes of cervical lymphadenitis is critical, as different entities call for different treatments. Despite modern diagnostic techniques for NTM infections their prompt and accurate diagnosis is still difficult. We assessed the value of different histological features in diagnosing clinically suggestive NTM cervical lymphadenitis in cases of granulomatous cervical lymphadenitis. METHODS AND RESULTS: A retrospective study of 30 patients with a clinical diagnosis of NTM cervical lymphadenitis was carried out. The patients were divided into three subgroups and several histological parameters were examined in each subgroup. A comparison was made with cases of proven tuberculous lymphadenitis. Four histological features (presence of microabscesses, ill-defined granulomas, noncaseating granulomas and a small number of giant cells) were found with significant statistical difference when comparison was made between the NTM group and the tuberculosis group. CONCLUSIONS: A rapid and accurate diagnostic procedure for NTM lymphadenitis is not yet available. Therefore, in the presence of a suggestive clinical picture for NTM lymphadenitis, we propose four histological features which support this diagnosis, thus allowing prompt therapeutic intervention.     

Tuberculous granulomatous inflammation associated with adenoma of parathyroid gland manifesting as primary hyperparathyroidism

A 36-year-old female presented with generalized bone pain, muscular weakness, and enlarged cervical lymph nodes. The biochemical findings and skeletal survey were suggestive of primary hyperparathyroidism (PHPT). CT of neck and thorax showed enlarged multiple lymph nodes in the cervical and superior mediastinal region. With a diagnosis of PHPT, she underwent cervical exploration and excision of enlarged right inferior parathyroid gland, along with biopsy of nodes. Histopathology revealed the features of parathyroid adenoma with a few foci of epithelioid granuloma and granulomatous lymphoadenitis. Smear and culture were negative for AFB. A positive PCR for Mycobacterium tuberculosis of the homogenates of parathyroid tumor confirmed tuberculous inflammation within the parathyroid adenoma. To the best of our knowledge, this is the first reported case of parathyroid adenoma associated with tuberculous pathology in a case of PHPT.     

Immunopathological study of eosinophils in eosinophilic granuloma of bone: Evidence for release of three cationic proteins and subsequent uptake in macrophages

Summary Eosinophils from two patients with eosinophilic granuloma of bone (EGB) were studied by combined immunohistochemical and immuno-ultrastructural methods with antibodies directed against three eosinophil granule proteins: major basic protein, eosinophil cationic protein, and eosinophil peroxidase. Immunohistostaining showed the presence and distribution of large numbers of eosinophils in the granuloma. Immuno-ultrastructural methods showed alterations of eosinophil fine structure associated with some steps in the release of granule proteins. No granule extrusion was seen, but rather cationic proteins diffused within cytoplasmic tubulo-vesicular structures. Furthermore, the three granule proteins were found within phagolysosomes of surrounding macrophages, suggesting an interaction between eosinophils and phagocytic cells at the destructive stage of EGB.     

Pleomorphic hyalinizing angiectatic tumor: cytomorphologic features on fine-needle aspiration

Pleomorphic hyalinizing angiectatic tumor (PHAT) is a rare low-grade neoplasm occurring predominantly in the subcutaneous tissue of the lower extremity, which is characterized histologically by intermixed bland spindle cells and larger pleomorphic cells, ectatic blood vessels with fibrin, and prominent hyalinization. Here we describe the cytologic features of PHAT seen on fine-needle aspiration of a right calf mass in a 46-year-old man. The smears were cellular, composed predominantly of bland spindle cells dispersed singly as well as in tissue fragments and characterized by open chromatin and small nucleoli. A second population of pleomorphic spindle cells with coarse chromatin, prominent nucleoli, and occasional intranuclear pseudoinclusions was also present. Many of the pleomorphic cells surrounded hyalizined vessels. No mitotic figures were identified. The cytologic diagnosis was a "spindle cell lesion, NOS" with the differential diagnosis including benign lesions and low-grade neoplasms, including PHAT and schwannoma.     

Tuberculous epididymo-orchitis mimicking a testicular tumour: a case report

Introduction

Isolated tuberculous epididymo-orchitis may closely mimic testicular tumour particularly in patients with no history of systemic TB thereby presenting a diagnostic and treatment challenges.

Case report

A 44-year old man presented with 4 months history of left scrotal mass and had left orchidectomy following a presumptive diagnosis of testicular tumour. Histopathological diagnosis of testicular tuberculosis was subsequently made. Although the patient was thereafter referred for antituberculosis treatment at the local tuberculosis treatment centre, he defaulted after commencing treatment.

Conclusion

Adequate evaluation of patients with testicular mass by means of abdominal and scrotal ultrasound coupled with fine needle aspiration cytology is critical to diagnostic accuracy, optimal treatment and possibility of avoiding surgery in those with testicular tuberculosis.     

A case of obstructive jaundice caused by tuberculous lymphadenitis: A literature review

Obstructive jaundice caused by tuberculous lymphadenitis is a rare manifestation of tuberculosis (TB), with 15 cases having been reported in Korea. We experienced a case of obstructive jaundice caused by pericholedochal tuberculous lymphadenitis in a 30-year-old man. The patient''s initial serum total bilirubin level was 21.1 mg/dL. Abdominal computed tomography revealed narrowing of the bile duct by a conglomerated soft-tissue mass involving the main portal vein. Abrupt obstruction of the common bile duct was observed on cholangiography. Pathologic analysis of a ultrasonography-guided biopsy sample revealed chronic granulomatous inflammation, and an endoscopic examination revealed esophageal varices and active duodenal ulceration, the pathology of which was chronic noncaseating granulomatous inflammation. Hepaticojejunostomy was performed and pathologic analysis of the conglomerated soft-tissue mass revealed chronic granulomatous inflammation with caseation of the lymph nodes. Tuberculous lymphadenitis should be considered in patients presenting with obstructive jaundice in an endemic area.     

Calcium oxalate crystal deposition in epithelioid histiocytes of granulomatous lymphadenitis: analysis by light and electronmicroscopy

In this study of 55 cases of granulomatous lymphadenitis of various aetiologies, both haematoxylin and eosin stained and unstained sections were examined by light and polarizing light microscopy for crystals within epithelioid histiocytes. This investigation was prompted by a case of granulomatous lymphadenitis in which the identification of ovoid birefringent structures within epithelioid histiocytes led to an initial false suggestion of foreign body reaction. Identical single, small, ovoid or biconvex, intensely birefringent crystals, invisible by ordinary light microscopy, were found within the cytoplasm of mononuclear epithelioid histiocytes in 37 cases. There was only minor crystal loss with routine H & E staining. The sections were also examined by scanning electronmicroscopy in secondary and backscattered electron imaging modes and 27 cases were found to contain biconvex crystals which were shown on X-ray energy dispersive spectroscopic microanalysis to be consistent with calcium oxalate. There was a good quantitative correlation between light and scanning electron microscopy. Tissue from the index case was also examined by transmission electronmicroscopy, and electron dense crystals were identified. We confirm the previous findings of ovoid oxalate crystals in a variety of granulomatous conditions including Mycobacterial infection, sarcoidosis and Crohn's disease. Ovoid crystals of calcium oxalate, a common finding in granulomatous lymphadenitis, appear to be endogenously derived, and should be more widely recognized in order to avoid misdiagnosis of foreign body reaction.     

Lymphocyte subpopulations in pyogranulomas of caseous lymphadenitis.

Pyogranulomas of ovine caseous lymphadenitis (CLA) are encapsulated lesions resulting from infections with Corynebacterium pseudotuberculosis, a bacterial pathogen able to grow within macrophages. Immunohistology of CLA lesions showed a band of lymphocytes lining the inside of the collagen capsule in intimate contact with necrotic tissue, the intracapsular lymphocytes being organized into three layers. The innermost layer, immediately adjacent to the central necrotic tissue consisted of a narrow band of MHC class II staining macrophages. Cells staining for CD4, CD8 and gamma delta T cell markers were unevenly distributed throughout the lymphoid layer, tending to be more numerous immediately external to the macrophage layer. The intracapsular lymphoid tissue contained a high proportion of CD8+ lymphocytes (CD4:CD8, 1.5:1) and of gamma delta lymphocytes (CD4:CD8:gamma delta, 1:0.7:0.8). External to the T cell-rich zone and adjacent to the surrounding collagen capsule was a dense band of cells, a proportion of which stained atypically for CD45R and were tentatively identified as B cells. CD8+ and gamma delta+ T cells showed similar distributions and their relative abundance, compared with CD4+ T cells, was a distinguishing feature of the CLA lesion. Staining for factor VIII-related antigen clearly showed endothelial venules throughout the intracapsular lymphoid tissue. The presence of endothelial venules and the organized architecture of the lymphoid tissue teleologically argues that lymphocytes are continually recruited into chronic CLA lesions and play an important role in the ongoing disease process.     

Fine-needle aspiration of metastatic prostatic neuroendocrine carcinomas: cytomorphologic and immunophenotypic features

Metastatic prostatic carcinoma may, in rare occasions, present as a neuroendocrine tumor. Its recognition is crucial to avert a wrongful exclusion of prostate as a primary site. We report five cases of metastatic prostatic neuroendocrine carcinoma diagnosed by image-guided fine-needle aspiration biopsy. The aspirate smears showed loosely cohesive or dyscohesive clusters of tumor cells with scanty (three cases) to moderate amount (two cases) of cytoplasm, speckled or coarse chromatin and inconspicuous nucleoli. Nuclear molding and necrosis were focally present in two cases. Immunohistochemically, the tumor cells were positive for synaptophysin or/and chromogranin, but negative for prostatic specific antigen and prostatic specific acid phosphatase. Review of prior prostate biopsies/resections revealed adenocarcinoma with focal neuroendocrine differentiation in all cases, with two cases being newly recognized on retrospective review. Confirming neuroendocrine differentiation in the prior biopsy/resection may help to establish a link between metastasis and prostate primary.     

Tuberculous pleural effusions: lymphocyte phenotypes in comparison with other lymphocyte-rich effusions

This study investigated whether the analysis of T cell subsets and of activation markers on T cells in pleural fluids can be helpful for diagnostic purposes in tuberculous pleurisy and other lymphocyte-rich pleural effusions. Pleural effusion fluids were obtained from 18 patients with tuberculous pleurisy (TB), 21 with effusions following radiotherapy (RT) for a malignant disease, and 11 with congestive heart failure (CHF). Lymphocyte subsets were analyzed by a battery of monoclonal antibodies using an immunoperoxidase method. The majority of the lymphocytes were CD3-positive T cells (TB, 86 +/- 7% of lymphocytes; RT, 81 +/- 8%; CHF, 84 +/- 12%). The ratios of CD4-positive helper-inducer to CD8-positive suppressor-cytotoxic T cells were higher than those reported for the peripheral blood but not significantly different between the study groups (TB, 3.3 +/- 1.9; RT, 2.8 +/- 1.4; CHF, 2.5 +/- 1.1). The activation marker studies revealed that only a few pleural T cells were positive for CD38, CD25 (interleukin-2 receptor), HLA-DR antigen, and OKT9 (transferrin receptor), the proportion of CD25-positive T cells being higher in TB and in RT than in CHF and the proportion of HLA-DR-positive T cells being higher in TB than in CHF (P less than 0.05). Significant differences were not observed relative to the natural killer-cytotoxic phenotypes staining positive for Leu-7 or for CD16. Thus, we concluded that phenotypic analysis of lymphocytes is of limited diagnostic usefulness to differentiate tuberculous from other nonmalignant effusions.     

Metastatic urothelial carcinoma with signet ring features: cytomorphologic findings in abdominal paracentesis

Signet ring cells, characterized by large clear cytoplasmic vacuoles eccentrically displacing and indenting the nuclei, seen in cytopathology effusion specimens are most commonly due to metastatic adenocarcinoma of gastric, esophageal, and breast origin. Urothelial carcinoma can display a wide range of differentiation and is an extremely rare cause of metastatic signet ring cells. Here, we report the case of a 75-year-old male with high-grade urothelial carcinoma with signet ring features, who was status-post chemoradiation and radical cystoprostatectomy. The patient subsequently developed an abdominal mass and ascites. The paracentesis cytology revealed a hypercellular specimen with malignant cells dispersed singly as well as in small fragments displaying pleomorphism, nuclear irregularity, hyperchromasia, and binucleation. Numerous malignant cells displayed well-formed signet ring morphology, identical to adenocarcinoma. This is the first report of metastatic high-grade urothelial carcinoma manifesting as signet ring cells in peritoneal fluid.     

Colloid cyst of the third ventricle: cytomorphologic features on stereotactic fine-needle aspiration

Stereotactic brain fine-needle aspiration (FNA) is a valuable diagnostic modality for evaluating space-occupying central nervous system disorders. Colloid cyst (CC) is a rare nonneoplastic lesion thought to arise from misplaced endodermal tissue in the anterosuperior portion of the third ventricle. This study summarizes cytomorphologic features of CC on FNA along with clinical, radiologic, and histopathologic correlation. Ten cases of CC of the third ventricle diagnosed on FNA were retrospectively reviewed for a period of 12 yr (1989-2000). Material was obtained under stereotactic radiologic guidance. Smears were stained with Diff-Quik and Papanicolaou stains and cell block sections with hematoxylin and eosin. The aspirates showed a characteristic sticky and viscous quality on gross examination. Smears showed abundant, amorphous, proteinaceous material with staining qualities similar to colloid aspirated from thyroid. This included a purplish, filmlike coating of the slide with occasional "cracking" artifact; thick, globular, eosinophilic fragments; and granular, ropelike, and somewhat viscous, mucinous material. Pathognomonic radiating hyphae-like structures were not seen. The cellular components varied from isolated cuboidal/columnar cells to large tissue fragments of glandular-type epithelium with focal ciliated border. Goblet cells were frequently identifiable, as were fragments of collagenous cyst wall. Stereotactic FNA of the CC of the third ventricle is an accurate and cost-effective diagnostic modality. Cytomorphology coupled with the radiologic features is sufficiently unique for the diagnosis of this rare pathologic entity.     

Dynamics of Mononuclear Phagocytes in Lymph Nodes and Granulomas in Chronic Tuberculous Inflammation

Quantitative changes in mononuclear phagocytes in lymph nodes and tuberculous granulomas in patients with generalized tuberculosis suggest that accumulation of these cells in granulomas occurs due to their recruiting from bone marrow precursors, rather than from lymph nodes. Antimycobacterial therapy leads to dissociation of granulomas accompanied by accumulation of macrophages in lymph nodes. The number of granulomas decreases, but not their size and relative content of epithelioid cells remain unchanged. With due regard of the microanatomy of granulomas, epithelioid cells are regarded as the main site of mycobacterium persistence and the object of targeted drug delivery.     

Atypical granular cell tumor of the thyroid: cytomorphologic features on fine needle aspiration

Granular cell tumors are uncommon soft tissue neoplasms of nerve sheath origin, which are predominately benign and are characterized by abundant granular cytoplasm, uniform nuclei, and indistinct cell borders. Features of malignancy include spindle cell morphology, necrosis, prominent nucleoli, increased nuclear to cytoplasmic ratio, nuclear pleomorphism, and increased mitotic rate. Granular cell tumors are most common in the soft tissues of the head and neck, but have only been rarely described in the thyroid gland. Here we report a case of an atypical granular cell tumor of the thyroid seen on fine needle aspiration, which displayed focal atypical cells with spindle cell morphology, increased nuclear to cytoplasmic ratio, and prominent nucleoli. The differential diagnosis of such findings is also presented.     

Elastofibroma dorsi has distinct cytomorphologic features, making diagnostic surgical biopsy unnecessary: cytomorphologic study with clinical, radiologic, and electron microscopic correlations

Elastofibroma dorsi (EFD) is a relatively rare soft tissue mass, probably of reactive nature. The lesion is typically located near the inferior margin of the scapula or between the inferior part of scapula and the chest wall in elderly women. Although location of the tumor together with the age/sex of the patients and radiologic findings is often suggestive of the diagnosis, tissue examination has been considered necessary to confirm the diagnosis. Although the histologic features of EFD are well known, there are only four single case reports of the cytologic findings in the English language literature. We describe the cytologic features of EFD in five patients with correlations to clinical, radiologic, histologic, and electron microscopic findings. The current study suggests that the fine-needle aspiration (FNA) features are highly diagnostic, permitting a firm diagnosis of EFD in a typical clinical setting and eliminating the need for preoperative histologic examination.     

Fine-needle aspiration biopsy of myxoid liposarcoma metastatic to the liver: cytomorphologic and cytogenetic features

Myxoid liposarcoma has characteristic cytomorphological features and carries a specific cytogenetic abnormality. Here we describe a case of myxoid liposarcoma metastatic to the liver, which was diagnosed by fine-needle aspiration biopsy. The aspirate smears revealed numerous oval to round tumor cells embedded in a myxoid background admixed with arborizing capillary vasculature. Some of the tumor cells showed adipocytic differentiation and a few lipoblasts were present. A fluorescence in situ hybridization analysis using CHOP break apart probe 12q13 demonstrated the presence of chromosomal translocation involving the CHOP gene, confirming the diagnosis. The case illustrates that cytomorphological evaluation with a targeted cytogenetic study can render a definite diagnosis of myxoid liposarcoma via fine-needle aspiration biopsy.     

Pleural fluid cytology of Hodgkin's disease: cytomorphologic features and the value of immunohistochemical studies

Two cases in which Hodgkin's disease (HD) was cytologically diagnosed in pleural effusions are presented. The presence of Reed-Sternberg (R-S) cells was confirmed by positive staining for both CD15 and CD30, and negative staining for leukocyte common antigen. In addition, the differential diagnosis of HD in effusion cytology is presented, including look-alikes of R-S cells that can potentially lead to an incorrect diagnosis. To the best of our knowledge, we believe this is only the second cytologic report of HD diagnosed in a pleural effusion using immunohistochemistry to confirm the diagnosis.     

Breast cancer with associated granulomatous axillary lymphadenitis: a diagnostic and clinical dilemma in regions with high prevalence of tuberculosis

Intratumoral granulomas and granulomas in lymph nodes draining breast carcinomas have been reported previously. However, in regions like Pakistan, where the incidence of tuberculosis (TB) is high, it is sometimes difficult to distinguish between TB and a non-specific granulomatous response especially if there is an association with focal necrosis. We present a series of cases of invasive breast carcinoma with an associated granulomatous reaction in lymph nodes with or without necrosis, which were further analyzed for a possible coexisting tuberculosis using special stains and PCR-based assays for the identification of Mycobacterium tuberculosis. Twenty-two cases were examined using ZN stain for AFB and PAS stain for fungal organisms. Nested PCR assays for M. tuberculosis DNA were performed on formalin-fixed, paraffin-embedded tissue. In all the cases, ZN stain for AFB and PAS stain for fungus were negative. M. tuberculosis DNA was detected in 11 (50%) out of the 22 cases. Six of 12 cases which had granulomas in association with necrosis were positive for MTB-DNA, while 5 of 10 cases without necrosis were also positive for MTB-DNA. It is concluded that the presence of granulomas with or without necrosis in association with malignancies should be further evaluated, particularly in regions with a high prevalence of tuberculosis, for the possibility of coexistent tuberculosis, as this may alter the postoperative management of the patient. PCR-based assays are recommended for the diagnosis of TB in cases where ZN is unhelpful for demonstrating AFB or no tissue is submitted for microbiological studies.