clinical history of hiv infection may be misleading in cytopathology

A fine needle aspiration FNA was performed that yielded scant mate-rial showing a morphologically bland spindle cell lesion [Figure 1], thought to represent a granulomatous reac-tion.. H

CytoJournal Richard DeMay, MD (University of Chicago, Chicago, USA)

Martha Pitman, MD (Harvard Medical School, Boston, USA)

Vinod B Shidham, MD, FIAC, FRCPath (Med College of WI, Milwaukee, USA)

Vinod B Shidham,

MD, FIAC, FRCPath

Medical College of Wisconsin, Milwaukee, WI, USA

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Case Report

Clinical history of HIV infection may be misleading in

cytopathology

Liron Pantanowitz*, Michael Kuperman, Robert A Goulart

Address: Department of Pathology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA

E-mail: *Liron Pantanowitz - lpantanowitz@hotmail.com.Michael Kuperman - michael.kuperman@baystatehealth.org;

Robert A Goulart - robert.goulart@baystatehealth.org

*Corresponding author

Published: 12 June 2010 DOI: 10.4103/1742-6413.64375 Received: 28 November 09

This article is available from: http://www.cytojournal.com/content/7/1/7

© 2010 Pantanowitz et al; licensee Cytopathology Foundation Inc.

This article may be cited as:

Pantanowitz L, Kuperman M, Goulart RA Clinical history of HIV infection may be misleading in cytopathology CytoJournal 2010;7:7

Available FREE in open access from: http://www.cytojournal.com/text.asp?2010/7/1/7/64375

Abstract

Human immunodeficiency virus (HIV)-infected patients are at an increased risk for developing

opportunistic infections, reactive conditions and neoplasms As a result, a broad range of conditions

are frequently included in the differential diagnosis of HIV-related lesions The clinical history of

HIV infection may, however, be misleading in some cases Illustrative cases are presented in which

knowledge of a patient’s HIV status proved to be misleading and increased the degree of complexity

of the cytologic evaluation Case 1 involved the fine needle aspiration (FNA) of a painful 3 cm

unilateral neck mass in a 38-year-old female with generalized lymphadenopathy Her aspirate

revealed a spindle cell proliferation devoid of mycobacteria that was immunoreactive for S-100 and

macrophage markers (KP-1, PGM1) Multiple noncontributory repeat procedures were performed

until a final excision revealed a schwannoma Case 2 was a CT-guided FNA of a positron emission

tomography positive lung mass in a 53-year-old man The acellular aspirate in this case contained

structures resembling fungal spore forms that were negative for mucicarmine and GMS stains, as

well as cryptococcal antigen immunocytochemistry A Von Kossa stain confirmed that these

pseudo-fungal structures were calcified debris Follow up revealed multiple calcified lung and hilar node

based granulomata Case 3 involved the cytologic evaluation of pleural fluid from a 47-year-old

man with Kaposi sarcoma and recurrent chylous pleural effusions Large atypical cells identified in

his effusion were concerning for primary effusion lymphoma Subsequent pleural biopsy revealed

extramedullary hematopoiesis, documenting these atypical cells as megakaryocytes These cases

demonstrate that knowledge of a patient’s HIV status can be misleading in the evaluation of cytology

specimens, with potential for misdiagnosis and/or multiple procedures To avoid this pitfall in the

setting of HIV infection, common entities unrelated to HIV infection and artifacts should always

be included in the differential diagnosis

Key words: AIDS, cytology, HIV, misleading

INTRODUCTION

Human immunodeficiency virus (HIV) causes acquired

immunodeficiency syndrome (AIDS) As CD4 T-cell

num-bers decline, HIV-infected patients become progressively

more susceptible to opportunistic infections (bacterial,

fungal, viral and parasitic) and the development of ma-lignancies AIDS-defining cancers include Kaposi sarcoma (KS), cervical cancer and high-grade non-Hodgkin lym-phoma Patients infected with HIV may also have unusual manifestations of common infections and neoplasms, such as spindle cell tumors associated with mycobacteria

one month later, which yielded an acellular specimen that was comprised of granular debris with several ovoid

bod-As patients infected with HIV are living longer due to the

benefits of antiretroviral therapy, they are now also more

likely to develop certain non-AIDS-defining cancers such

as lung cancer, hepatocellular carcinoma and Hodgkin

lymphoma.[1] HIV-infected patients are also at increased

risk for developing specific reactive conditions, such as

generalized lymphadenopathy with follicular lymphoid

hyperplasia and Castleman disease.[2] As a result, a broad

range of benign (reactive and infectious) and neoplastic

conditions are frequently included in the differential

diagnosis of HIV-related lesions However, this wide

differential might at times mislead the cytopathologist

Moreover, as conditions unrelated to HIV infection may

also arise in this setting, these entities also need to be

con-sidered in the differential diagnosis of a lesion arising in

the HIV positive individual Illustrative cases are presented

in which knowledge of a patient’s HIV status proved to

be misleading and increased the degree of complexity of

the cytologic evaluation

CASE REPORTS

CASE 1

A 38-year-old HIV positive female with a CD4 cell count

of 260 cells/mm3 and HIV viral load of 191,528 copies/

mL presented with left neck pain She was nạve to

an-tiretroviral therapy An ultrasound of her neck revealed

four enlarged, hypoechoic, enhancing masses in the upper

lateral neck interpreted to be lymph nodes A fine needle

aspiration (FNA) was performed that yielded scant

mate-rial showing a morphologically bland spindle cell lesion

[Figure 1], thought to represent a granulomatous

reac-tion Special stains for mycobacteria (modified Kinyon

stain) and fungi (GMS stain) were negative The patient

underwent a second FNA one week later followed by an

ultrasound-guided core needle biopsy Both the FNA and

core biopsy again demonstrated a spindle cell

prolifera-tion with positive immunoreactivity for S100 [Figure 2]

and the macrophage markers KP1 and PGM1 Markers

for epithelial membrane antigen (EMA), CD34, desmin,

smooth muscle actin and keratin cocktail were negative

Repeat Kinyon and GMS stains were negative At this

stage, definitive excision was recommended Accordingly,

the patient underwent a left neck lymph node biopsy

However, while this biopsy revealed a reactive lymph

node with follicular lymphoid hyperplasia, no spindle

cell lesion was identified As a result, two weeks later a

neck surgical exploration was performed with removal of

a retromandibular mass Histological examination of this

mass proved it to indeed be a schwannoma [Figure 3]

CASE 2

Incidental nodules were found on a chest X-ray in a

53-year-old HIV positive male A follow-up positron

emission tomography (PET) and CT scan raised the

pos-sibility of a neoplastic process A lung FNA was performed

Figure 2: S-100 immunoreactive spindle cell fragment within cell block

material (original magnification x200).

Figure 1: Fragment of morphologically bland spindle cells seen on direct

smear (Pap stain; original magnification x200).

Figure 3: Schwannoma excision specimen showing an Antoni type A cellular

area of spindle-shaped cells (H and E stain; original magnification x200).

ies that resembled budding fungal spore forms measuring

up to 15 µm or larger [Figure 4] Mucicarmine and GMS

stains were negative Immunocytochemistry for

cryptococ-cal antigen was also negative A von Kossa stain performed

on cell block material was positive in calcific debris,

in-cluding pseudo-fungal forms [Figure 5] Further imaging

studies revealed that the patient had multiple calcified

granulomata in both lungs and within hilar lymph nodes

CASE 3

A 47-year-old male patient with a past medical history

significant for smoking, AIDS, anemia (hematocrit 35.3%)

and KS presented with recurrent chylous pleural effusions Multiple pleurocentesis procedures were performed with fluid submitted for cytological evaluation The majority

of cells in these effusions were reactive mesothelial cells and admixed granulocytes Also identified in these pleural effusions [Figures 6 and 7] were scattered large cells with atypical, hyperchromatic and occasionally multinucleated nuclei The possibility of primary effusion lymphoma (PEL) was entertained Immunostains were performed that showed these large cells to be positive for the mega-karyocytic markers factor VIII and CD61 [Figure 8], but negative for CD20, CD3 and LNA-1 LNA-1 is a biomarker

Figure 4: Ovoid pseudo-fungal structures among a) acellular debris with b) some that appear to have a cell wall and c) others that appear unencapsulated (Pap

stain; original magnification x600).

a

b

c

Figure 5: a) Acellular cell block material with fragmented calcified debris that b) stains positively with a von Kossa stain for calcium (original magnification

x200).

for human herpesvirus-8 (HHV8) infection A keratin

cocktail stained only reactive mesothelial cells and a

CD68 immunostain highlighted numerous macrophages

CD20 and CD3 stains revealed a mixed background of

lymphocytes that demonstrated polytypic

immunoreactiv-ity with kappa and lambda markers A myeloperoxidase

immunostain showed frequent early myeloid

(myelo-cytes and promyelo(myelo-cytes) and eosinophilic elements

Material was not submitted for flow cytometry Modified

Kinyon and GMS stains were negative for mycobacteria

and fungi, respectively A parietal pleural biopsy showed

dense fibrous plaques and adhesions with extramedullary

hematopoiesis, confirming that the large atypical cells were

megakaryocytes This patient was not known to have an

underlying hemolytic anemia or hemoglobinopathy He

subsequently developed multiple myeloma two years later

DISCUSSION

Lack of pertinent clinical information provided with speci-men samples that are submitted to the clinical and anatomic laboratories is a frequent complaint of pathologists Inad-equate knowledge of a patient’s clinical history may hinder the pathologic interpretation The three cases presented demonstrate how the knowledge of a patient’s HIV status,

in contrast, can occasionally be misleading in the evaluation

of cytology specimens, with potential for misdiagnosis and/

or multiple potentially unnecessary procedures Taking into consideration the high prevalence of HIV and AIDS around the world, and limited resources for diagnosis in develop-ing countries, cytology (e.g., FNA) has proven to be a useful method for diagnosis, reducing the necessity for surgical excision, and facilitating rapid triage for therapy.[3]

Figure 6: Single large atypical cells with a) hyperchromatic and b) multinucleated nuclei are shown in pleural fluid admixed with chronic inflammatory cells

(Pap stain; original magnification x600)

Figure 8: A megakaryocyte showing CD61 immunoreactivity (original

magnification x600).

Figure 7: Cell block material containing a large central megakaryocyte (H

and E stain; original magnification x600).

In case 1, the spindle cell lesion originally identified in

the FNA material was subsequently histologically proven

to represent a schwannoma The differential diagnosis

of a spindle cell proliferation/lesion in an HIV infected

patient includes entities somewhat unique to HIV such as

KS, mycobacterial spindle cell pseudotumor and Epstein

Barr Virus (EBV)-associated smooth muscle tumors, as well

as spindle cell lesions independent of HIV infection (e.g.,

nodular fasciitis, thymoma, mesenchymal sarcomas, etc.)

Most FNA specimens of KS have a bloody background

in which intact to loosely cohesive clusters of bland

spindle-shaped cells are distributed.[4-6] Closely packed KS

spindle cells are usually overlapping and have indistinct

cytoplasmic borders Vascular spaces containing blood

and metachromatic globular structures that correspond

to the eosinophilic globules seen in histologic sections

may rarely be present In difficult cases, detection of

HHV8 using the LNA-1 immunocytochemical stain may

be necessary Mycobacterial pseudotumor is an exuberant

spindle cell lesion induced, mainly within lymph nodes,

by atypical mycobacteria.[7-8] As a result, acid-fast bacilli

should be present in these pseudotumors The spindle

cells in mycobacterial pseudotumor are also positive for

S-100 protein and CD68 immunostains S-100 protein is

not strictly specific to nervous tissue and its tumors, but

may be seen in several other tumor cell types such as

me-lanocytic lesions and selected histiocytic proliferations.[9]

Indeed, the presence of S-100 immunoreactivity in spindle

(neural) cells of our first case was initially thought to

in-dicate cells of histiocytic origin.[9] Staining of spindle cells

with macrophage markers in this case was misleading The

monoclonal antibody CD68 (KP1) reacts not only with

fi-brohistiocytic lesions, but also melanocytic lesions, neural

tumors, lymphoma and some epithelial neoplasms.[10-11]

A high incidence of smooth-muscle tumors (leiomyomas

and leiomyosarcomas) has been reported in association

with HIV infection, including children with AIDS.[12 -14]

HIV-associated leiomyosarcomas have been reported to

occur in uncommon locations such as the lung,

pericar-dium, pleura, spleen, adrenal gland, lymph node and

orbit.[12] A potential role for EBV has been suggested in

the tumorigenesis of HIV-associated leiomyosarcomas

Therefore, along with smooth muscle markers, stains to

demonstrate EBV (LMP and/or EBER) infection within

smooth muscle cells may be of diagnostic aid

Patients infected with HIV are also at increased risk for

fungal opportunistic infections Several of these fungal

infections may be dimorphic (i.e., exhibit fungal and

yeast phases), such as pulmonary histoplasmosis caused

by Histoplasma capsulatum The identification of hyphae

or yeast forms on cytological smears takes into account

morphological criteria (e.g., size, shape, type of budding in

the yeast forms) and additional staining characteristics.[15]

Round to oval fungal forms are a common morphologic

finding of H.capsulatum (size range 2–5 µm), Cryptococcus

neoformans (size range 5–15 µm), and Blastomyces derma-tidis (size range 8–20 µm) Several of these fungi may

also demonstrate budding (e.g., narrow-based budding

of H.capsulatum versus broad-based budding of Blasto-myces), a thick capsule (e.g., Cryptococcus neoformans) or a thick refractile wall (e.g., Blastomyces dermatidis) In case

2, fragmented calcific debris that formed round bodies was initially mistaken for potential fungal forms How-ever, unlike fungi these calcified structures did not stain with mucicarmine or GMS stains Intrinsic and extrinsic contaminants (e.g., airborne fungal spores and pollen)[16]

and even crystals[17] may be mistaken for microorganisms, especially in the HIV positive host

Pleural disease encountered in the HIV-infected patient may be due to infection (mycobacteria, bacterial monia and more rarely other microorganisms like pneu-mocystosis), malignancy (lymphoma, KS and carcinoma), Castleman’s disease, or may accompany systemic problems (for example, heart or renal failure).[18-20] In the USA, the prevalence of HIV-related pleural effusion among hospital-ized AIDS patients is 2-20%.[19] AIDS-related lymphomas involving pleural effusions may be primary (i.e., there is

no extracavitary involvement or identifiable contiguous mass) or secondary (i.e., preceded by an extracavitary systemic lymphoma).[20] In case 3, our patient had a his-tory of KS Bloody or chylous pleural effusion occurs in approximately 1/3 to 2/3 of patients with KS[21-22] and it was unclear in this particular case if KS contributed to his effusions The presence of atypical cells in the pleural fluid of case 3 was very concerning for classic PEL Other entities within the differential diagnosis were metastatic carcinoma, atypical/malignant mesothelial cells, and other neoplasms (e.g., melanoma and sarcoma) PEL is a high-grade non-Hodgkin lymphoma of B-cell origin that

is strongly associated with HHV8 infection Pre-existing KS

is often reported in a large proportion of patients with PEL.[23]

Cytologically, PEL cells are large atypical cells that range from immunoblast-like to anaplastic forms Immunophe-notypically these lymphoma cells are CD45, CD30 and LNA-1 (HHV8) positive, lack B-cell and T-cell antigens in the majority of cases, coexpress plasma cell markers (e.g., CD138), and are variably positive for EMA In case 3, the atypical cells proved to be megakaryocytes, a component

of this patient’s extramedullary hematopoiesis Extramed-ullary hematopoiesis is the formation and development of blood cells outside of the bone marrow There have been several prior reports of patients presenting with pulmonary extramedullary hematopoiesis, most of which were due to secondary processes such as myeloproliferative disorders, hemolytic anemias, and hereditary spherocytosis.[24-25] Al-though the driving force for extramedullary hematopoiesis

in our patient was unclear, he did subsequently develop multiple myeloma

In summary, we present three cases which illustrate how

knowledge of a patient’s HIV status was misleading in the

evaluation of varying cytology specimens, with potential

for misdiagnosis and/or multiple unnecessary procedures

In the setting of HIV infection, common entities unrelated

to HIV infection must be maintained within the

dif-ferential diagnosis Contaminants and artifacts in these

patients have the potential to masquerade and mimic

significant infections The use of ancillary studies including

cytochemical stains and immunocytochemical studies are

invaluable in such cases to establish an accurate diagnosis

COMPETING INTEREST STATEMENT BY

ALL AUTHORS

No competing interest to declare by any of the authors

AUTHORSHIP STATEMENT BY ALL

AUTHORS

Each author acknowledges that this final version was read and

approved All authors of this article declare that we qualify for

authorship as defined by ICMJE http://www.icmje.org/#author

Each author has participated sufficiently in the work and take

public responsibility for appropriate portions of the content

of this article.

ETHICS STATEMENT BY ALL AUTHORS

As this is case report without identifiers, our institution does

not require approval from Institutional Review Board (IRB) (or

its equivalent)

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