Cytokine profiles in patients with toxoplasmic lymphadenitis in the setting of pregnancy

INTRODUCTION

Majority of Toxoplasma gondii infections are benign and asymptomatic; however, some patients experience toxoplasmic lymphadenitis (TL). Factors associated as to whether infection will be symptomatic or not are unknown.

METHODS

Dye test titers of patients with acute toxoplasmosis (pregnant and not pregnant) with TL (TL+) were compared with those in patients with asymptomatic acute infection (TL-). Additionally, mean levels of 62 serum cytokines were compared between TL+ and TL- pregnant women and between TL+ pregnant and non-pregnant women.

RESULTS

During acute infection, mean dye test titer was higher in TL+ than in TL- patients (p=0.021). In addition, out of 62 cytokines, CXCL9andCXCL10 levels were higher (p<0.05) and resistin mean levels were lower (p<0.05) in pregnant women with TL+ compared to TL-. Among patients with TL+, levels of VCAM1andCCL2 were lower (p<0.05) in pregnant women than in non-pregnant women.

CONCLUSION

Here we report differences in dye test titers in patients with acute infection. Cytokine responses vary according to the presence of TL+ and to the pregnancy status. Factors underlying these differences are presently unknown and require further studies to define individual and combined roles of cytokines in TL+.

Toxoplasmosis presented as a submental mass: a common disease, uncommon presentation

Submental mass secondary to toxoplasmosis is not common in clinical work. A diagnosis of toxoplasmosis is rarely considered by physicians. Here we describe a 50-year-old woman presented with a progressive, painful, submental and left neck swelling for 1 month. After having obtained an insufficient evidence from the fine-needle biopsy, the patient finally received an excisional biopsy which highly indicated the possibility of lymphadenopathy consistent with toxoplasmosis. Diagnosis of toxoplasmosis was finally established by a combination of the pathological criteria, together with the positive serological finding. According to review the clinical presentations, pathological characteristics, diagnostic standard and treatment of this disease, the article aims to remind otolaryngologists who are evaluating a neck mass should be aware of the infectious cause of lymphadenopathy and the possibility of toxoplasmosis.

Bancroftian filariasis in children and adolescents: clinical–pathological observations in 22 cases from an endemic area

In areas where bancroftian filariasis is endemic, the clinical manifestations of the disease, which are often very varied, appear most frequently during early adulthood or later. In consequence, very little attention, if any, has been given to the signs and symptoms of the disease in childhood. In an attempt to fill this gap, clinical and pathological observations were made, in Brazil, on 22 children (aged 2-15 years) who were infected with Wuchereria bancrofti. There was a predominance of lymph-node involvement. In all but three (14%) of the children (who had adult parasites in their intrascrotal lymphatic vessels), the adult worms were located in the afferent or efferent vessels of draining lymph nodes, predominantly in the inguinal region. None of the patients presented with distal lymphoedema, and the adenopathy was characterized by painless, localized, lymph-node enlargement, without signs of inflammation in the overlying skin. Histologically, the alterations in the lymphatic vessels and surrounding structures were similar to those described in adult patients, and depended essentially on adult-parasite viability. The localization of the adult worms in the paediatric cases was peculiar and distinct from that observed in adult patients, in whom the adult parasites are usually found in extra-nodal lymphatic vessels. In areas endemic for bancroftian filariasis, therefore, filarial infection should be considered as a possible cause of adenopathy. For the differential diagnosis of adenopathy in young patients from endemic areas, the authors recommend the use of ultrasound and other non-invasive diagnostic tools, as alternatives to excisional biopsies, which are often unnecessary in bancroftian filariasis.

Lymphatic filariasis and onchocerciasis

Lymphatic filariasis and onchocerciasis are parasitic helminth diseases that constitute a serious public health issue in tropical regions. The filarial nematodes that cause these diseases are transmitted by blood-feeding insects and produce chronic and long-term infection through suppression of host immunity. Disease pathogenesis is linked to host inflammation invoked by the death of the parasite, causing hydrocoele, lymphoedema, and elephantiasis in lymphatic filariasis, and skin disease and blindness in onchocerciasis. Most filarial species that infect people co-exist in mutualistic symbiosis with Wolbachia bacteria, which are essential for growth, development, and survival of their nematode hosts. These endosymbionts contribute to inflammatory disease pathogenesis and are a target for doxycycline therapy, which delivers macrofilaricidal activity, improves pathological outcomes, and is effective as monotherapy. Drugs to treat filariasis include diethylcarbamazine, ivermectin, and albendazole, which are used mostly in combination to reduce microfilariae in blood (lymphatic filariasis) and skin (onchocerciasis). Global programmes for control and elimination have been developed to provide sustained delivery of drugs to affected communities to interrupt transmission of disease and ultimately eliminate this burden on public health.

[Roles of histologic examination and polymerase chain reaction in diagnosis of toxoplasmic lymphadenitis]

OBJECTIVE

To study the roles of histologic examination and polymerase chain reaction in diagnosis of toxoplasmic lymphadenitis (TL).

METHODS

Forty-six archival cases of histologically diagnosed TL, encountered during the period from April, 1999 to September, 2009 and with the paraffin-embedded lymph node tissue blocks available, were enrolled into the study. The presence of genome fragments of Toxoplasma gondii (T. gondii) was analyzed using semi-nested polymerase chain reaction (PCR). Thirty cases of one or two histopathologic triad of TL as the controls.

RESULTS

The positive rate of PCR in TL group was 76.1% (35/46), as compared to 10.0% (3/30) in the control group. The difference was of statistical significance. The sensitivity and specificity of the histologic triad in diagnosing TL was 92.1% (35/38) and 71.1% (27/38), respectively. The predictive value of positive and negative PCR results was 76.1% (35/46) and 90.0% (27/30). respectively.

CONCLUSIONS

The high specificity but low sensitivity of applying the histologic triad in diagnosing TL cases may be due to the occurrence of atypical histologic pattern. The sensitivity is improved with the use of semi-nested PCR in detecting T. gondii DNA.

Diagnosis of myiasis by fine needle aspiration cytology: a case report

BACKGROUND

Myiasis is the infestation of tissues and organs by dipteran larvae and is endemic in tropical areas. Diagnosis usually is made by demonstration of a larva or larvae in infected tissue, generally recognizable to the naked eye. In our case, diagnosis was based on fine needle aspiration cytology (FNAC).

CASE

A 59-year-old female patient with a painful neck mass was examined at an otorhinolaryngologic department after symptoms for several weeks. The lesion was found to be an absceding lymphadenitis, based on clinical symptoms, palpation and imaging (ultrasound and computed tomography). The lesion did not improve with repeated courses of antibiotics, so surgery was performed. Pus cultures collected after incision were negative, leaving origin of the inflammation undetermined. Smears from FNA of the residual mass demonstrated a worm-like pathogen alien to most European pathologists' experience. The pathogen was identified as a dipteran larva, leading to accurate etiologic diagnosis of myiasis. More scrupulous examination of the patient's history revealed she had spent her vacation in Australia, where she probably acquired the infection.

CONCLUSION

Our case demonstrates the growing importance of the pathology of infectious diseases. One reason for this may be the ever-increasing possibility, frequency and distance of travel.

New cytologic clues in localized Leishmania lymphadenitis

OBJECTIVE

To describe new cytologic clues to diagnose localized leishmania lymphadenitis (LLL).

STUDY DESIGN

The study examined cytologic smears of 170 cases of LLL referred to our department from November 1989 to October 2004. A total of 120 cases were confirmed by detecting Leishman-Donovan (LD) bodies in at least 1 of the cytologic smears and 50 cases, which were histologically confirmed. For comparison we studied cytologic smears of 20 cases of tuberculous lymphadenitis, 20 cases of toxoplasma lymphadenitis and 20 cases of granulomatous lymphadenitis of unspecified causes.

RESULTS

Cases were divided into 4 major groups. Cytologic findings in these groups were studied to find highly suggestive clues. Cytologic findings present in most of these groups, but absent or very rare in other granulomatous lymphadenitis, were LD kinetoplasts, plasma cells with different shapes of inclusions and lymphogranular bodies. Rare findings not reported previously were: intraneutrophilic LD bodies, hematoxylin body-like inclusions, fibroblasts, cytoplasmic blebbing and floating parasitophorous vacuoles.

CONCLUSION

Despite previous reports emphasizing detecting LD bodies in diagnosing LLL, we present cytologic clues highly suggestive of this self-limited disease when LD bodies cannot be detected or are very few on the smears.

Dry type leishmanial lymphadenitis presented as two large parotid and cervical masses

BACKGROUND

Cutaneous leishmanisis (CL) is a common disease in Iran, particularly in Kerman and Bam and Kerman province. Lymphadenitis resulting from leishmania tropica (dry type) with, or without, cutaneous lesion is rare. Localized leishmanial lymphadenitis (LLA) is a specific clinico-pathologic presentation of inflammatory changes caused by leishmanial parasites or antigen within an isolated lymph node without any systemic manifestation.

CASE REPORT

A 55-year-old Iranian woman presented with two slow growing large nodules (masses) on the left preauricular and the left cervical areas. The nodules were large, painless, mobile, multilobulated, and associated with a small skin papule on the left-side of the cheek distal to the masses.

RESULTS

Histopathologic examination of both the skin lesion and the lymph nodes suggested the leishmanial etiology of skin papule and lymphadenitis. The Leishman-bodies (amastigotes) were demonstrated in two lymph nodes and a skin lesion. The clinical picture plus pathological finding and the response to meglumine-antimoniate confirmed LLA.

CONCLUSION

Lymph node involvement is another rare manifestation of dissemination of infection with dermotropic leishmania. This presentation of CL should not be treated with the ordinary local treatments such as curettage, cryotherapy or surgical excision.

A simple duplex-PCR protocol for routine diagnosis and follow up of canine leishmaniasis

The introduction of PCR has efficiently improved diagnosis of canine leishmaniasis. In order to provide a robust, efficient and reliable diagnostic method, a duplex PCR assay targeting the Leishmania infantum kDNA minicircle and the canine GAPDH gene as inner control was designed. Sensitivity of the assay reached 0.15 parasites/ml blood. Development, testing and application of this system on a group of 10 dogs during therapy administration (60 days) are also described. Six dogs (out of eight that have been showing a positive PCR result on peripheral blood during the study) were tested negative at day 62, indicating a reduction of parasitaemia at the end of the treatment period. All the animals had a positive PCR on lymph node aspirate both at the beginning and at the end of treatment. These findings seem to suggest that, in order to test therapy efficacy, PCR on whole blood could be a useful assay in dogs that have a positive PCR at the beginning of the treatment, while PCR positivity on lymph nodes lasts longer than the observation period during therapy administration. The presence of the GAPDH inner control band efficiently contributed to prevent false negatives, by highlighting samples affected by haemoglobin inhibition or inappropriate DNA isolation.

The differential agglutination test as a diagnostic aid in cases of toxoplasmic lymphadenitis

Lymphadenopathy (LN) is the most common clinical manifestation of acute acquired toxoplasma infection in humans. The diagnosis of toxoplasmic lymphadenitis (TL) is established by serological methods and/or lymph node biopsy. In the United States, the differential agglutination (of acetone [AC]-fixed versus that of formalin [HS]-fixed tachyzoites) test (AC/HS test) has primarily been used in assessments of pregnant women as a component of the toxoplasma serological profile to distinguish between recently acquired infections and infections acquired in the distant past. We studied the AC/HS test in patients with TL to define its usefulness in diagnosing individuals presenting with LN and to determine its kinetics after the onset of LN. One hundred nine consecutive patients (158 serum samples) diagnosed serologically and by lymph node biopsy as having TL were studied. Specific patterns in the AC/HS test were noted to be dependent on the time from the clinical onset of LN (COLN). Acute AC/HS patterns were observed for more than 75% of patients who according to their histories had developed their TL within 6 months after COLN. Acute patterns were not observed beyond the 12th month except for a single patient for whom an acute pattern (400/800) persisted to the 13th month after COLN. Equivocal patterns were observed up to 36 months after COLN. Nonacute patterns were observed only for serum samples drawn at least 13 months after COLN. A nonacute pattern in an individual at less than 12 months after COLN should suggest an etiology other than TL. In such cases, investigation for alternative causes, including malignancy, should be instigated.

Detection of clinical-stage specific molecular Toxoplasma gondii gene patterns in patients with toxoplasmic lymphadenitis

Three cases of symptomatic toxoplasmic lymphadenitis, together with a serologic profile of recent infection, are described, for which quantitative real-time PCR (LightCycler PCR) targeting different parasite genes was designed, in order to quantify Toxoplasma gondii DNA in acute and follow-up blood specimens. Similar parasite gene kinetics and DNA concentrations were observed in the patients studied. However, the profile of each target gene investigated was different. While the level of B1 DNA remained elevated for the entire time of observation, irrespective of clinical and serologic resolution, the SAG-1 gene was detected at the end of acute symptomatic disease, overlapping with a strong anti-T. gondii IgA antibody response, and persisting for over 3 months after infection and clinical recovery. With respect to the two bradyzoite genes investigated (SAG-4 and MAG-1), levels peaked during the symptomatic phase, but did not fall until 2 or 3 months of follow up. The real-time PCR assay with new alternative targets to the B1 gene may have potential for monitoring the clinical outcome of disease and for providing molecular information regarding the actual state of infection.

Evidence based criteria for the histopathological diagnosis of toxoplasmic lymphadenopathy

AIMS

To formulate evidence based histopathological criteria for the diagnosis of acquired toxoplasmic lymphadenitis, in an area of high tuberculosis prevalence.

METHODS

Multiple histopathological parameters were assessed in a consecutive sample of biopsies from 68 patients presenting with lymphadenopathy with a duration of less than six months. Serum IgM enzyme linked immunosorbent assay was used as the standard reference test for the diagnosis of toxoplasmic lymphadenitis. The sensitivity, specificity, and likelihood ratios of various histological parameters were estimated.

RESULTS

The presence of microgranulomas (p < 0.0001), paracortical widening (p = 0.006), paracortical hyperplasia (p = 0.02), monocytoid B cells in sinuses (p = 0.007), lower than grade 2 macrogranuloma (p = 0.002), and the absence of giant cells (p = 0.05) were found to discriminate between IgM positive cases and IgM negative controls. Using a composite criterion-(1) presence of microgranulomas, (2) lower than grade 2 macrogranuloma, (3) absence of giant cells, and (4) follicular hyperplasia-toxoplasmic lymphadenitis can be diagnosed with a high degree of sensitivity (100%), specificity (96.6%), and positive likelihood ratio (29).

CONCLUSION

Toxoplasma lymphadenitis can be diagnosed with a high degree of confidence using the specific histopathological criteria identified here.

Fine needle aspiration of lymphadenopathy in visceral leishmaniasis

OBJECTIVE

To illustrate the cytomorphologic features of Leishmania lymphadenitis associated with visceral leishmaniasis (V/L) and post-kala-azar dermal leishmaniasis (PKDL) and to highlight the fact that Leishmania lymphadenitis must he included in the differential diagnosis of patients presenting with lymphadenopathy, particularly in areas endemic for the disease.

STUDY DESIGN

Fine needle aspiration (FNA) was routinely done in 21 cases of lymphadenopathy in VL (18 cases) and PKDL (3 cases), and the detailed cytomorphologic features were correlated with the respective histopathologic findings.

RESULTS

Amastigote forms of Leishman-Donovan (LD) bodies were seen in 19 cases both intracellularly, in histiocytes and multinucleate giant cells, and extracellularly. The FNA smears revealed a polymorphous population of cells composed of lymphocytes, histiocytes, plasma cells, giant cells and tingible body macrophages. In a few cases, epithelioid cell granulomas were also seen. The cytomorphologic features were confirmed and correlated on histopathology.

CONCLUSION

Not all lymphadenopathy in VL and PKDL is due to Leishmania lymphadenitis. Demonstration of LD bodies on FNA smears helps with the early diagnosis of VL and PKDL with lymphadenopathy where the diseases are endemic.

Fine needle aspiration of toxoplasmic (Piringer-Kuchinka) lymphadenitis: a cytohistologic correlation study

OBJECTIVE

To define the cytomorphologic features of toxoplasmic lymphadenitis (TL) and to establish the diagnostic sensitivity and specificity of the cytologic diagnosis.

STUDY DESIGN

A cytohistologic correlation study of 11 patients in which a histologic diagnosis of TL was available. These cases were analyzed in a blind study among other cases of nonneoplastic lymphadenopathies. The results of the study are expressed in terms of diagnostic sensitivity and specificity. Although not included in the study, 3 other cases of TL with serologic confirmation were also reviewed.

RESULTS

Microgranulomas were a characteristic finding in TL. They consisted of small clusters of epithelioid histiocytes, each with abundant cytoplasm and an eccentric, oval nucleus. Diff-Quik-stained smears had cytoplasm with particularly pale staining and a homogeneous appearance. Most microgranulomas had a monotonous appearance with a few, small lymphocytes accompanying the epithelioid cells. No necrosis, suppurative changes or giant cells were present. Blind examination by 4 reviewers led to a correct diagnosis of TL in 9 of the 11 cases. Eight of the 9 cases were recognized by each of the 4 reviewers. One false positive diagnosis was made by 1 of the reviewers. The sensitivity of the diagnosis was 72.7-81.8% and the specificity 98.8-100%.

CONCLUSION

This study showed high sensitivity and specificity for the cytologic diagnosis of TL. Given the appropriate clinical context, the presence of characteristic epithelioid microgranulomas permits a diagnosis of TL. The cytologic diagnosis can be easily confirmed with serologic studies, thereby avoiding biopsy.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman's disease) previously misdiagnosed as Toxoplasma Lymphadenitis

Here we describe a case of Rosai-Dorfman Disease (RDD) in a 25-year-old female patient from Turkey who was previously misdiagnosed with Toxoplasma Lymphadenitis, and review the manifestations and treatment of this rare entity. To the best of our knowledge this is the third description of RDD [Sinus Histiocytosis with Massive Lymphadenopathy (SHML)], involving bilateral cervical lymphadenopathy and nephromegaly previously misdiagnosed as Toxoplasma Lymphadenitis. Representative clinical, radiographic and histological findings are presented. Its etiology, diagnosis and management are also reviewed. Sinus Histiocytosis with Massive Lymphadenopathy is a rare disorder of unknown etiology, usually associated with lymph node enlargement in various superficial or deep sites. The key histologic feature of SHML is the presence of various numbers of large, pale histiocytic cells that contain within their cellular borders apparently engulfed lymphocytes (emperipolesis); these distinctive large, pale cells are S-100 protein positive CD-68 positive and CD1a negative by immunostaining. According to the literature the most effective treatment found was surgical debulking.

Evaluation of the immunoglobulin G avidity test for diagnosis of toxoplasmic lymphadenopathy

Toxoplasmic lymphadenopathy (TL) is the most common clinical manifestation of acute acquired toxoplasma infection in normal individuals. The diagnosis is established by serologic methods and lymph node biopsy. Recently, tests for avidity of toxoplasma immunoglobulin G (IgG) antibodies have been introduced to help discriminate between recently acquired and distant infection with the parasite. We studied an avidity test to define the usefulness of this method and to determine the evolution of the IgG avidity in TL. Seventy-three consecutive patients diagnosed as having TL were studied. IgG avidity test titers were noted to be time dependent from the clinical onset of lymphadenopathy. Low IgG avidity test results were observed in patients who had developed lymphadenopathy from <1 month to 17 months prior to the sampling of sera, emphasizing that low IgG avidity test results are not reliable for diagnosis of recently acquired infection. In contrast, high IgG avidity test results were observed only in patients who had developed lymphadenopathy at least 4 months earlier. Thus, a high IgG avidity test result in an individual who has recent onset of lymphadenopathy (e.g., within 2 to 3 months of sera sampling) suggests a cause other than toxoplasmosis. In such cases, further workup is warranted in order to determine the cause of the lymphadenopathy.

[Toxoplasmosis in patients with lymphoid hyperplasia of the head and neck]

OBJECTIVES

To investigate the incidence of toxoplasmosis in patients with lymphoid hyperplasia of the head and neck.

PATIENTS AND METHODS

In this study, 53 patients (32 males, 21 females; mean age 11.2+/-4.3 years, range 5 to 22) were investigated. There were hypertrophic tonsillitis in 13 patients, hypertrophic tonsillitis and adenoid hyperplasia in 22 patients, adenoid hyperplasia in 10 patients, and lymphadenopathy of the neck in eight patients. In venous blood samples, IgM and IgG antibodies for Toxoplasma gondii were investigated with the enzyme-linked immunoabsorbent assay (Axsym, Abbott).

RESULTS

Positive IgG was determined in 23 patients (48%) with hypertrophic tonsillitis (n=6), hypertrophic tonsillitis and adenoid hyperplasia (n=10), adenoid hyperplasia (n=3), and lymphadenopathy of the neck (n=4). Positive IgM was determined in 5 patients (9.4%) with hypertrophic tonsillitis (n=1), hypertrophic tonsillitis and adenoid hyperplasia (n=1), and lymphadenopathy of the neck (n=3).

CONCLUSION

Toxoplasmosis, which is known to cause lymphadenopathy, may be a reason for lymphadenopathy of the neck. Toxoplasmosis should be considered in the differential diagnosis of untreated patients with tonsillitis, adenoid hyperplasia, and chronic neck lymphadenopathy.

Fine needle aspiration cytologic diagnosis of toxoplasma lymphadenitis. A case report with detection of a Toxoplasma bradycyst in a Papanicolaou-stained smear

BACKGROUND

Fine needle aspiration (FNA) cytologic diagnosis of toxoplasmic lymphadenitis with demonstration of a tissue cyst containing bradyzoites has been very rarely reported.

CASE

A 17-year-old female presented with a mobile, painless, 2-cm-diameter swelling over the right suprascapular area. Clinical diagnosis was lipoma. FNA smears showed features of reactive lymphoid hyperplasia, including tingible body macrophages and groups of epithelioid histiocytes. A Toxoplasma cyst with bradyzoites was also demonstrated in a Papanicolaou-stained smear. Following FNA cytodiagnosis, serologic tests revealed a high titer of IgG and the presence of IgM-specific antibodies to Toxoplasma gondii, indicating active/recent disease.

CONCLUSION

FNA cytology is a valuable tool for the diagnosis of toxoplasmic lymphadenitis. Papanicolaou stain is appropriate for demonstration of the parasite. Serology is an excellent adjunct in clinching the diagnosis.

Microfilariae in association with other diseases. A report of six cases

BACKGROUND

Lymphatic filariasis is a major public health problem in tropical countries. Earlier reports have reported microfilariae as an incidental finding in body fluids and fine needle aspiration smears from various sites.

CASES

The findings of body fluid cytology and fine needle aspiration smears from six patients with microfilariae in association with other conditions--tubercular pleural effusion/lymphadenitis, pregnancy and non-Hodgkin's lymphoma--are presented. Three patients demonstrated an associated eosinophilic cellular exudate. Adherence of inflammatory cells to microfilariae was seen in two patients.

CONCLUSION

Although microfilariae in cytologic smears are considered incidental findings, the association of microfilariae with debilitating conditions suggests that it is an opportunistic infection and needs further study.

Subclassification of localized Leishmania lymphadenitis in fine needle aspiration smears

OBJECTIVE

To describe the cytologic findings of localized Leishmania lymphadenitis and discuss the differential diagnosis.

STUDY DESIGN

The study group consisted of 133 cases. All of them were diagnosed by fine needle aspiration (FNA) study. The ages ranged between 3 and 80 years, 102 were male and 31 female. Seventy lymph nodes were excised.

RESULTS

The FNA smears revealed a polymorphic population of cells composed of lymphocytes, histiocytes, giant cells, abnormal plasma cells and tingible body macrophages. Leishman-Donovan (LD) bodies were identified in all cases, but their number differed from case to case. Granulomas, dendritic cells, mast cells and lymphoglandular bodies were identified in a substantial number of cases. Depending upon the presence of characteristic cytologic findings, the cases were divided into five major groups: acute inflammation with giant cells, histiocytic granulomas, epithelioid cell granulomas, plasma cell type and mixed histioplasmacytic type.

CONCLUSION

Leishmaniasis is an uncommon cause of cervical lymphadenitis but should be considered in the differential diagnosis of unexplained lymphadenopathy in endemic countries. Demonstration of LD bodies is necessary for the diagnosis of this self-limited condition, for which no treatment is required.

[Polymerase chain reaction applied for detection of Toxoplasma gondii in lymph nodes]

In order to investigate the morbidity of toxoplasmic lymphadenitis, polymerase chain reaction (PCR) was used to detect DNA of Toxoplasma gondii within lymph nodes in 3 groups of 120 patients with different diseases. After extracting the DNA of each sample, PCR was employed to amplify toxoplasma DNA. The results showed that the amplification product of 210 bp was confirmed in 7 patients: 3 cases of Hodgkin's disease (HD), 2 cases of non-Hodgkin's lymphoma (NHL) and 2 cases of chronic lymphadenitis (CL). Each PCR product was then subjected to Southern blot hybridization. Besides the 7 cases proved by PCR, 1 case of CL was found positive. The positive percentages of HD, NHL and CL were 9.38% (3/32), 4.88% (2/41), and 6.38% (3/47), respectively. The total positive rate was 6.67% (8/120).

Fine needle aspiration of toxoplasmic lymphadenitis in an intramammary lymph node. A case report

BACKGROUND

Cytologic findings of toxoplasmic lymphadenitis (TL) have been only sporadically reported. Intramammary lymph node is an extremely rare site for TL.

CASE

A 47-year-old, healthy, female presented with a breast tumor, which was aspirated. The cytomorphologic features were interpreted as suggestive of TL. Histopathology of the excisional biopsy specimen and subsequent serologic examination confirmed the diagnosis.

CONCLUSION

We obtained several characteristic findings in aspiration of TL. Of these, epithelioid cell clusters and monocytoid cells were the most diagnostic.

Lymph node infection by Trichomonas tenax: report of a case with co-infection by Mycobacterium tuberculosis

In an 82-year-old woman, presenting with fever and asthenia, cervical adenopathy was noted. Clinical and radiological investigations were fruitless. Laboratory examinations detected a refractory anemia. The lymph node was excised and showed numerous trichomonads on touch preparations. Histologically, the node showed caseous necrosis and macrophagic reaction. Diagnosis of lymph node infection by Trichomonas tenax was made. Three weeks later, culture of the node showed Mycobacterium tuberculosis and let us conclude co-infection. T tenax is usually regarded as a harmless saprophyte of the oral cavity. This exceptional observation shows for the first time an invasive potential of T tenax. It raises questions about links with tuberculosis and refractory anemia.

Demonstration of parasites in toxoplasma lymphadenitis by fine-needle aspiration cytology: report of two cases

Two cases of toxoplasma lymphadenitis diagnosed by fine-needle aspiration (FNA) cytology, in which the microorganisms were identified in the cytologic preparations, are presented. The first case was that of an 8-yr-old boy with bilateral cervical lymphadenopathy of 2-mo duration, in which an FNA specimen of one of the lymph nodes in a Papanicolaou-stained smear disclosed a toxoplasma cyst, and in Wright-Giemsa preparation, dispersed tachyzoites and a pseudocyst. The second case was that of a 52-yr-old man with enlargement of a single lymph node in the neck, of 3-mo duration, FNA of which in Wright-Giemsa preparation disclosed numerous tachyzoites dispersed free in exudate, and also within cells, forming pseudocysts. In both cases, immunocytochemistry by the peroxidase method for Toxoplasma gondii antigen was positive. The tachyzoites seen in Wright-Giemsa preparations, when subjected to fluorescence microscopy, emitted autofluorescence, facilitating their identification. While the presence of parasites in toxoplasma lymphadenitis is quite unusual, having been reported occasionally in histologic preparations and only rarely in cytologic FNA materials, our 2 cases suggest that in active disease, tachyzoites may not be so uncommon in FNA specimens. Besides the use of immunocytochemistry in the diagnosis of the disease, air-dried preparations stained by the Wright-Giemsa method are valuable for the demonstration of such parasites through careful search, along with the possible use of fluorescence microscopy.

[Lymphadenopathy caused by Toxoplasma in an intramammary lymph node: role of molecular biology in the diagnosis]

We describe a case of Toxoplasma gondii lymphoadenopathy in an intramammary lymph node in a 22 year old woman. Clinical evidence and ultrasound were suggestive for fibroadenoma, while cytology on fine needle aspiration suspected a lymphomatous lesion. The pathological examination demonstrated a lymph node with granulomatous foci with epithelioid histiocytes, consistent with Toxoplasma gondii lymphadenopathy. The pathological finding was confirmed by serological tests and by PCR (Polymerase Chain Reaction) using specific primers designed on ribosomal 18s DNA sequence of Toxoplasma gondii. The aim of this work is to emphasize the role of molecular biology techniques as an aid to pathological diagnosis in parasite diseases.

Fine needle aspiration cytodiagnosis of toxoplasmic lymphadenitis

OBJECTIVE

To study six cases of toxoplasmic lymphadenitis in which the diagnosis was made by fine needle aspiration cytology and confirmed by subsequent serology.

STUDY DESIGN

For cytologic study the material was received as needle and syringe washings, air-dried smears and alcohol-fixed smears, which were prepared and appropriately stained. Additionally, cell blocks were made, processed, cut and stained.

RESULTS

The cytohistologic features were characterized by a polymorphous population of cells, germinal centers, a few epithelioid-type cells and histiocytes with intracellular organisms resembling Toxoplasma gondii. Serologic testing for toxoplasma in all the cases revealed elevated titers.

CONCLUSION

Lymphadenitis due to Toxoplasma infection is common and should be considered in the diagnosis of unexplained lymphadenopathy at all sites, especially the cervical region. Serologic confirmation should be recommended for all suspected cases of this self-limited condition, for which no treatment is necessary. Fine needle aspiration cytodiagnosis can eliminate the need for hospitalization and surgery.

Morphology and diagnostics of human toxoplasmosis

Toxoplasmosis has regained clinical importance. In addition to intrauterine fetal infections, the acquired toxoplasmosis endangers an increasing number of immunocompromised adults. This disease affects not only oncologic patients, but also organ transplant recipients and, above all, AIDS patients. Toxoplasmosis has five clinical subtypes: lymphadenopathy, encephalitis, chorioretinitis, disseminated toxoplasmosis and congenital toxoplasmosis. In biopsies of different organs and autopsies of persons who died as a result of an infectious disease, the pathologist is involved in the diagnostic procedures. The findings of the parasites in tissue specimens still constitute the morphologic feature of toxoplasmosis. Differential diagnosis has been improved by immunohistologic methods for demonstrating toxoplasmas in tissue specimens and by the use of polymerase chain reaction for identification of toxoplasmatic antigens. This review describes the pathomorphology and possibility regarding the diagnosis of toxoplasmosis.

Congenital toxoplasmosis transmitted from an immunologically competent mother infected before conception

Congenital transmission of Toxoplasma gondii from a mother who was apparently immunologically competent and who had toxoplasmic lymphadenitis 2 months before conception is described. Since no T. gondii-specific serological data were available for this mother from the time her lymph node biopsy specimen was obtained, the specimen was studied by polymerase chain reaction (PCR) to determine whether the T. gondii B1 gene was present. The predictive diagnostic value of histologic findings previously considered to be classic signs of T. gondii lymphadenitis also was studied. This was done by correlation of serological tests diagnostic of acute acquired T. gondii infection and presence of characteristic findings in biopsy specimens from persons without known immunocompromise. Both PCR and review of the characteristic features of her lymph node biopsy specimen confirmed the diagnosis of preconceptual infection in the mother. We also discuss two other cases in which apparently immunologically competent mothers with preconceptually acquired infection transmitted this parasite to their fetuses.

Value of lymph node biopsy in the diagnosis of acquired toxoplasmosis

Toxoplasmic lymphadenitis generally involves a solitary lymph node in the head and neck regions, without systemic symptoms. In order to determine the frequency of toxoplasmic lymphadenitis, we reviewed the histological sections of 731 consecutive patients with reactive lymph node hyperplasia. Amongst 731 patients, 112 had histological features supporting a diagnosis of toxoplasmic lymphadenitis (15.3 per cent). In 80 of these patients (71 per cent), either Indirect Haemaglutination test (IHA), in 37 cases, or the Enzyme-Linked Immunosorbent Assay (ELISA) for detecting toxoplasmic IgG or IgM antibodies, in 43 cases, were performed. In 76 out of 80 patients (95 per cent), histological features correlated well with serological studies. The IHA test was positive in 30 patients with a titre of 1/64 or higher. The IgG-ELISA test was positive in 11 whereas the IgM-ELISA test was positive in 28 patients. These results provide further evidence of the distinctive nature of the histological changes in toxoplasmic lymphadenitis, which should enable the clinician to make a confident diagnosis of acute acquired toxoplasmosis.

Necrotizing and suppurative lymphadenitis in Leishmania major infections

The pathology of lymph nodes and subcutaneous nodules in 6 patients with cutaneous leishmaniasis (Oriental sore) due to Leishmania major is described in this paper. In 3 patients enlarged epitrochlear lymph nodes were found to be associated with primary skin lesions in the forearm. The lymph node in one patient showed a necrotizing granulomatous reaction that simulated tuberculous lymphadenitis. Leishmania parasites were, however, found in sections of the node, and staining for mycobacteria was negative. The second patient presented with an abscess and a discharging sinus in the epitrochlear region. Parasites were found in smears of the pus and cultures for bacteria were negative. The lesion healed with antimonial therapy. In the third patient the lesion resembled cat-scratch disease and showed stellate abscesses and granulomas. Leishmania parasites were also identified in the sections. Sections of a subcutaneous nodule from the fourth patient showed a necrotizing granuloma. The lesion healed spontaneously and the patient became leishmanin-positive. In two other patients fine needle aspiration of the subcutaneous nodules showed parasites, granuloma and necrosis. We concluded that L. major disseminates from the primary cutaneous lesion via the lymphatics to the subcutaneous tissues and the regional lymph nodes. The subcutaneous nodules and lymphadenopathy may persist long after the primary lesion had healed. The primary lesion is sometimes inconspicuous. Necrotizing and suppurative lymphadenitis due to L. major have to be distinguished from other causes of necrosis and suppuration such as tuberculosis and cat-scratch disease.

The characterization of Leishmania from patients with lymphadenopathy in Shiraz, Iran

Leishmania were cultured from enlarged lymph nodes of 6 of 18 patients with localized lymphadenitis and no other sign or symptom of leishmaniasis in Shiraz, Iran. The organisms failed to produce visible lesions when injected intradermally or intraperitoneally into Swiss outbred white or Balb/c mice. Golden hamsters similarly injected appeared well 16 weeks later, but histological examination of their spleens and livers revealed a few amastigotes in sections of the liver of one. Lectin agglutination profiles of promastigotes cultured from 2 of the patients were identical with those obtained with the World Health Organization reference strain of L. tropica (MHOM/SU/74/K27). Isoenzyme characterization of one of the isolates showed it to be L. tropica zymodeme LON18.

A preliminary study of filariasis related acute adenolymphangitis with special reference to precipitating factors and treatment modalities

Episodic adenolymphangitis (ADL) is one of the important clinical manifestations of lymphatic filariasis. Recurrent ADLs contribute to the progress of the disease and also have important socioeconomic implications since they cause significant loss of man days. The present study was conducted in order to identify the precipitating factors responsible for ADL attacks and also to examine the different modalities of treatment. Sixty-five individuals with filariasis related ADL attacks, who are residents of Alleppey district (endemic for Brugia malayi) were studied. All efforts were taken to identify the precipitating factors for ADLs in these individuals. They were hospitalized for a period of five days or more. All of them received symptomatic antipyretic/antiinflammatory therapy and topical antibiotic/antifungal treatment of the affected limbs. They were then randomly allocated to one of the following four regimens: group I - symptomatic alone; group II - symptomatic plus antibiotics; group III - symptomatic followed by diethylcarbamazine citrate (DEC) and group IV - symptomatic plus antibiotic followed by DEC. Patients in groups III and IV received DEC every three months up to one year. There was a significant relationship between the number of ADL attacks and the grade of edema. Presence of focus of infection in the affected limb could be identified in 28 of the 65 patients. In the majority of patients (48) response to treatment was rapid (resolution in less than five days). Neither antibiotics nor DEC (given at intervals of three months) appeared to alter the frequency of ADL attacks. On the otherhand simple hygienic measures combined with good foot care and local antibiotic/antifungal cream application (where required), were effective in reducing the number of ADL attacks.

Studies on the serodiagnosis of toxoplasmic lymphadenitis

The purpose of this study was to determine the value of conventional and newer serological tests (toxoplasmic serological profile) in the diagnosis of toxoplasmic lymphadenitis (TL). We studied 40 consecutive patients with biopsy-proven TL. Cervical, axillary, or occipital adenopathy was present in 72.5%, 20%, and 7.5% of the patients, respectively. Low-grade fever, fatigue, general malaise, or sore throat were present in only 6 (15%) of the 40 patients. A positive result for all serological tests was time dependent from the clinical onset of lymphadenopathy. The initial serum samples were positive for antibody for each patient, as shown by a Sabin-Feldman dye test. Between 3 and 6 months after clinical onset of TL, all of the patients had antibody titers of > or = 1:1,024. The ELISA was positive for IgM antibodies in all of the patients in the first 3 months. Detection of IgA or IgE antibodies or an acute pattern in the differential agglutination test was helpful in diagnosing TL in those patients who had negative, low-positive, or equivocal titers of IgM antibodies (as measured by ELISA) after 3 months. A toxoplasmic serological profile on the first serum specimen drawn after clinical onset of TL had a sensitivity of 100%. It is advisable to obtain such a serological profile in cases of asymptomatic lymphadenopathy before biopsy is carried out, especially for those individuals who have negative or equivocal IgM antibody titers.

Episodic adenolymphangitis and lymphoedema in patients with bancroftian filariasis

In order to explore the relationship between acute and chronic disease, age-specific data on the frequency and duration of episodic adenolymphangitis (ADL) in patients with 3 defined grades of lymphoedema in bancroftian filariasis were examined. The age distribution of grades I and II exhibited a convex age profile, but that of grade III showed a monotonic increase. The mean duration of oedema increased with its grade (grade I, 0.3 years; grade III, 9.9 years). The mean number of ADL episodes in the previous year for all cases was 4.2 and it increased with grade (grade I, 2.4 and grade III, 6.2). The mean duration of each ADL episode for all cases was 4.1 d and it was independent of grade and age. The mean period lost to ADL episodes in the previous year was 17.5 d; it increased from 9.4 d with grade I to 28.5 d with grade III. The results imply that there is a dynamic progression through the grades of lymphoedema and that the frequency of ADL episodes is positively associated with this progression. However, the study design could not separate cause from effect.

Visceral leishmaniasis: an unusual cervical presentation

Visceral leishmaniasis is an infectious disease with a classical clinical presentation of fever, anaemia and splenomegaly forming the three cardinal signs. A rare presentation of the disease is described where cervical lymph node enlargement was the only sign and there were no symptoms. It is emphasised that with extensive travel to and from areas of endemic leishmaniasis now established, it is important that clinicians and pathologists become acquainted with the characteristics of the disease.

Localized Leishmania lymphadenitis. Immunohistochemical studies

Tissues from 10 patients with localized leishmania lymphadenitis were stained by immunoperoxidase technique for leishmanian antigens, immunoglobulins (Ig), complement, components, alpha 1-antitrypsin, and fibrin and by routine and chloroacetate esterase techniques. Lymph nodes with leishmania lymphadenitis showed a granulomatous process with a varying degree of necrosis, leishmanian amastigotes, abundant plasma cells, and focal fibrosis. Leishmanian antigens stained by rabbit anti-Leishmania tropica antiserum was detected in lymph nodes with granulomatous lymphadenitis (eight cases examined) and in a skin lesion but not in a lymph node showing only nonspecific hyperplasia. Positive antigen staining was seen in leishmanian amastigotes, granulomata, and (in three cases) vascular smooth muscles. Dominant plasma cell classes were IgG and IgE. Macrophages and granulomata stained positively for IgG and IgE (but not for IgM or IgA), faintly for C3, and strongly for alpha 1-antitrypsin. Mast cells were few. IgG and IgE may be involved in a specific way in this condition; formation of immune complexes with leishmanian antigens leads to immunologically mediated lysis of the host macrophages. This finding is important for the understanding of the pathogenesis of leishmania lymphadenitis and for effective elimination of the parasites.

[Infectious cervical adenopathy]

Cervical adenopathy is often found on examination, but rarely causes clinical problems. If the adenopathy persists for a longer period then three to four weeks and no infectious causes are found, further investigations are needed, especially to exclude a malignancy. The chronic infectious adenopathies are discussed: mycobacterial (tuberculous and atypical), toxoplasmosis, cat-scratch disease and actinomycosis.

Infrequent detection of Toxoplasma gondii genome in toxoplasmic lymphadenitis: a polymerase chain reaction study

The diagnosis of toxoplasmic lymphadenitis is currently established by histologic evaluation with confirmation by serologic studies. We used a sensitive and specific polymerase chain reaction methodology for the identification of toxoplasmic genomes previously reported by others to investigate whether this technology could contribute to the diagnosis. We were able to reliably detect toxoplasmic genomes in paraffin-embedded tissues of toxoplasmic encephalitis and myocarditis, and serial dilution studies indicated a high degree of sensitivity. Nonetheless, we identified toxoplasmic genomes in frozen tissue from only one of nine cases of toxoplasmic lymphadenitis. In the one positive case, only one of three frozen samples from the lymph node biopsy was positive, indicating a focal infection within the lymph node. It is concluded that polymerase chain reaction studies, at their current level of sensitivity, are not of great use in contributing to the evaluation of cases of suspected toxoplasmic lymphadenitis, which continues to be best diagnosed by accurate histopathologic examination.

Toxoplasmic lymphadenitis--a clinicopathological study

Forty-three cases of toxoplasmic lymphadenitis were studied. They constituted 0.5% of all lymph node biopsies and 4.2% of reactive lymphadenitis. The histological findings supporting a diagnosis of toxoplasmosis were correlated with serological studies. The condition primarily affects young men, causing cervical lymph node enlargement and varying degrees of fatigue, malaise, cough and fever. It is usually self-limited. This study emphasizes the need for clinicians to consider toxoplasmosis in the differential diagnosis of lymphadenopathies.

Intraglandular toxoplasmosis lymphadenitis of the parotid gland

Toxoplasmosis is a protozoan infection manifested by systemic findings as well as generalized or localized lymphadenopathy. Although lympadenitis is the most common clinical form, involvement of the intraglandular nodes within the parotid gland found is a rare occurrence during the course of the disease. This unusual form may mimic a parotid mass, and can cause difficulties in differential diagnosis. In this article, a case of intraglandular parotid lymphadenitis which developed due to toxoplasmosis is presented, and the relevant literature is reviewed.