ABSTRACT

Francisella tularensis is a gram-negative coccobacilusthat causes zoonotic disease tularemia. Histopathologi-cal examination of lymph node biopsy in tularemia re-veals suppurative granulomatous inflammation potenti-ally associated caseous necrosis. Diagnosis is mainlymade on the evidence of elevated agglutinating antibo-dies against F. Tularensis. In this study we aimed toevaluate the cytological features of ulceroglandular tu-laremia cases and to demonstrate the role of fine need-le aspiration cytology in the diagnosis of tularemia.

Fine needle aspiration cytology findings of six cervicallymphadenopaties that had established diagnoses of tu-laremia both clinically and serologically, were evalua-ted and the cytomorphological features were described.

All of the cases revealed suppurative inflammation andsome caseous necrosis and in four cases epithelioid his-tiocytes and multinuclear giant cells were observed ad-ditionally.

The differential diagnosis of tularemia principally fromtuberculosis and other types of bacterial lymphadenitiswas made and the place of fine needle aspiration cyto-logy among other diagnostic laboratory tests for tulare-mia was evaluated.

Key words: Tularemia, fine needle aspiration, cytology

ÖZET

Tularemi gram negatif kokobasil olan Francisella tula-rensis’in etken oldu¤u zoonal bir hastal›kt›r. Histopato-lojik olarak lenf nodu biyopsisinde tulareminin yol aç-t›¤› de¤ifliklikler genel olarak kazeifikasyon nekrozu ilebirlikte seyredebilen granülomatöz pürülan lenfadenitfleklinde gözlenmektedir. Tularemi tan›s› esas olarakklinik bulgular› destekleyen Francisella tularensis’ekarfl› aglütinasyon gösteren antikorlar›n yüksek seviye-lerinin gösterilmesi ile konmaktad›r. Bu çal›flmada iseserolojik olarak orofaringeal tularemi tan›s› alan olgu-lar›n ince i¤ne aspirasyon sitolojisi materyallerindekisitolojik özellikler gözden geçirilerek tularemi tan›s›ndai¤ne aspirasyonunun de¤erinin ortaya konulmas› amaç-land›.

Klinik ve serolojik olarak tularemi tan›s› alan alt› has-tan›n servikal lenf nodu ince i¤ne aspirasyon sitolojisisonuçlar› de¤erlendirilmifl ve sitomorfolojik özellikleritan›mlanm›flt›r.

Alt› olgunun tamam›nda süpüratif inflamasyon bulgula-r› yan› s›ra kazeifikasyon nekrozu gözlenirken, ayr›cadördünde epiteloid histiyositler ve multinükleer devhücreler izlendi.

Bu bulgular ile klinik ve histopatolojik olarak baflta tü-berküloz olmak üzere granülomatöz hastal›klar ve di-¤er bakteriyel lenfadenitler ile ay›r›c› tan› yap›lm›fl, in-ce i¤ne aspirasyon sitolojisinin tularemi tan›s›ndaki la-boratuvar tan› yöntemleri aras›ndaki yeri de¤erlendi-rilmifltir.

Anahtar sözcükler: Tularemi, ince i¤ne aspirasyonu,sitoloji

Fine needle aspiration cytology findings incases diagnosed as oropharyngeal tularemialymphadenitis

Orofaringeal tularemi lenfadeniti tan›s› alan olgulardaince i¤ne aspirasyon sitolojisi bulgular›

Banu DO⁄AN GÜN1, Burak BAHADIR1, Güven ÇELEB‹2, Gamze NUMANO⁄LU1,fiükrü O¤uz ÖZDAMAR1, Gamze MOCAN KUZEY3

Zonguldak Karaelmas Üniversitesi T›p Fakültesi Patoloji1 ve ‹nfeksiyon Hastal›klar› ve Klinik Mikrobiyoloji2 Anabilim Dal›,Hacettepe Üniversitesi T›p Fakültesi Patoloji3 Anabilim Dal›, ZONGULDAK

Corresponding Author: Dr. Banu Do¤an Gün, ZonguldakKaraelmas Üniversitesi T›p Fakültesi, Patoloji Anabilim Dal›,67600, Kozlu, Zonguldak

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Turkish Journal of Pathology 2007;23(1):38-42

INTRODUCTION

Francisella tularensis is a gram-negativecoccobacillus that causes zoonotic disease, tula-remia and it was first demonstrated as a plaque-like disease of rodents in Tulare County, Cali-fornia, by McCoy (1-3). This zoonotic bacteri-um is carried both with arthropod vectors, andwild and domestic animals (particularly withcats that have eaten infected rodents or rabbits).Transmission through water contaminated byinfected rodents has also occurred (1,4).

Clinical features of the disease depend onthe source of inoculation. Six clinical forms ha-ve been recognized: ulceroglandular, oculoglan-dular, lymphadenoid, typhoidal, oropharygealand pulmonic (3).

Clinical diagnosis of tularemia is difficultto make, as symptoms are nonspecific and ofteninitially resemble influenza or other respiratorytract infections. Laboratory diagnosis is alsoproblematic. Serologic studies (including ELI-SA and agglutination assays) are the most com-monly employed diagnostic methods. Immuno-histochemical studies, fluorescent antigen tes-ting and immunoelectron microscopic examina-tion have also been used to detect Francisellatularensis (1,4,5).

Tularemia is an emerging disease in Tur-key with the outbreaks during last years (6-7).Endemic and sporadic tularemia cases were se-en predominantly in Marmara and WesternBlack Sea region and also in Zonguldak provin-ce in 2004 and 2005 (8-11).

In this study we aimed to detect the cyto-logical features of ulceroglandular tularemia ca-ses diagnosed by serological methods and to de-monstrate the role of fine needle aspiration cyto-logy in the diagnosis of tularemia.

MATERIALS and METHODS

We reviewed cytologic, histologic and cli-

nical features of six cases with a serologicallyestablished diagnosis of tularemia. In each casefine needle aspiration cytology was performedusing 23-25 Gauge needles. Also in two casesthe palpable lymph nodes were surgically exci-sed. A portion of the smears were air-dried andstained with Giemsa, while the remaining sme-ars were wet-fixed with alcohol and subsequ-ently stained by hematoxylin-eosin. In two ca-ses histochemical Ziehl-Neelsen staining foracid fast bacilli was also performed.

RESULTS

The age of our 4 female and 2 male pati-ents ranged from 16 to 64 years. All of the pati-ents presented with a soft to firm cervical mas-ses varied between 4 to 10 cm in diameter andthey were associated with fever (38-40°C), ge-neralized body aches, often prominent in the lo-wer back and sore throat. Three patients had ahistory of close relation with rodents. Serologi-cally their serum agglutinating antibodies aga-inst F. tularensis were diagnostic for tularemiaand their titers ranged between 1:320 and1:2560.

Grossly all aspirated materials were puru-lent. All smears showed an abscess-like imagewith multiple neutrophils, macrophages, necro-tic materials and also amorphous basophilic ma-terial consisted of caseification necrosis (Figure

Figure 1. Suppurative inflammation and abcess formation(HE x40).

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Fine needle aspiration cytology findings in cases diagnosed as oropharyngeal tularemia lymphadenitis

1). In three cases epithelioid histiocytes withmultinuclear giant cells were demonstrated (Fi-gure 2-3).

Paraffin sections of two cases revealed

suppurative granuloma formation with abscess-like material in the center and epithelioid cellsand some multinuclear giant cells in the perip-hery (Figure 4). These sections were stained his-tochemically, but no microorganism was detec-ted.

DISCUSSION

Fine needle aspiration cytology is the firstmethod to be performed on the superficially en-larged lymph nodes. With this technique, reacti-ve, inflammatory and neoplastic conditions oflymph nodes are correctly diagnosed in nearlyevery case. So using this cytological method,the number of the surgical excisions will be dec-reased (12-13).

In tularemia lymphadenopaty, the histo-pathological features vary with the stage of thedisease. In the very early stage, there are onlyreactive changes without necrosis. Abscess for-mation with or without epithelioid cell reactionsis observed during the second and caseous nec-rosis during the fourth week (3,5,14). Stellatenecrosis may also be seen (15).

When caseous materials with epithelioidcells are present in the fine needle aspirationmaterials, firstly tuberculosis should be conside-red in the differential diagnosis. In tuberculosislymphadenitis, when lymph nodes are seconda-rily infected, abscess formation which is almostsimilar to tularemia abscesses may appear (16-17). Also in a large number of tuberculosis ca-ses showing suppurative inflammation, acid fastbacilli were masked with excessive purulentexudate (16). However tularemia cases revealmore dense inflammation which extends beyondcapsule (18). In these instances the serologicaland clinical features will aid in establishing thecorrect diagnosis (3,15,18).

Cat-scratch disease and lymphagranulomavenerum demonstrate focal areas of necrosiswith accumulation of polimorphous nuclear leu-

Figure 3. A multinuclear giant cell with an amphophilic cyto-plasm (HE x100).

Figure 4. Epitheliod histiocytes with multinuclear giant celland a suppurative inflammation at the center (HE x100).

Figure 2. Granulomatous inflammation in the cytologicalmaterial (Giemsa’s stain x10).

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Turkish Journal of Pathology 2007;23(1):38-42

kocytes with granulomatous organization. In tu-laremia cases with stellate necrosis, the differen-tial diagnosis from cat-scratch lymphadentiswill be difficult. The identification of microor-ganism is necessary for the diagnosis. Althoughlenfogranuloma venerum has a similiar histopat-hological appearance, clinical features, predilec-tion for male gender, localization of the lesionand laboratory findings will lead to diagnosis(3,15).

Other bacterial infections such as yersinio-sis, typhoid fever, melioidosis and listeriosis cancause suppurative infections in the lymph no-des. Gram’s stain is useful in identifying thepresence and type of the bacteria. Bacteriologicstudy of smears and cultures may be indispen-sable for specific etiologic identification (15).

One of the major difficulties with interpre-tation of cytologic findings of lymph nodes isthat some suppurative lymphadenopaties maymask malignant disease. Necrosis and massiveneutrophilic infiltrate can occur spontaneouslyand be prominent findings in smears obtainedfrom patients with Hodgkin’s disease (19).

In conclusion, necrosis and massive neut-rophilic infiltrate with epithelioid histiocytesand multinuclear giant cells is a prominent fin-ding in smears obtained from patients with tula-remia. However other bacterial and fungal in-fections with granulomatous and suppurative le-sions may reveal similiar features. Therefore fi-ne needle aspiration cytology for the diagnosisof tularemia is not a useful method per se. Ho-wever this technique is a safe procedure whichdoes not require hospitalisation. It is also morecost effective and less time consuming than asurgical excision.

Moreover fine needle aspiration will pro-vide rapid diagnosis for the clinically suspectcases of tularemia and the cytological evaluati-on of the aspirate will play an important role inthe identification of other pathological entitiesresponsible for lymphadenopathy. Furthermore

the aspirate can be cultured or used for the mo-re complex investigations if required.

REFERENCES

1. Lamps LW, Havens JW, Sjostedt, Page LP, Scott MA.Histologic and molecular diagnosis of tularemia: a po-tential bioterrorism agent endemic to North America.Mod Pathol 2004;17:489-495.

2. Eliasson H, Lindback J, Nuorti JP, Arneborn M, Gie-secke J, Tegnell A. The 2000 tularemia outbreak: a ca-se-control study of risk factors in disease-endemic andemergent areas, Sweden. Emerg Infect Dis2002;8:956-960.

3. Winn WC Jr, Kissane JM. Bacterial Diseases. In:Damjanow I, Linder J (Eds.) Anderson’s Pathology. St.Louis, Missouri, Mosby-Year Book Inc; 1990. p. 806-807.

4. Dennis DT, Inglesby TV, Henderson DA, Bartlett JG,Ascher MS, Eitzen E, et al. Tularemia as a biologicalweapon medical and public health management. JA-MA 2001;285:2763-2773.

5. Johansson A, Berglund L, Eriksson U, Goransson I,Wollin R, Forsman M, et al. Comparative analysis ofPCR versus culture for diagnosis of ulceroglandular tu-laremia. J Clin Microbiol 2000;38:22-26.

6. Atmaca S, Leblebicio¤lu H, Ünal R, Tekat A, fieflen T,Koyuncu M ve ark. Samsun ve çevresinde görülen tu-laremi olgular›. KBB-Forum 2005;4:171-172.

7. Erbay A, Dokuzo¤uz B, Baykam N, Güvener E, DikerS, Y›ld›rmak T. Ankara yöresinde tularemi. ‹nfeksiyonDergisi 2000;14:453-458.

8. Gurcan S, Otkun MT, Otkun M, Arikan OK, Ozer B.An outbreak of tularemia in Western Black Sea regionof Turkey. Yonsei Med J 2004;29:17-22.

9. K›l›çturgay K, Gök›rmak F, Gediko¤lu S, Helvac› S,Töre O, Tolunay fi. Bursa'da tularemi epidemisi. ‹nfek-siyon Dergisi 1989;3:149-156.

10. Gürcan fi, Otkun Tatman M, Otkun M, Ar›kan O, ÖzerB, Gediko¤lu S. Bolu-Gerede-Yaz›kara Köyü'nde tula-remi epidemisi. ‹nfeksiyon Dergisi 2003;17:145-149.

11. Gediko¤lu S, Göral G, Helvac› S. Bursa'daki tularemiepidemisinin özellikleri. ‹nfeksiyon Dergisi 1990;4:9-15.

12. Layfield LJ, Glasgow BJ, DuPuis MH. Fine needle as-piration of lymphadenopathy of suspected infectiousetiology. Arch Pathol Lab Med 1985;109:810-812.

13. Skoog L, Tani E. Lymph nodes. In: Gray W, McKeeGT (Eds.) Diagnostic Cytopathology. Boston, Churc-hill Livingstone; 2003. p. 501-510.

14. Schricker RL, Eigelsbach HT, Mitten JQ, Hall WC.Pathogenesis of tularemia in monkeysaerogenicallyexposed to Franciella Tularensis 425. Infect Immun1972;5:734-744.

15. Ioachim HL, Ratech H (Eds.) Ioachim’s Lymph NodePathology. Philadelphia, Lippincott Williams&Wil-

41

Fine needle aspiration cytology findings in cases diagnosed as oropharyngeal tularemia lymphadenitis

kins; 2002. p. 69-236.16. Kumar N, Jain S, Murthy NS. Utility of repeat fine ne-

edle aspiration in acute suppurative lesions follow upof 263 cases. Acta Cytol 2004;48:337-340.

17. Getachew A, Tesfahunegn Z. Is fine needle aspirationa usefull toll for the diagnosis of tuberculosis lympha-denitis? East Afr Med J 1999;76:260-263.

18. Sutinen S, Syrjala H. Histopathology of human lymphnode tularemia caused by Francisella tularensis var pa-laearctica. Arch Pathol Lab Med 1986;110:42-46.

19. Vicandi B, Jimenez-Heffernan JA, Lopez-Ferrer P,Gamallo C, Viguer JM. Hodgkin’s disease mimickingsuppurative lympadenitis: a fine needle aspiration re-port of five cases. Diagn Cytopathol 1999;20:302-306.

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