Imprint cytology of hepatosplenic suppurative candidal granuloma complicating acute leukaemia: Three case reports

Dear Dr. Bedrossian: Infection by Candida albicans and occasionally by other species of Candida is quite often seen in patients having intensive chemotherapy for acute leukemia or malignant lymphoma. Among them, hepatosplenic candidiasis is a distinctive clinical entity. We report here, the cytological features of imprint smears from splenectomy specimens of three cases of splenic candidiasis. The patients were 17-, 22and 52-year-old Japanese females, respectively. All three cases had a history of acute promyelocytic leukemia. Under a diagnosis of hepatosplenic candidiasis, liver biopsy and splenectomy were performed, and the imprint cytology specimens were obtained in all three cases. Cytologically, all three cases showed essentially similar findings. Cytological examination of the imprint smears demonstrated numerous neutorophils, small lymphocytes, and histiocytes with or without epithelioid cell features (Fig. 1A). The background contained numerous necrotic debris (Fig. 1A). Scattered medium-to-large fragments of epithelioid cells accompanied by various neutrophlis and small lymphocytes were also observed. These epithelioid cells had ovalto spindle-shaped nuclei with abundant amphophilic cytoplasm and frequent small but conspicuous nucleoli (Fig. 1B). There were no detectable organisms in the lesion by Papanicolau and Giemsa stain. However, Periodic acid-Schiff and Grocott stain demonstrated a few candidal yeast and hyphae (Fig. 1C). Histologically, suppurative granulomas contained more number of polymorphonuclear leucocytes and deposits of fibrin in necrotic centers surrounded by a thick zone of palisaded epithelioid histiocytes, with occasional multinucleated giant cells (Fig. 1D). Small lymphocytes were seen among the epithelioid histiocytes. Histologically, direct biopsy or splenectomy specimens of splenic candidiasis demonstrated distinctive necrotizing granuloma (NG) often with Langhans’ giant cells and incorporating Candida yeasts and pseudohyphae. The cytological findings of the present three cases closely paralleled the histological findings of splenic candidiasis. Moreover, cultures are usually negative even before treatment of splenic candidiasis. Special stain using imprint cytological specimens seems to be useful for early diagnosis of splenic candidiasis. Various infectious granulomatous processes affect the spleen. Fine-needle aspiration cytology (FNAC) findings of tuberuculosis, histoplasmosis, blastomycosis, and cryptoccoccosis have been well described in the literature. Among these, smears from patients with tuberculosis rarely contained only necrotic materials and neutrophils. This cytological finding appears similar to the cytological findings of the present three cases in some aspects. However, cytological specimens of candidal NG contained fragments of epithelioid cells. In Japan, FNAC of the spleen is relatively rarely performed because of the possible association of complications of hemorrhage. However, imprint cytology is safe and simple procedure. The cytological findings obtained from imprint cytology specimens in the present three cases contributed to the cytological diagnosis of the spleen. *Correspondence to: Masaru Kojima, M.D., Ph.D., Department of Anatomic and Diagnostic Pathology, Dokkyo Medical University School of Medicine, Mibu, Japan. E-mail: mkojima@dokkyomed.ac. jp Received 3 April 2009; Accepted 21 May 2009 DOI 10.1002/dc.21131 Published online 6 July 2009 in Wiley InterScience (www. interscience.wiley.com).