Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Brief Report
2008:74:4;352-356
doi: 10.4103/0378-6323.42902
PMID: 18797056

Fine needle aspiration cytology in leprosy

PVS Prasad1 , Raj Varghese George1 , PK Kaviarasan1 , P Viswanathan2 , Rehana Tippoo2 , C Anandhi3
1 Department of Dermatology Venereology and Leprosy, Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalai Nagar-608 002, India
2 Department of Pathology, Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalai Nagar-608 002, India
3 Department of Microbiology, Rajah Muthiah Medical College and Hospital, Annamalai University, Annamalai Nagar-608 002, India

Correspondence Address:
PVS Prasad
88 AUTA Nagar, Sivapuri Post, Annamalai Nagar-608 002, Tamil Nadu
India
How to cite this article:
Prasad P, George RV, Kaviarasan P K, Viswanathan P, Tippoo R, Anandhi C. Fine needle aspiration cytology in leprosy. Indian J Dermatol Venereol Leprol 2008;74:352-356
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology

Abstract

Background: Laboratory diagnosis of leprosy by slit skin smear and skin biopsy is simple but both techniques have their own limitations. Slit skin smear is negative in paucibacillary cases whereas skin biopsy is an invasive technique. Fine needle aspiration cytology (FNAC) from skin lesions in leprosy with subsequent staining with May-Grunwald-Giemsa (MGG) stain has been found useful. Aim: To evaluate the possible role of cytology in classifying leprosy patients. Methods: Seventy-five untreated cases of leprosy attending the outpatient department were evaluated. Smears were taken from their skin lesions and stained using the MGG technique. Skin biopsy was also done from the lesions, which was compared with cytology smears. Results: A correlation of clinical features with FNAC was noticed in 87.5% of TT, 92.1% of BT, 81% of BL, and 66% of LL cases. Correlation of clinical with histopathological diagnoses revealed 12.5% specificity in TT leprosy, 55.3% in BT, 52.4% in BL and 50% in LL, and 100% in neuritic and histoid leprosy cases. Both correlations were found to be statistically significant by paired t test analysis. Thus, it was possible to distinguish the tuberculoid types by the presence of epithelioid cells and the lepromatous types by the presence of lymphocytes and foamy macrophages. Conclusion: FNAC may be used to categorize the patients into paucibacillary and multibacillary types, but is not a very sensitive tool to classify the patients across the Ridley-Jopling spectrum.
Keywords: Fine needle aspiration cytology, Hansen′s disease, Leprosy, Mycobacterium leprae, Skin biopsy

Introduction

The Ridley-Jopling (RJ) classification currently in use for classifying leprosy is based on widely acknowledged clinical, bacteriological, immunological, and histological parameters. [1],[2],[3],[4] It divides the leprosy spectrum into ′five′ clinically and histologically recognizable groups. Application of the RJ scale in the classification of leprosy helps in understanding the immunology of the patient to predict prognosis and possible complications. But, histopathological investigation is an invasive procedure and leads to a biopsy scar, which may not be cosmetically acceptable. Slit skin smear technique stained with Ziehl-Neelsen (ZN) is considered as a simple field procedure for the diagnosis of leprosy. However, its application is limited to the determination of the presence or absence of acid fast bacilli (AFB).

Fine needle aspiration cytology (FNAC) is a safe and noninvasive procedure. The first recorded utilization of this technique is available from St. Bartholomew′s hospital in the year 1833. Later, Sir James Paget widely used this technique. [5] In 1989, Ridley used ZN stain to study the nature of the exudates and to assess their cytology. [6] In 1994, Singh et al , used FNAC to diagnose a case of nodular lepromatous leprosy [7] and later used the same technique in 30 leprosy cases. [8] We undertook the present study to evaluate the possible utility of cytology in classifying lesions of leprosy on the R-J scale.

Methods

This study included all new leprosy patients attending the outpatient department of the Rajah Muthiah Medical College Hospital during a one-year period. Two independent assessors, including the investigator, confirmed the clinical diagnosis. Skin lesions were examined for their number, size, shape, margin, erythema, border, infiltration, dryness, and loss of hair and sensation. Similarly, all peripheral and cutaneous nerves were palpated for their number, size, nodularity, abscess formation, and tenderness. These findings were entered in a chart. Patients were classified according to RJ criteria into tuberculoid (TT), borderline tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL), and lepromatous (LL) types. Slit skin smears were done for all patients followed by staining using the Z-N technique by a microbiologist. Skin biopsy was performed in all patients and two pathologists reported them independently. Histological classification of leprosy was based on standard histopathological criteria defined by Ridley. [9] This involved the evaluation of cell types composing the granulomas, i.e ., epithelioid cell or macrophage, cellular infiltrate containing lymphocytes, and bacterial load in Fite′s stain.

FNAC was done from skin lesions after obtaining informed consent. The site was cleaned with alcohol and an assistant pinched the skin for 30 seconds to blanch the skin, as done in the slit skin smear technique. A 20 mL syringe was fitted with a 21-gauge needle and the assistant created negative pressure by holding back the piston with the forefinger and index finger of the right hand. The aspirated material was transferred onto glass slides. The flat surface of another slide was used to smear the material. The smears were air-dried and stained with May-Grunwald-Giemsa (MGG) stain. Cytological smears were coded and independently assessed by two pathologists who were not informed about the classification of the patients according to the R-J scale. Cytological specimens were considered adequate if there was a cellular yield of inflammatory cells. We followed the criteria laid down by Singh et al, in reporting the cytology smears after adopting a few modifications [8] given in [Table - 1]. The results were analyzed using t test.

Results

One hundred five cases out of a total of 21,850 patients who attended the outpatient department during the study period were new leprosy cases. Out of these, 75 patients, who were willing to undergo the study procedures, were selected for the study. The total number of leprosy cases comprised 0.48% of the dermatology outpatient population. Their ages were 4-72 years with a mean age of 31.2 years. Most patients belonged to the 21-40 years′ age group. There were 53 males including three male children and 22 females including three female children; the male: female ratio was 2.4:1. The shortest duration of the disease was one month in fourteen patients whereas the longest duration was ten years in a tuberculoid leprosy patient. The correlation of classification of the patients using clinical features with the FNAC findings and histopathological findings is shown in [Table - 2],[Table - 3],[Table - 4],[Table - 5].

Correlation of clinical diagnosis with features of FNAC Comparing clinical and FNAC features revealed that out of eight cases of TT leprosy, seven cases (87.5%) fulfilled the criteria while epithelioid cells were also seen in one case. Among 38 cases of BT leprosy, 32 cases (92.1%) showed epithelioid cells in addition to lymphocytes. Three cases showed predominantly epithelioid cells while the rest showed nonspecific changes.

Of the 21 cases of BL leprosy, 13 cases (81%) showed many lymphocytes and a few foamy macrophages without epithelioid cells, whereas there were predominantly foamy macrophages with a few lymphocytes in four cases. In four other patients, FNAC revealed a mixture of all cells including a few epithelioid cells. Out of six cases of LL, four cases (66%) showed foamy macrophages and a few lymphocytes [Figure - 1] and the remaining showed only a few lymphocytes.

A histoid leprosy patient showed elongated, spindle-shaped cells along with scattered lymphocytes; Fite′s stain was strongly positive. A purely neuritic leprosy patient showed scattered lymphocytes along with benign, spindle-shaped cells and adipose tissue in the FNAC from the nerve.

Correlation of clinical and histopathological featuresOn correlating FNAC with the histopathology of skin lesions, we found that out of three patients who had been histopathologically confirmed as TT, only one showed epithelioid cells but no cohesive epithelioid cell granuloma. The second patient showed a few lymphocytes and the third many lymphocytes and histiocytes. Hence, this correlation does not have any statistical significance. Among 30 BT patients, 50% showed lymphocytes and epithelioid cell transformation. The remaining showed a mixed picture. Out of 12 BL patients, ten patients showed a mixture of foamy macrophages, histiocytes, and lymphocytes. Five out of seven LL patients showed foamy macrophages with a few lymphocytes [Figure - 1].

Among the 18 patients diagnosed as having indeterminate leprosy by histopathological examination, 14 patients showed a few lymphocytes with epithelioid cells and histiocytes while a few lymphocytes and macrophages were seen in the remaining cases.

Correlations among clinical and histological diagnoses and FNAC are shown in [Table - 6], which shows a variation from 12.5-92%.

Discussion

In our study, various types of skin lesions such as macules, infiltrated papules, plaques, and nodules were observed. Out of 75 biopsies including one nerve biopsy, histological evidence of leprosy was absent in only three cases, which could be due to inadequate representation of the biopsy site.

Correlation of clinical diagnoses with FNAC examination revealed varying results contrary to expectations. We could not observe organized granulomas reported by Singh et al . [8] We did however, notice a very high correlation between clinical diagnoses and FNAC in all types of leprosy. Singh et al , [8] did not differentiate between TT and BT leprosy while we noticed organized collections of epithelioid cells in one case, which was highly consistent with BT. Correlation was also high in BL and LL types where there were scanty cellular infiltrates and more foamy macrophages. Macular lesions are common in leprosy cases in India. We also observed macules in 42.5% of our study cases, which could be responsible for the poor cellularity observed in cytology. This was also observed in the earlier study by Singh et al . [8]

Thus, it was possible to distinguish tuberculoid types by the presence of epithelioid cells and lepromatous types by the presence of lymphocytes and foamy macrophages.

Ridley [6] examined cellular exudates in slit skin smears by the Z-N technique for AFB and observed that this generated more information on the immune status of the patient than the estimation of BI and MI alone. However, Z-N staining does not provide morphological details comparable to MGG. [8]

Singh et al , opined that cytological features of LL showed negative images of M. leprae on MGG-stained smears, which were later confirmed by AFB staining, [8] but not observed in the present study. On FNAC, we could not appreciate cohesive epithelioid cell granulomas with lymphocytes in tuberculoid spectrum. Lymphocytes form a major part of smears in the borderline types of the disease. In this study also, we found the largest number of lymphocytes in BL leprosy. Fite′s stain from FNAC was also positive in one case of ′histioid′ leprosy, which should stimulate interest for future studies. Application of histological criteria to cytological smears did not give us the expected results observed by others, [8] hence, we could not agree that the diagnosis and classification of leprosy were simplified by cytology.

Correlation of clinical with histopathological diagnoses was 12.5-50% in various types of leprosy in our study but 60-80% in earlier studies. [9],[10] Niranjana Murthy et al , observed a maximum correlation in BL and LL cases, [10] whereas this was only true in BT, BL, and LL cases in our study. Eighteen cases (24%) were histologically diagnosed as indeterminate and were clinically classified into various types depending on the number and type of skin lesions, which could explain the difference in the results in our study. Recently, in a comparative evaluation of skin and nerve histopathology in single skin lesion leprosy in 27 patients, the clinicopathological correlation was found to be positive in 51.85% of skin biopsy specimens. [11]

As we have only adopted the R-J scale for classification, indeterminate cases did not form a part of our clinical classification. However, indeterminate cases were diagnosed histologically in 18 cases, out of which 14 patients showed evidence of a tuberculoid spectrum and four cases showed a lepromatous spectrum by FNAC. This finding correlated with clinical diagnoses.

From this study, we conclude that FNAC only supplements histopathological diagnosis in some cases and can not be taken as a sensitive investigation for the diagnosis of leprosy. However, it has excellent value in patients who are not willing to undergo a biopsy and also serves to classify the patients quickly into pauci- or multibacillary types while awaiting the final pathology results. FNAC is a simple, cost-effective method of investigation that is more useful in TT and LL patients.

References
1.
Jopling WH, McDougall AC. Definition, epidemiology and world distribution. In: Jopling WH, McDougall AC, editors. Handbook of Leprosy. 5 th ed. New Delhi: CBS Publishers; 1996. p. 1.
[Google Scholar]
2.
Noordeen SK. The epidemiology of leprosy. In: Hastings RC editor. Leprosy 2 nd ed. London: Churchill Livingstone; 1994. p. 29-45.
[Google Scholar]
3.
WHO Expert committee on leprosy 1988 Sixth report. Technical Report Series 768, Geneva: World Health Organization.
[Google Scholar]
4.
Ridley DS, Jopling WH. Classification of leprosy according to immunity: A five group system. Int J Lepr 1966;34:255-73.
[Google Scholar]
5.
Frable WJ. Fine-needle aspiration biopsy: A review. Hum Pathol 1983;14:9-28.
[Google Scholar]
6.
Ridley MJ. The cellular exudate: Mycobacterium leprae relationship and the critical reading of slit smears. Lepr Rev 1989;60:229-40.
[Google Scholar]
7.
Singh N, Arora VK, Ramam M. Nodular lepromatous leprosy: Report of a case diagnosed by FNA. Diagn Cytopathol 1994;11:373-5.
[Google Scholar]
8.
Singh N, Bhatia A, Gupta K, Ramam M. Cytomorphology of Leprosy across the Ridley-Jopling spectrum. Acta Cytol 1996;40:719-23.
[Google Scholar]
9.
Nayak SV, Shivarudrappa AS, Nagarajappa AH, Sacchidanand S, Ahmed SM. Role of modified rapid AFB method in histopathological sections of Hansen's disease. Indian J Dermatol Venereol Leprol 2003;69:173-4.
[Google Scholar]
10.
Moorthy BN, Kumar P, Chatura KR, Chandrasekhar, Basavaraja. Histopathological correlation of skin biopsies in leprosy. Indian J Dermatol Venereol Leprol 2001;61:299-301.
[Google Scholar]
11.
Reddy RR, Singh G, Sacchidanand S, Okade R, Shivakumar V, Uday A, et al . Indian J Dermatol Venereol Leprol 2005;71:401-5.
[Google Scholar]

Fulltext Views
344

PDF downloads
143
Show Sections