Journal of Cytology
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Year : 2010  |  Volume : 27  |  Issue : 4  |  Page : 123-126
Cytomorphological spectrum of subcutaneous and intramuscular cysticercosis: A study of 22 cases


Department of Pathology, Pt. B.D. Sharma Post Graduate University of Medical Sciences, Rohtak, Haryana, India

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Date of Web Publication27-Nov-2010
 

   Abstract 

Background: Cysticercosis is more common than usually thought. Fine needle aspiration cytology (FNAC) plays an important role in prompt recognition of this disease.
Aims: To study the role of FNAC in the diagnosis of cysticercosis.
Materials and Methods: Twenty-two patients with subcutaneous and intramuscular nodules, who were clinically diagnosed as tuberculous lymphadenitis, reactive lymphadenitis, lipoma, neurofibroma and cysticercosis were included in the present study.
Results: In nine cases, a definitive diagnosis of cysticercosis was obtained in the form of fragments of parasite bladder wall and, biopsy confirmed the diagnosis. In the rest 13 cases, larval fragments could not be identified on the aspirates and the diagnosis of parasitic inflammation was suggested on the basis of other cytomorphological findings. Follow-up biopsy confirmed the diagnosis of cysticercosis.
Conclusions: FNAC in cysticercosis is a low-cost outpatient procedure. The cytological diagnosis is quite straightforward in cases where the actual parasite structure is identified in the smears. However, in other cases, presence of eosinophils, histiocytes which may be in palisaded clusters or not, a typical granular dirty background, etc., are the features which should always alert the pathologist to this possibility.

Keywords: Cysticercosis; fine needle aspiration cytology; parasite.

How to cite this article:
Gill M, Dua S, Gill P S, Gupta V, Gupta S, Sen R. Cytomorphological spectrum of subcutaneous and intramuscular cysticercosis: A study of 22 cases. J Cytol 2010;27:123-6

How to cite this URL:
Gill M, Dua S, Gill P S, Gupta V, Gupta S, Sen R. Cytomorphological spectrum of subcutaneous and intramuscular cysticercosis: A study of 22 cases. J Cytol [serial online] 2010 [cited 2014 Dec 25];27:123-6. Available from: http://www.jcytol.org/text.asp?2010/27/4/123/73294



   Introduction Top


Human cysticercosis commonly manifests as subcutaneous and intramuscular nodules. It is endemic in America, Africa and Asia. In India, it is more common in northern parts. The common sites of involvement include brain, muscle, eye and heart. Man occasionally serving as the larval host of Taenia solium becomes infected either by drinking contaminated water or by eating uncooked vegetables infected with eggs. [1] The preoperative diagnosis of cysticercosis can be made by radio imaging [computed tomography (CT) scan and magnetic resonance imaging (MRI)] and serological tests like complement fixation test, hemagglutination, radioimmunoassay and enzyme linked immunosorbent assay (ELISA). Fine needle aspiration cytology (FNAC) is now available as a preoperative tool for the diagnosis of subcutaneous cysticercosis. The diagnosis is confirmed by the histopathological examination of the excised specimen. Apart from studying the role of FNAC in the diagnosis of subcutaneous cysticercosis, the present study was done to analyse the cytomorphology of actual parasite and to study the cytological features suggestive of cysticercosis in those cases where the actual parasite could not be demonstrated.


   Materials and Methods Top


FNAC is an outpatient procedure in our hospital. More than 8000 FNACs of all foci are performed every year. This study included 22 patients presenting with palpable subcutaneous and intramuscular nodules at different sites. FNAC was performed with 22-gauge needle. Aspirated material was smeared on the glass slides and stained with Papanicolaou stain after fixation in 95% alcohol and with May-Grόnwald-Giemsa stain after air drying. Subsequent excision biopsy was also evaluated. The sections were reviewed and findings were correlated with the cytological findings.


   Results Top


The study included 22 patients in the age group 3-52 years. Nine patients in the present study were females and 13 were males. The mean age at diagnosis was 22.73 years. Eight cases presented with neck swelling, 7 with arm swelling, 3 with abdominal wall swelling, 2 with swelling axilla, one with swelling cheek and one with swelling breast. The clinical features of all patients are tabulated [Table 1]. All the patients presented with painless slow growing nodule, soft to firm in consistency, and the provisional diagnoses were lipoma, neurofibroma, tuberculous lymphadenopathy and cysticercosis. In seven cases, the aspiration yielded clear fluid and the rest of the cases yielded purulent fluid. All aspirations were performed without complications.
Table 1 :Clinical and cytological features in 22 cases included in the present study

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In nine cases on FNAC, actual parasite structures were demonstrable in the smears although the cytomorphology was not exactly the same in all cases [Figure 1],[Figure 2],[Figure 3],[Figure 4]. None of these cases showed the presence of hooklets. Follow-up biopsy confirmed the diagnosis. In the rest 13 cases, the cytological findings were very much suggestive of a parasitic cyst; however, no parasite could be seen. The smears showed a mixed inflammatory infiltrate comprising neutrophils, lymphocytes, eosinophils, histiocytes and giant cells (in varying proportions in different cases). In 5 of these 13 cases, well-formed epithelioid cell granulomas were also evident. These cases were subjected to Ziehl Neelson staining which was noncontributory in all. No actual parasite structure could be demonstrated in any of these cases. A cytological diagnosis of parasitic cyst was suggested and excision was advised. Follow-up biopsy confirmed the diagnosis of cysticercosis.
Figure 1 :Photomicrograph showing wall of cysticercosis cellulosae (a and b) (Giemsa, ×100), (c-f) higher magnification (Giemsa, ×400)

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Figure 2 :Wall of cysticercus with surrounding acute inflammatory cells (Giemsa, ×400)

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Figure 3 :Photomicrograph showing epithelioid cell granulomas (Giemsa, ×400)

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Figure 4 :Photomicrograph of tissue section showing cysticercus larva enclosed in a thin fibrous cyst wall (H and E, ×100)

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   Discussion Top


Human cysticercosis is the larval infestation of the cestode T. solium. The cysticercus can be found in any organ, but is especially common in skeletal muscle, subcutaneous tissue, eyes and the central nervous system. Fully developed cysticerci are opalescent, milky white cysts, elongated to oval and about 1 cm in diameter. The cyst contains fluid and a single invaginated scolex. The scolex has a rostellum, four suckers and 22-32 small hooklets. The cyst wall is multilayered, 100-200 mm thick and covered by microvilli. The outer, cuticular layer appears smooth and hyalinized and is frequently raised in projections. [2] Beneath the tegument is a row of tegumental cells. The inner layer or parenchyma is loose and reticular, containing mesenchymal cells and calcerous corpuscles. [3] The calcareous corpuscles are a unique feature of cestode tissue. These spherical, noncellular masses occur in the parenchyma and are especially prominent in larval cestodes. The corpuscles take on a bluish purple color in hematoxylin and eosin (H and E). [4]

Cyticerci nodules in the skin are difficult to differentiate from benign mesenchymal tumors and lymphadenitis on clinical grounds alone. [5] The cytomorphological identification of larvae in FNAC smears by different workers has widened the diagnostic utility of FNAC in skin nodules. [2],[5],[6] Suspicion about a parasitic lesion starts with the presence of eosinophils, neutrophils, palisading histiocytes and giant cells in an aspirate from subcutaneous nodule. The diagnosis of cysticercus is made when fragments of larval cuticle and parenchyma are identified. The presence of scolex in cytology smears is an uncommon finding. [6],[7],[8] No scolex was seen in any of our aspirates.

Viable cysticerci may not cause any inflammatory response. However, when they degenerate, there is an infiltration of inflammatory cells, associated with the development of foreign body granulomas. The viable cyst and the necrotic and calcified lesions all have distinctive cytomorphological patterns. The viable cyst yields clear fluid and shows fragments of bladder wall in a clear acellular background. Aspirates of necrotic lesions may contain fragments of bladder wall, including calcareous corpuscles and detached single hooklets. [9]

FNAC in cysticercosis is a low-cost outpatient procedure. It is one of the tools for preoperative diagnosis and may even obviate the need for open biopsy. [ 10] The cytological diagnosis is quite straightforward in cases where actual parasite structure is identified in the smears. However, in other cases, the presence of eosinophils, histiocytes which may be in palisaded clusters or not, a typical granular dirty background, etc., are the features which should always alert the pathologist to this possibility. Nonetheless, in still some cases of cysticercosis, none of these features may be present, and the inflammatory infiltrate may also be variable. Cysticercosis is more common than usually thought. In all inflammatory/cystic/inflammatory cystic lesions, the possibility of cysticercosis should be kept in mind.

 
   References Top

1.Chatterji KD. Parasitology protozoology and helminthology in relation to clinical medicine. 12th ed. Calcutta: Chatterjee Medical Publishers; 1980. p. 116-32.  Back to cited text no. 1
    
2.Vuong PN. Fine needle aspiration cytology of subcutaneous cysticercosis of the breast. Case report and pathogenic discussion. Acta Cytol 1989;33:659-62.   Back to cited text no. 2
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3.Kamal MM, Grover SV. Cytomorphology of subcutaneous cysticercosis. A report of 10 cases. Acta Cytol 1995;39:809-12.  Back to cited text no. 3
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4.Ash LR, Orihel TC. Larval cestode parasite in humans. Atlas of human parasitology. 3 rd ed Chicago: IL: American Society of Clinical Pathologists 1990. p. 236-7.  Back to cited text no. 4
    
5.Kung IT, Lee D, Yu HC. Soft tissue cysticercosis diagnosis by fine-needle aspiration. Am J Clin Pathol 1989;92:834-5.  Back to cited text no. 5
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6.Verma K, Kapila K. Fine needle aspiration diagnosis of cysticercosis in soft tissue swellings. Acta Cytol 1989;33:663-6.  Back to cited text no. 6
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7.Kumar ND, Misra K. Fine-needle aspiration cytology of subcutaneous cysticercosis. Diagn Cytopathol 1991;7:223-4.  Back to cited text no. 7
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8.Rajwanshi A, Radhika S, Das A, Jayaram N, Banerjee CK. Fine-needle aspiration cytology in the diagnosis of cysticercosis presenting as palpable nodules. Diagn Cytopathol 1991;7:517-9.  Back to cited text no. 8
[PUBMED]    
9.Handa U, Garg S, Mohan H. Fine needle aspiration in the diagnosis of subcutaneous cysticercosis. Diagn Cytopathol 2008;36:183-7.  Back to cited text no. 9
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10.Adhikari RC, Aryal G, Jha A, Pant AD, Sayami G. Diagnosis of subcutaneous cysticercosis in fine needle aspirates: a study of 10 cases. Nepal Med Coll J 2007;9:234-8.  Back to cited text no. 10
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Correspondence Address:
Shivani Dua
House No. 636, Sector 14, Rohtak, Haryana
India
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DOI: 10.4103/0970-9371.73294

PMID: 21157562

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    Figures

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    Tables

  [Table 1]

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