Journal of Cytology
Home About us Ahead of print Instructions Submission Subscribe Advertise Contact e-Alerts Login 
Users Online:1312
  Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
 Table of Contents    
IMAGES IN CYTOPATHOLOGY  
Year : 2020  |  Volume : 37  |  Issue : 2  |  Page : 110-111
Fine-needle aspiration of malakoplakia presenting as a peri-rectal mass after intestinal transplant


Department of Pathology and Laboratory Medicine, Medstar Georgetown University Hospital, Washington DC, USA

Click here for correspondence address and email

Date of Submission08-Nov-2019
Date of Decision24-Jan-2020
Date of Acceptance27-Feb-2020
Date of Web Publication02-Apr-2020
 

How to cite this article:
Dimopoulos YP, Zeck J, Kallakury B. Fine-needle aspiration of malakoplakia presenting as a peri-rectal mass after intestinal transplant. J Cytol 2020;37:110-1

How to cite this URL:
Dimopoulos YP, Zeck J, Kallakury B. Fine-needle aspiration of malakoplakia presenting as a peri-rectal mass after intestinal transplant. J Cytol [serial online] 2020 [cited 2020 May 28];37:110-1. Available from: http://www.jcytol.org/text.asp?2020/37/2/110/281789




This case highlights the potential risk factors associated with the development of malakoplakia and demonstrates the important role of fine-needle aspiration (FNA), which can lead to rapid diagnosis and exclusion of more serious entities.

A male patient in his thirties developed short gut syndrome secondary to operations to treat bowel perforation injuries. The patient underwent a small and large bowel transplant and was subsequently treated with immune suppressors. His course was complicated by three episodes of acute rejection and a septate fluid collection surrounding the rectum. Drainage of the fluid was performed and  Escherichia More Details coli was isolated; in addition, blood cultures at the time isolated Klebsiella oxytoca. A PET/CT scan revealed fluorodeoxyglucose (FDG) avid lymphadenopathy in the mesentery and increased FDG uptake in what was thought to be a peri-rectal “mass.” In addition, the patient was found to have a positive quantitative EBV blood test. The decision to perform an endoscopic FNA of the peri-rectal “mass” was made. The endoscope was introduced through the anus and advanced to the rectum, where a clean based ulcer with an underlying prominent bulge was noted. On endoscopic ultrasound, a 32.1 mm in greatest dimension hypoechoic lesion in the perirectal space was visualized, corresponding to the region of the ulcer and bulge seen on endoscopy. Two passes with a 22-gauge needle were performed, and the material was subsequently placed in alcohol fixative.

The FNA material was received at the cytology laboratory in alcohol fixative, from which one Papanicolaou (PAP) stained monolayer smear and a cell block were prepared. Sections of the cell block were stained with Hematoxylin and Eosin (H and E), PAS (with and without diastase), Von-Kossa, Prussian blue, AFB, and GMS stains.

On the  Pap smear More Details, multiple macrophages with abundant granular cytoplasm were present. Some of the macrophages contained pathognomonic Michaelis–Gutmann (M-G) bodies, with many of these bodies additionally identified in the extracellular space [Figure 1]a. H and E stains of cell block sections revealed similar findings [Figure 1]b. On special stains, the M-G bodies were positive with Von-Kossa and PAS-diastase resistant [Figure 1]c and negative for iron. AFB and GMS stains for microorganisms were negative. Taken together, these results supported the diagnosis of malakoplakia.
Figure 1: (a) Pap stain of alcohol-fixed FNA aspirate (original magnification of 40×) with multiple macrophages and M-G bodies (red arrows). (b) Corresponding cell block preparation (original magnification of 40×) (M-G bodies, green arrows). (c) Special stains of the cell block material (original magnification of 40×), showing the characteristic staining pattern of the M-G bodies, including PAS positivity (left, yellow arrows) and Von-Kossa positivity (right, blue arrows)

Click here to view


Malakoplakia is a chronic granulomatous disease of unknown etiology, involving macrophage lysosomal-bactericidal defects in the context of bacterial infection or immune suppression.[1] The urinary bladder, kidney, and colon are the organs most commonly involved.[1],[2] Tissues involved by malakoplakia reveal macrophages with abundant cytoplasm containing the pathognomonic M-G bodies, concentrically layered basophilic inclusions, likely representing partially digested bacterial cell wall products in the phagolysosomes of macrophages.[1]

Organ transplant patients exhibit many risk factors for developing malakoplakia. Most reports concerning transplant patients have occurred in the context of renal transplant, with fewer reports implicating liver and heart transplant.[3],[4] Our patient was on a variety of immunosuppressive medications for rejection prophylaxis of an intestinal transplant. A peri-rectal abscess containing Escherichia coli and bacteremia with Klebsiella oxytoca was also demonstrated, both of which species have been associated with developing Malakoplakia. Although these risk factors for malakoplakia were known, this unusual disease was not considered in the original differential diagnosis.

Several other important differential diagnoses were considered at the time of FNA of the rectal “mass.” Post-transplant lymphoproliferative disorder was a serious consideration, supported by the finding FDG avidity on PET/CT and a positive quantitative blood test for EBV. Another important consideration for the “mass” was neoplasia. Infection with mycobacterial and fungal species can lead to granulomatous inflammation with abundant histiocytes and can complicate immunocompromised states.

FNA cytology in the evaluation of our patient revealed abundant macrophages containing M-G bodies with special stain characteristics in concordance to what has been described in the literature.[5] Negative GMS and AFB stains confirmed the absence of demonstrable fungal and acid-fast organisms. Taken altogether, these findings lead to the diagnosis of malakoplakia.

FNA-based diagnosis of malakoplakia is unusual but has been previously described.[5],[6] The rapidity and the relative ease of access to samples compared with biopsies make FNA an attractive initial approach for lesions in patients with specific risk factors. Given that malakoplakia is an unusual and challenging diagnosis to make clinically and a broad differential diagnosis must be entertained, cytology can prove helpful, especially in avoiding diagnostic pitfalls. In addition, our patient highlights the multiple risk factors for developing malakoplakia associated with bowel transplant patients. To our knowledge, this is the first report of malakoplakia in an intestinal transplant patient.

Ethical Approval

Not applicable. Per the MedStar Office of Research integrity, case reports including 3 or fewer individuals do not meet the U.S. Department of Health and Human Services (DHHS) definition of research and therefore do not require Institutional Review Board (IRB) review but are still subject to Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. No Protected Health Information (PHI) was disclosed during the preparation of the case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kohl SK, Hans CP. Cutaneous malakoplakia. Arch Pathol Lab Med 2008;132:113-7.  Back to cited text no. 1
    
2.
Karasavvidou F, Potamianos SP, Barbanis S, Stathakis E, Psychos A, Kapsoritakis AN, et al. Malakoplakia of the colon associated with colonic adenocarcinoma diagnosed in colonic biopsies. World J Gastroenterol 2007;13:6109-11.  Back to cited text no. 2
    
3.
Kamishima T, Ito K, Awaya H, Mitchell DG. MR imaging of bilateral renal malacoplakia after liver transplantation. AJR Am J Roentgenol 2000;175:919-20.  Back to cited text no. 3
    
4.
Elkeeb D, Hopkins Z, Wada D, Rhoads JLW. A case of primary cutaneous malakoplakia in a cardiac transplant recipient. JAAD Case Rep 2018;4:982-4.  Back to cited text no. 4
    
5.
Merritt AJ, Thiryayi SA, Rana DN. Malakoplakia diagnosed by fine needle aspiration (FNA) and liquid-based cytology (LBC) presenting as a pararenal mass in a transplant kidney. Cytopathology 2014;25:276-7.  Back to cited text no. 5
    
6.
Srivastava R, Aggarwal S, Arora VK. Cutaneous malakoplakia: Diagnosed cytologically. Indian J Pathol Microbiol 2012;55:257-8.  Back to cited text no. 6
  [Full text]  

Top
Correspondence Address:
Dr. Jay Zeck
Department of Pathology and Laboratory Medicine, Medstar Georgetown University Hospital, 3900 Reservoir Road NW, Washington - 20007, DC
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOC.JOC_141_19

Rights and Permissions


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed153    
    Printed21    
    Emailed0    
    PDF Downloaded30    
    Comments [Add]    

Recommend this journal