Journal of Cytology
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 Table of Contents    
IMAGES IN CYTOPATHOLOGY  
Year : 2020  |  Volume : 37  |  Issue : 3  |  Page : 147-148
Anal cytology screening: An aid to diagnose tuberculosis infection in HIV/AIDS


1 DNB Resident, Department of Internal Medicine, Sir Gangaram Hospital, New Delhi, India
2 Senior Consultant, Department of Internal Medicine, Sir Gangaram Hospital, New Delhi, India
3 Senior Consultant, Department of Cytopathology, Sir Gangaram Hospital, New Delhi, India

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Date of Submission18-Jan-2020
Date of Decision26-Feb-2020
Date of Acceptance08-May-2020
Date of Web Publication30-Jun-2020
 

How to cite this article:
Chopra S, Kakar A, Bakshi P. Anal cytology screening: An aid to diagnose tuberculosis infection in HIV/AIDS. J Cytol 2020;37:147-8

How to cite this URL:
Chopra S, Kakar A, Bakshi P. Anal cytology screening: An aid to diagnose tuberculosis infection in HIV/AIDS. J Cytol [serial online] 2020 [cited 2020 Aug 5];37:147-8. Available from: http://www.jcytol.org/text.asp?2020/37/3/147/288600





   Case Top


A 19-year-old heterosexual male, resident of Uzbekistan and a known case of human immunodeficiency virus (HIV), presented with complaints of warty lesions around penis, scrotum, and anal areas for last 2 years. There was no history of fever or any other systemic complaint. He gave history of high-risk sexual behavior. General physical and systemic examination was normal except for multiple warty lesions around anus, scrotum, and penis, pinkish in color, 3–5 mm in size, nontender, and nonindurated [Figure 1]. His recent absolute CD4 count was 509 cells/μl. He was on combination antiretroviral therapy (tenofovir, emtricitabine, and lamivudine) and isoniazid prophylaxis.
Figure 1: (a) Perianal warts (condyloma acuminate); (b) acid fast bacilli on ZN staining, 100×; (c) epitheloid cell granuloma, 400×; and (d) atypical squamous cells of undetermined significance, 200×

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As a part of evaluation, liquid-based anal cytology was done in outpatient department. Large warty lesions were excised, and smaller lesions were cauterized under local anesthesia. Anal cytology smear showed many polymorphs, necrotic debris with superficial and intermediate squamous epithelial cells. Few epithelioid cell granulomas were seen [Figure 1]. Occasional epithelial cells showed enlarged irregular nucleus with perinuclear halo, that is, low-grade squamous intraepithelial lesion. On Ziehl Neelsen (ZN) staining, acid fast bacilli were demonstrated in the anal smear [Figure 1]. Human Papilloma Virus (HPV) DNA testing was also done on same sample by hybrid capture-2 technique and was positive for high-risk strains.


   Discussion Top


Anal liquid-based cytology in patients of HIV/AIDS has been suggested by many guidelines as a standard of care to ensure early diagnosis of malignant and premalignant conditions. Despite widespread availability of Papanicolaou/ Liquid Based Cytology (LBC), it is rarely used by clinicians in this setting. In a recent review, it was suggested that incidence of anal cancer in patients living with HIV/AIDS is increasing. The risk is more in patients who have history of sex with men or those with condylomata.[1]

Anal cancer is rare to diagnose and difficult to approach with 5-year survival rate of 65.7%.[2] The incidence of anal cancer is increasing at an average rate of 2.2% per year for the last decade. Much of this increase is due to the rise of new high-risk immunocompromised populations in the last three decades, including HIV-infected patients and organ transplant recipient.

Anal canal tumors have similarity to cervical cancer as it shares high rate of HPV coinfection—particularly HPV 16 subtype with studies reporting rates over 90% in cervical cancer, while perianal tumors' HPV coinfection rate varies from 30% to 80%.[3] In select high-risk populations, HPV testing has been shown to be an important and clinically useful screening tool in conjunction with anal liquid-based cytology testing. Bethesda system used to report cervical cytology is followed in anal lesions as well.[4] Anal LBC sample is collected in the same manner as is used in conventional pap using either broom-type device or plastic spatula and endorectal brush. The sample cells are suspended in a methanol-based fixative solution. The ThinPrep processor disperses the sample to separate debris; cells are then collected onto a filter with a vacuum and transferred to a microscope slide for cytological interpretation.

Gastrointestinal tuberculosis accounts for 1% of all cases of tuberculosis, among which 1% is in anal region. Anal tuberculosis generally presents as perianal nonhealing ulcer, perianal abscess, anal fissure, perianal warts, or atypical presentations like pilonidal sinus. Diagnosis depends on the microscopic detection of acid fast bacilli using ZN staining and culture.[5]


   Conclusion Top


Although liquid-based cytology is a screening tool for ruling out malignant/premalignant lesions of anus, it can occasionally help in diagnosis of opportunistic infections. There are handful of reports on diagnosis of fungus, varicella, and protozoal infection diagnosed on liquid-based anal cytology.[6] There are handful of reports on tuberculosis detected on cervical cytology in females.[7],[8] To the best of our knowledge, this is the first report of anal tuberculosis diagnosed in men by liquid-based cytology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014;58:1-10.  Back to cited text no. 1
    
2.
Myerson RJ, Karnell LH, Menck HR. The National Cancer Data Base report on carcinoma of the anus. Cancer 1997;80:805-15.  Back to cited text no. 2
    
3.
Hillman RJ, Garland SM, Gunathilake MP, Stevens M, Kumaradevan N, Lemech C, et al. Human papillomavirus (HPV) genotypes in an Australian sample of anal cancers. Int J Cancer 2014;135:996-1001.  Back to cited text no. 3
    
4.
Darragh TM, Colgan TJ, Thomas Cox J, Heller DS, Henry MR, Luff RD, et al. The Lower Anogenital Squamous Terminology Standardization project for HPV-associated lesions: Background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol 2013;32:76-115.  Back to cited text no. 4
    
5.
Sultan S, Azria F, Bauer P, Abdelnour M, Atienza P. Anoperineal tuberculosis: Diagnostic and management considerations in seven cases. Dis Colon Rectum 2002;45:407-10.  Back to cited text no. 5
    
6.
Rodriguez Urrego P, Caplivski D, LaBombardi V, Chen H, Szporn A. Thinprep morphology of amebic cysts in anal cytology sampled: morphologic features and comparison to conventional smears. Modern Pathology 2010;23(104):456.  Back to cited text no. 6
    
7.
Seth A, Kudesia M, Gupta K, Pant L, Mathur A. Cytodiagnosis and pitfalls of genital tuberculosis: A report of two cases. J Cytol 2011;28:141-3.  Back to cited text no. 7
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8.
Samantaray S, Parida G, Rout N, Giri SK, Kar R. Cytologic detection of tuberculous cervicitis. Acta Cytol 2009;5:594-6.  Back to cited text no. 8
    

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Correspondence Address:
Dr. Atul Kakar
Medident Clinic, 31, South Patel Nagar, New Delhi - 110 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOC.JOC_167_19

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