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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 19  |  Issue : 2  |  Page : 141-143

Fine needle aspiration cytology of lymph node in erythema nodosum leprosum: A case report with review of literature


Department of Pathology, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India

Date of Web Publication11-Aug-2014

Correspondence Address:
Bhagyashri R Hungund
A-13/4, Jawaharlal Nehru Medical College Staff Quarters, Nehru Nagar, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.138439

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  Abstract 

The acute manifestations and subsequent complications call for early recognition and management of erythema nodosum leprosum (ENL). Its diagnosis is conventionally based on skin biopsy and slit skin smears. Fine needle aspiration cytology (FNAC) has been found to be a simple and useful tool in the diagnosis of this entity. Lymphadenopathy is a known manifestation of leprosy and its reactions. The present case is reported to underscore the importance of FNAC of lymph node in diagnosis of ENL. A 39-year-old male, known case of lepromatous leprosy on treatment, presented with fever, joint pains, raised lesions all over the body and enlarged bilateral inguinal lymph nodes. FNA of the lymph node revealed characteristic features of ENL. FNA of lymph nodes is simple, non-invasive, useful tool in early diagnosis of ENL.

Keywords: Erythema nodosum leprosum, fine needle aspiration cytology, leprosy, lymph node


How to cite this article:
Hungund BR, Dafale SR, Kangle R, Chavan RY, Pilli GS. Fine needle aspiration cytology of lymph node in erythema nodosum leprosum: A case report with review of literature. J Mahatma Gandhi Inst Med Sci 2014;19:141-3

How to cite this URL:
Hungund BR, Dafale SR, Kangle R, Chavan RY, Pilli GS. Fine needle aspiration cytology of lymph node in erythema nodosum leprosum: A case report with review of literature. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2020 Aug 8];19:141-3. Available from: http://www.jmgims.co.in/text.asp?2014/19/2/141/138439


  Introduction Top


Leprosy is a chronic infectious disease caused by Mycobacterium laprae. It presents with clinicpathological manifestations across the spectrum of tuberculoid (TT) to lepromatous (LL) leprosy. According to the Ridley and Jopling classification. TT and LL represent the polar ends of spectrum with good immunity and lesser bacillary load in earlier and poor immunity and high bacillary load in later. Borderline tuberculoid (BT), borderline borderline (BB) and borderline lepromatous (BL) represent the mid spectrum and the unstable forms. [1] Reactions of leprosy, which are manifestations of immunological phenomenon contribute to the burden of leprosy. [2] Two types of reaction are seen in leprosy. Type I reaction is seen mainly in the unstable forms with an upgrading and downgrading patterns. Type II reaction or erythema nodosum leprosum (ENL) is seen most commonly in LL and less commonly in BL. ENL usually develops following institution of chemotherapy, although it may precede the diagnosis and initiation of therapy in about 10% of cases. [3] The acute manifestations of ENL and subsequent complications due to nerve impairment call for early recognition and management of this entity. [2] Histopathology of the skin biopsy has been the gold standard in the diagnosis of ENL. Slit skin smears that have been conventionally stained with modified Zeihl-nelsen (ZN) stain has been used mainly for assessment of bacterial load and mycobacterial index. However, both of these procedures are traumatic, expensive and time consuming. [4] Fine needle aspiration cytology (FNAC) is a simple and minimally invasive procedure and has been successfully utilized in diagnosis of lymphadenopathy. Lymph node enlargement is one of the clinical manifestations of ENL and can thus be best possible and accessible site for FNA in the diagnosis of leprosy reactions.

We herein report a case of ENL which was diagnosed by FNA of lymph node to underscore the importance of FNAC, especially of lymph nodes in the diagnosis of reactions of leprosy.


  Case Report Top


A39-year-old male presented to the hospital with fever, joint pains and raised lesions all over the body of 1 week duration and inguinal pain and swelling of 3 days duration. Patient was diagnosed with LL leprosy 8 months back and was started on multidrug therapy for leprosy.

On general physical examination, the patient was febrile (Temperature = 100°C) with tender bilateral inguinal lymphadenopathy. Multiple erythematous well-defined plaques were seen on trunk extremities and face. Radial, ulnar and lateral popliteal nerves were thickened and tender. The sensations in these nerves were normal. The haematological investigations revealed neutrophilic leucocytosis.

Hence, FNA of the inguinal lymph node was performed. The smears were stained with Papaniculaou, May-grünwald-Giemsa (MGG) stain and modified ZN stain. The smears showed cellular smears with good number of foamy macrophages interspersed with reactive lymphoid cells with plenty of neutrophils in the back ground [Figure 1]. Modified ZN stained smears showed foamy histiocytes containing lepra bacilli [Figure 1]. In view of above features, a diagnosis of LL leprosy with Type II reaction (ENL) was made on cytology. The diagnosis was confirmed on histopathological examination of skin biopsy [Figure 2]. The patient was treated for Type II reaction and his symptoms improved. He was continued with his multidrug therapy for LL leprosy.
Figure 1: Fine needle aspiration cytology of lymph node showing numerous foamy macrophages and neutrophils. (Papaniculaou ×400) and Macrophages showing numerous intracellular and extracellular acid fast lepra bacilli (modified Zeihl-nelsen; ×1000)

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Figure 2: Skin biopsy showing features of erythema nodosum leprosum with thinned out epidermis, foamy macrophages and neutrophilic infiltrate amidst the macrophages (H and E ×200)

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  Discussion Top


Leprosy is one of the major health problems in India with a prevalence of 0.7/10,000 population. [5] The reactions of leprosy contributes immensely to the burden of leprosy. [2] The manifestations are largely confined to skin, peripheral nervous system and upper respiratory tract. However, it can also affect lymph nodes, spleen, liver bone marrow, eyes and testes. [3] Lymph node involvement in leprosy has been well documented with inguinal lymph node being the most common site involved. [6]

Skin biopsy and slit skin smears stained with ZN stain have conventionally been used for assessment of bacteriological and morphological index of leprosy. But these techniques have their own limitations. [7] FNAC, is a simpler and non-invasive technique. Its role has been studied in leprosy and its reactions in skin lesions and nerves. [8],[9],[10],[11]

Recently Gulati et al. reported two cases of LL leprosy diagnosed primarily on cytology emphasizing the role of FNAC in early diagnosis of leprosy. [7] Ahamad et al. studied the utility of FNAC in the diagnosis and classification of leprosy across the Ridley-Jopling spectrum based on the ratio of foamy histiocytes and epitheloid cells. They suggested that FNAC can be used as an alternative to slit skin smears and biopsy. [4] There are very few studies for cytodiagnosis of reactions of leprosy. Malik et al. suggested that criteria used in histology can be used satisfactorily to cytology smears. [9] Studies have also stressed the importance of FNA in the follow-up of leprosy. [12] Recently there have been case reports of FNA diagnosis of ENL. [13],[14] Presence of large number of neutrophils, foamy macrophages and acid fast bacilli (AFB) positivity are the criteria that are described oftenly. Suppurative aspirate, high cellular yield, lymphocytes, blood vessels, collagen and elastin, fibro fatty background, negative images of bacilli on MGG stained smears are the other findings described in the cytodiagnosis of ENL. [14] All these features have been mainly described on the FNA of skin lesions. However, diagnosis of ENL on FNA of lymph nodes is rare. Lymph node involvement is well documented in leprosy and lymphadenopathy has also been feature of Type II reaction of leprosy. [15] Cases of leprosy presenting as nodular lymph node swelling have been reported. [15],[16] The lymphadenopathy presents with clinical dilemma and the need to consider other differential diagnoses such as tuberculosis, lymphoma etc., has been realized. [15],[16] In the present case, the diagnosis of ENL was made on FNAC of inguinal lymph node with cytological features which included presence of foamy histiocytes, good number of neutrophils and AFB positivity and the diagnosis was confirmed on histopathological examination of skin biopsy.


  Conclusion Top


The present case emphasizes the role of FNA of lymph node as a simple, non-invasive, useful tool in early diagnosis of ENL. However, more studies are needed to assess the sensitivity and specificity of FNAC of lymph node in diagnosis of ENL.

 
  References Top

1.Lucas S. Bacterial disease. In: Elder D, Elenitsos R, Jaworsky C, Johnson Jr B, editors. Lever's Histopathology of the Skin. 8 th ed. New York: Lippincott-Raven; 1997. p. 457-508.  Back to cited text no. 1
    
2.Khawita I, Walker SL, Lockwood DN. Leprosy type 1 reactions and erythema nodosum leprosum. An Bras Dermatol 2008;83:75-82.  Back to cited text no. 2
    
3.Gelber RH. Leprosy (Hansen's disease). In: Braunwald E, Fauci AS, Kasper DL, Longo DL, Hauser SL, Jameson JL et al., editors. Harrison' Principles of Internal Medicine. 17 th ed. New York: McGraw-Hill; 2008. p. 1021-7.  Back to cited text no. 3
    
4.Ahamad MS, Ahmed AS, Rahman AJ. Fine needle aspiration cytology of lymph node in leprosy. Bangladesh Med Res Counc Bull 2009;35:69-70.  Back to cited text no. 4
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5.Park K, editor. Park's Text Book of Preventive and Social Medicine. 20 th ed. Jabalpur, India: Banarasidas Bhanot; 2009.  Back to cited text no. 5
    
6.Kar HK, Mohanty HC, Mohanty GN, Nayak UP. Clinico-pathological study of lymph node involvement in leprosy. Lepr India 1983;55:725-38.  Back to cited text no. 6
[PUBMED]    
7.Gulati A, Kaushik R, Kaushal V. Cytological diagnosis of lepromatous leprosy: A report of two cases with review of literature. J Cytol 2012;29:203-4.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Singh N, Bhatia A, Gupta K, Ramam M. Cytomorphology of leprosy across the Ridley-Jopling spectrum. Acta Cytol 1996;40:719-23.  Back to cited text no. 8
    
9.Malik A, Bhatia A, Singh N, Bhattacharya SN, Arora VK. Fine needle aspiration cytology of reactions in leprosy. Acta Cytol 1999;43:771-6.  Back to cited text no. 9
    
10.Nigam PK, Kumar P, Pathak N, Mittal S. Fine needle aspiration cytology in reactional and non-reactional leprosy. Indian J Dermatol Venereol Leprol 2007;73:247-9.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Vijaikumar M, D'Souza M, Kumar S, Badhe B. Fine needle aspiration cytology (FNAC) of nerves in leprosy. Lepr Rev 2001;72:171-8.  Back to cited text no. 11
    
12.Singh N, Arora VK, Bhatia A, Bhattacharya SN. A plea for routine use of fine-needle aspiration cytology in the diagnosis and followup of leprosy. Int J Lepr Other Mycobact Dis 1996;64:84-5.  Back to cited text no. 12
    
13.Anshu, Gangane N, Vagha S, Samal N. Cytodiagnosis of erythema nodosum leprosum. A case report. Acta Cytol 2002;46:386-8.  Back to cited text no. 13
    
14.Siddaraju N, Roy SK, Bundele MM, Badhe BA, Thappa DM. Fine needle aspiration cytologic diagnosis of erythema nodosum leprosum: A case report. Acta Cytol 2007;51:800-2.  Back to cited text no. 14
    
15.Kiran KU, Krishna Moorthy KV, Meher V, Rao PN. Relapse of leprosy presenting as nodular lymph node swelling. Indian J Dermatol Venereol Leprol 2009;75:177-9.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.Singh P, Mushtaq D, Bala J, Kapur K, Rana A. Lepropmatous lymphadenitis mimicking non hodgkins lymphoma: A case diagnosed by fine needle aspiration cytology. J Clin Diagn Res 2011;5:869-71.  Back to cited text no. 16
    


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