Well-differentiated Lymphocytes Research Articles

Chronic Lymphocytic Leukemia in a Cockatiel (Nymphicus hollandicus).

A 24-year-old, female cockatiel (Nymphicus hollandicus) was diagnosed and treated for chronic lymphocytic leukemia. Diagnosis was based on a persistent lymphocytosis, with counts increasing 10 times from reference intervals with a high percentage of well-differentiated lymphocytes in the bone marrow. Immunohistochemical staining confirmed neoplastic cells of T-cell origin. Specific treatment for the disease was initially withheld but commenced based on an increasing lymphocytosis and decreasing packed cell volume. Therapeutic management of the cockatiel's chronic lymphocytic leukemia was based on human protocols. Treatment with chlorambucil stabilized the disease but did not result in a significant regression of the neoplasm. The bird was euthanatized 15 months after the initial diagnosis and 8 months after treatment commenced. On the postmortem examination, extensive T-cell lymphocytic infiltration was found throughout the internal organs.

Pediatric Case of Primary Cutaneous Eosinophil-Rich CD30+ Anaplastic Large-Cell Lymphoma With Follicular Mucinosis

We report a pediatric case of primary cutaneous CD30 anaplastic large-cell lymphoma showing a combination of rare histopathologic features. The patient was a 14-year-old boy who had a solitary 2 × 1-cm ulcerated nodule with purulent discharge and undermined borders located in the right preauricular area that had been present for 3 weeks. Histopathologically, there was a dense, nonepidermotropic multinodular to diffuse infiltrate involving the reticular dermis and, focally, the subcutis. The infiltrate was composed of numerous eosinophils, neutrophils, small well-differentiated lymphocytes, and large pleomorphic and anaplastic cells. Eosinophils dominated the infiltrate. Focally, the infiltrate was accentuated around hair follicles, many of which manifested features of follicular mucinosis and/or collections of neutrophils in the follicular epithelium. Occasional hair follicles were partly destroyed by the infiltrate. A conspicuous feature was a prominent myxoid change in the stroma surrounding the hair follicles and eccrine glands. Immunohistochemically, the large lymphoid cells expressed CD2, CD3, CD4, and CD30.

Benign reactive lymphoid hyperplasia affecting both the conjunctiva and the cornea

Dear Editor, Benign reactive lymphoid hyperplasia (BRLH), though rare, may be found in the conjunctiva. However, it has not been reported to involve the cornea. We describe a case of BRLH affecting both the conjunctiva and the cornea bilaterally. A 50-year-old woman with hand movements visual acuity over 2 years presented with bilateral corneal opacities (Fig. 1a and b). The dense white stromal opacities were avascular, and had fluffy edges sparing the superotemporal cornea. The corneal surfaces were smooth, and did not stain with fluorescein. She also had a diffuse pink fleshy mass in the bulbar conjunctiva bilaterally, except for the superior portions covered by the upper eyelids. Intraocular pressure measured 30 and 29 mmHg in the right and left eyes respectively. Optical coherence tomography confirmed that the lesion was confined within the inferior corneal stroma (Fig. 1c and d). Conjunctival biopsy showed a diffuse infiltrate of smallsized, well-differentiated lymphocytes with occasional tangible-body macrophages (Fig. 1e). Immunohistochemically, these cells were positive for CD20, CD79a, BCL2, CD3 and CD5 and negative for CD10, CD23 and Cyclin D1. Staining for both κ and 1 light-chains were positive. Systemic investigations did not reveal evidence of infection or lymphoproliferative disorders. The patient underwent a left penetrating keratoplasty (PK), and the corneal button showed deep stromal infiltration of mature lymphoid cells forming follicles with germinal centres (Fig. 1f). Immunohistochemistry demonstrated positive CD20, CD79a and some T-cell subsets, while BCL2 immunostaining pattern does not show neoplastic proliferation. There were no light-chain restrictions. Post-operative visual acuity was 6/18, and she elected not to undergo PK for the fellow eye (Fig. 2). No recurrence was noted during the 1-year follow-up period. The corneal stroma is a transparent tissue composed mainly of collagen fibrils and some interspersed population of heterogeneous bone marrow-derived cells [1]. Some reports have shown the normal cornea to contain Tlymphocytes, mainly at the vascularised limbic area and occasionally at the centre, but only confined to the superficial cellular layer [2, 3]. One case series also reported the presence of B-lymphocytes in the superficial epithelial layers and upper third of the fibrous stroma [4]. However, the presence of lymphocytes within the central corneal stroma has not been described. Our patient presented with proliferation of lymphocytes, showing similar immunohistological features in the conjunctiva and the cornea. The presence of lymphoid follicles with germinal centres and a mixture of mature, polyclonal Band T-lymphocytes favour the diagnosis of BRLH rather than lymphoma. As the pattern of distribution was similar in the cornea and the conjunctiva, but sparing the unexposed superior subtarsal area, sun exposure might have been a contributing factor in this infiltration. This paper has not been presented in any conferences.

Long-term Treatment of Chronic Lymphocytic Leukemia in a Green-winged Macaw (Ara chloroptera)

A 32-year-old green-winged macaw (Ara chloroptera) was diagnosed with chronic lymphocytic leukemia based on progressive lymphocytosis and the presence of a monomorphic population of well-differentiated lymphocytes in the bone marrow of a clinically normal bird. Chemotherapy was initiated because of rapidly increasing peripheral lymphocyte counts. In addition to oral prednisone (1 mg/kg once daily), oral chlorambucil (1 mg/kg twice weekly) was initiated but was discontinued after 6 weeks because of thrombocytopenia. The leukocyte count was stabilized for 29 weeks with the concurrent use of oral cyclophosphamide (5 mg/kg 4 d/wk) and daily prednisone, and the bird exhibited a good quality of life. The bird died shortly after the chemotherapy was inadvertently discontinued. The neoplastic cells from this macaw stained positive for CD-3 antibody and negative for Bla.36, suggesting the leukemia was of T-cell origin. This is the first report of long-term treatment of a macaw with cyclophosphamide and documents thrombocytopenia in a macaw secondary to chlorambucil treatment.

Diagnosis and Treatment of Chronic T-Lymphocytic Leukemia in a Green Tree Monitor (Varanus prasinus)

A 13-year-old male green tree monitor (Varanus prasinus) presented with lethargy and chronic weight loss. Complete blood count (CBC) revealed marked leukocytosis (total leukocyte count = 278.1 × 103/μl) and peripheral blood films were characterized by marked lymphocytosis comprised of small, well-differentiated lymphocytes. Bone marrow aspiration revealed increased cellularity with a predominance of well-differentiated lymphocytes. Using immunocytochemistry, neoplastic lymphocytes in peripheral blood films were positive for CD3 epsilon and negative for CD79a and BLA.36, consistent with T-cell chronic lymphocytic leukemia (CLL). Distal tail necrosis was noted 17 days post-presentation and treated with partial caudectomy. Treatment was initiated for CLL with 0.8 mg/kg prednisone q 48 h 22 days post-presentation. CBC on days 94 to 151 post-presentation showed marked reduction in leukocytosis (counts remaining below 40.0 × 103/μL). The animal displayed improvement in activity, appetite, and gained weight during the initial treatment period. Marked leukocytosis (253.4 × 103/μL) returned on day 203 post-presentation, and on day 206 post-presentation the monitor received 0.08 mg/kg chlorambucil PO once in addition to ongoing prednisone administration. The animal died 210 days post-presentation. Histopathologic examination revealed neoplastic lymphocyte infiltration in the bone marrow at multiple sites as well as in liver, spleen, gall bladder, pancreas, kidneys, esophagus, and the oral cavity. Lymphocyte infiltration in multiple organs was primarily associated with areas of dense lymphocytic infiltrates surrounding blood vessels. This report describes the first published attempt of CLL treatment in a saurian species.

Follicular lymphoid hyperplasia of the palate: Case report and literature review

Follicular lymphoid hyperplasia (FLH) of the palate is a very rare benign, proliferative process, with only 20 cases published so far in the English language literature. We describe a case, in a 55-year-old Caucasian female, who developed a swelling in the left posterior hard palate. Bony involvement was absent. Importantly, the medical history was positive for a previous non-Hodgkin lymphoma. Following incisional biopsy, histological examination revealed a vaguely nodular lymphoid proliferation composed of small well-differentiated lymphocytes. The lymphoid follicles were positive for CD20, CD79a, CD10, CD21 and BCL6, while negative for BCL2. The parafollicular areas revealed positivity for CD3, CD5, CD30, and CD15. Both areas were CD45 positive. Subsequent immunoglobulin heavy chain gene rearrangement analysis revealed a polyclonal lesion. No further treatment was instituted, and the patient is currently being followed-up every three months. This report demonstrates that FLHs are especially important due to their clinical and, occasionally, microscopic resemblance to follicular lymphomas. Morphologic and immunohistochemical analyses and molecular studies are essential to achieve accurate diagnosis and to implement appropriate management.

Evaluation of Fractional Analysis of Bronchoalveolar Lavage Combined with Cellular Morphological Features

The value of bronchoalveolar lavage (BAL) still remains controversial, prompting a need for further improvement. The purpose of this study was to develop and evaluate a sequential analysis of cell content in fractional BAL (FBAL) from the airways and alveolar sacs with incorporation of the cellular morphologic features. Initially, 30 ml saline was infused into a subsegmental lobe of the lung and the recovered fluid was assigned as FBAL-I being mainly originated from whole airways. The second and third lavages (FBAL-II and FBAL-III) each were performed using 50 ml saline being from more distal portions of airways and alveolar sacs respectively in the same lobe. Total cell number/ml and percentages of macrophages, lymphocytes, neutrophils, and eosinophils in each fraction together with their morphological alterations and mast cells, basophils and Masson bodies were assessed. In the 12 controls, percentage of neutrophils was high and lymphocytes and macrophages were low in FBAL-I while in FBAL-III, neutrophils decreased to nearly nil and lymphocytes and macrophages were increased. Analysis of FBAL from 76 patients with sarcoidosis and 14 with hypersensitivity pneumonitis (HP) revealed that a predominance of small, round and well-differentiated lymphocytes with relative absence of neutrophils, basophils and Masson bodies correlated best with sarcoidosis. In contrast, neutrophil predominance and presence of lymphocytes having deep nuclear indentations and abundant cytoplasm with a process resembling a "hand-mirror" correlated well with HP. Evaluation of FBAL together with cellular morphological features especially characteristics of lymphocytes provides valuable information for establishing the diagnosis in interstitial lung diseases.

Lymphoepithelioma-Like Carcinoma of the Bartholin Gland

The authors report a case of lymphoepithelioma-like carcinoma originating in the Bartholin's gland in a 52-year-old woman. The tumor showed distinct morphologic features including variably sized and shaped nodules and syncytial sheets of large epithelial cells that contained large round nuclei with vesicular chromatin and prominent nucleoli and that were permeated and surrounded by small, well-differentiated lymphocytes and plasma cells. Focally, the neoplastic nodules blended with residual acini of the Bartholin gland. In the transitional areas, there were few acini that evidenced squamous cell metaplasia with partial or complete replacement of mucinous cells by squamous epithelium that showed dysplastic changes. In addition, some ducts in the transitional areas manifested lymphocyte infiltration of their walls. The uninvolved residuum of the Bartholin gland was unremarkable except for a few ruptured ducts or acini with extravasated stromal mucin. Immunohistochemically, the tumor cells were positive for p16, as were acini with metaplastic and dysplastic changes. Neither Epstein-Barr virus nor human papillomavirus was identified in the lesional tissue by polymerase chain reaction. This seems to be the first full-documented report of lymphoepithelioma-like carcinoma originating in the Bartholin gland.

Hyperplasia of Hair Follicles and Other Adnexal Structures in Cutaneous Lymphoproliferative Disorders

We studied 53 cutaneous lymphoproliferative disorders, all of which manifested hair follicle hyperplasia. There were 42 cases conforming to the description of pseudolymphomatous folliculitis (PLF) and 11 cases of authentic lymphomas including mycosis fungoides, CD30+ anaplastic large cell lymphoma, diffuse large B-cell lymphoma, B-cell small cell lymphoma/leukemia, and peripheral T-cell lymphoma, not otherwise specified. All patients with PLF clinically presented with a solitary nodule preferentially involving the face. Beside hair follicle hyperplasia, the typical features were a dense infiltrate of small well-differentiated lymphocytes, lymphoplasmacytoid cells, plasma cells, and epithelioid histiocytes forming tiny granulomas. Some unusual or worrisome features recognized included eccrine/apocrine duct hyperplasia, subcutis/muscle infiltration, lymphocyte "smudging," single file infiltration, and large atypical cells. Immunohistochemically, T-cell predominant cases dominated in the series. All 34 tested cases revealed a polyclonal pattern of kappa and lambda immunoglobulin (Ig) light chain expression. In 4 cases, scattered CD30+ cells were identified. Monoclonal rearrangements of T-cell receptor (TCR) and IgH genes were detected in 19 and 3 cases respectively, including 1 case with dual T-cell receptor/IgH rearrangement. Three of 30 tested cases proved positive for herpes simplex virus-1, whereas herpes simplex virus-2 always tested negative. Of 31 cases tested for Borrelia burgdorferi, 30 specimens were negative. In 9 cases, fluorescent in situ hybridization for t(11;18) and t(14;18) revealed none of the above translocations. The most common treatment modality was surgical removal. Forty patients with a mean follow-up of 3.7 years included 39 patients with no evidence of disease and 1 individual with local recurrence. The comparison of "clonal cases of PLF" and those with polyclonal population or in which clonality remained undetermined revealed no differences between the 2 groups in the clinical presentation, pathologic, and immunohistochemical features. We conclude that hyperplasia of hair follicles and other adnexa can be seen not only in the condition currently known as PLF, but also in genuine cutaneous lymphomas and may be just a happenstance secondary to a basic pathologic process.

Atypical lymphocytic lobular panniculitis: a clonal subcutaneous T‐cell dyscrasia

Atypical lymphocytic lobular panniculitis (ALLP) is a recently described entity characterized by waxing and waning plaques. A morphologic and biologic continuum with subcutaneous panniculitis-like T-cell lymphoma has been suggested. Between 2003 and 2007, we encountered five patients with ALLP. Comprehensive phenotypic and molecular studies were performed using multiplex polymerase chain reaction. The patient population comprised four women, one man and two boys, age range of 6-42 years. All patients had a similar clinical presentation, being one of the recurrent infiltrative plaque-like lesions. All cases showed a permeation of the interstitial spaces of the subcutis by well-differentiated lymphocytes unaccompanied by significant fat necrosis. Molecular studies showed a clonal and/or oligoclonal profile in all cases. In all cases in which multiple biopsies were obtained, there was preservation of the identical T-cell clonotypes at different biopsy sites and over time. No patient progressed to lymphoma. One patient achieved remission with isotrentinoin. ALLP represents a form of cutaneous lymphoid dyscrasia given the relatively self-limited nature of the eruption, albeit in the context of clinical recurrence.

Absence of Epstein-Barr Virus, Human Papillomavirus, and Simian Virus 40 in Patients of Central European Origin With Lymphoepithelioma-like Carcinoma of the Skin

The authors report 10 cases of lymphoepithelioma-like carcinoma (LELC) of the skin and the results of a molecular biological study for HPV, EBV, and SV40 in lesional tissues. All patients originated from Central Europe. There were seven men and three women, ranging in age from 57 to 86 years. Locations included the face (n = 4), scalp (n = 2), penis (n = 2), and retroauricular area (n = 1); location was unknown for one subject. All but two patients presented with a tumor confined to the skin; in both patients with the penile carcinoma, the tumors had metastasized to an inguinal lymph node. Six patients with available follow-up included four individuals with no evidence of tumor metastasis or recurrences at 2, 3, 4, and 5 years, one patient who died with metastatic disease 7 years after diagnosis, and one patient who died of an unrelated course. Microscopically, all cases showed distinctive features of LELC characterized by variably sized and shaped nodules or syncytial sheets of epithelial cells that contained vesicular chromatic and prominent nucleoli and that were permeated and surrounded by small, well-differentiated lymphocytes and plasma cells. Because all 10 cases studied proved negative for EBV, HPV, and SV40, these viruses seem to play no causal role in LELC of the skin in patients from Central Europe.

Primary Cutaneous Lymphoproliferative Disorders With Dual Lineage Rearrangement

We present a series of 15 cases of cutaneous lymphoma and pseudolymphoma with dual lineage rearrangement identified among approximately 1200 cases of cutaneous lymphoproliferative disorders assessed in our 4 institutions during the last 8 years in which the results of both T-cell receptor and immunoglobulin heavy chain rearrangement investigations were available. On the basis of the clinicopathologic information, the cases were retrospectively subdivided into 2 categories: (1) cases with definite features of cutaneous lymphoma or pseudolymphoma (n = 11) and (2) cases with unclassifiable disease (n = 4). The detection of dual genotype in the first group did not influence the final diagnosis; 7 cases represented cutaneous B-cell lymphomas, 3 pseudolymphomas, and 1 case lymphomatoid papulosis. The presence of monoclonal T-cell receptor-gene rearrangements in these cases may be explained either by monoclonal or oligoclonal expansion of exuberant T cells (or B cells in case of lymphomatoid papulosis) or by lineage infidelity. Three patients with unclassifiable disease had several clinical and histopathologic features in common. They were elderly, presented with solitary lesions, were in good general health and histopathologically demonstrated a dense multinodular infiltrate containing approximately an equal number of T and B cells and a high number of histiocytes forming granulomas, with prominent granulomatous features in 2 cases. B cells were either scattered with the infiltrate or formed collections vaguely resembling follicles; Reed-Sternberg-like cells were seen in 2 cases. B cells showed expression neither of immunoglobulin light chain. The T-cell component was represented mainly by small, well-differentiated lymphocytes or slightly pleomorphic cells, with some medium-sized convoluted cells. Epstein-Barr virus was not detected by polymerase chain reaction. The exact classification of these cases is unknown; they differ histopathologically from previously published cases of bigenotypic cutaneous lymphomas. They may merely represent a growth or reactive pattern, but, on the other hand, may be low-grade lymphomas. If so, they may be histopathologically related to cutaneous Hodgkin disease, T-cell/histiocyte-rich large B-cell lymphoma, or composite lymphomas. Further reports are needed to identify these lesions to clarify their nature and biologic potential.

Cytologic diagnosis ofLawsonia intracellularisproliferative ileitis in a Japanese snow macaque (Macaca fuscata)

Diffuse ileal thickening and ileocecocolic lymphadenomegaly were observed during exploratory laparotomy in a 2-year-old male Japanese snow macaque (Macaca fuscata) that had flu-like signs and diarrhea. Cytologic examination of ileal biopsy imprints revealed many mature, mildly karyolytic neutrophils and fewer well-differentiated lymphocytes, eosinophils, macrophages, and plasma cells in a background containing amorphous, necrotic material. Tightly cohesive sheets of moderately pleomorphic epithelial cells also were seen. The cytologic diagnosis was chronic, active, mixed inflammation with atypical epithelial cells and necrosis. Histologically, the mucosal and crypt epithelium was moderately hyperplastic with a loss of goblet cells, increased mitoses, and frequent crypt abscesses. Within the lamina propria and extending into the submucosa was a marked neutrophilic infiltrate, with low numbers of lymphocytes, histiocytes, plasma cells, and eosinophils. The histologic diagnosis was chronic, diffuse, marked suppurative and lymphocytic ileitis. Warthin-Starry silver staining of the ileal biopsy and imprint specimens demonstrated numerous pleomorphic, curved bacilli consistent with Lawsonia intracellularis. Polymerase chain reaction (PCR) and immunohistochemistry confirmed the identity of the infectious agent. L intracellularis infection may be underdiagnosed because silver stain is required to visualize the organism with light microscopy and because the pathognomonic crypt hyperplasia may be complicated by secondary pathologic changes. Application of silver stain to cytologic specimens should be considered when distal intestinal lesions associated with hyperplastic epithelium, with or without inflammation, hemorrhage, or necrosis, are identified in animals with clinical signs of enteritis, especially in frequently affected species or in stressed or young animals.

Quilty B Lesions on Endomyocardial Biopsies: Are They Associated with Subsequent Histologic Rejection in Cardiac Transplant Patients?

616 The Quality effect in endomyocardial biopsy specimens from heart transplant recipients is reported to be benign and unrelated to rejection. The Quilty lesion is further divided into Quilty A lesions and Quilty B lesions. Quilty A lesions are well-differentiated lymphocytes solely in the endocardium. In the Quilty B lesion, lymphocytic infiltration is seen encroaching upon the myocytes sometimes with myocyte injury. There is concern that the Quilty B lesions represent an early form of rejection. To address this, we reviewed 1145 endomyocardial biopsies from January 1, 1997 to October 1, 1997. Of the total, there were 428 Quilty A lesions and 76 Quilty B lesions seen on endomyocardial biopsy. Six of 428 Quilty A lesions (1.4%) and 2 of 76 Quilty B lesions (2.6%) progressed to a grade 3A or greater lesion on subsequent endomyocardial biopsy. There was no clinical evidence of rejection at the time Quilty lesions were noted on endomyocardial biopsy.Conclusion: The presence of Quilty B lesions on endomyocardial biopsies have a low incidence of progression to ≥ 3A rejection on subsequent endomyocardial biopsy similar to the Quilty A lesions. This suggests that both the Quilty A and B lesions do not represent early forms of progressive histologic cardiac rejection.

Mitteilungen – Communications Histopathologie des hématodermies

This histologic classification is based upon the arrangement and cytologic composition of the infiltrate. We separate diseases with intraepidermal exocytosis from diseases without intraepidermal exocytosis. In the first group, mycosis fungoides is the most important: the infiltrate is often polymorphous, but sometimes it consists of histiocytes and lymphocytes. Varying number of Sézary cells are present. The Woringer-Kolopp syndrome and histiocytosis X are included in this group as well. The second group comprises many neoplastic diseases: mycosis fungoides without Pautrier microabscesses, so-called 'reticulosis', 'Crosti's reticulosis', leukemia and lymph node lymphoma. Difficulties may arise in the differential diagnosis between these various diseases with well-differentiated lymphocytes and without intraepidermal exocytosis. These diseases must also be differentiated from the non-malignant lymphocytic infiltrates found in lupus erythematosus, lymphocytoma cutis and Jessner's lymphocytic infiltration of the skin.