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Herpes simplex virus infections in pulmonary cytology rarely represent pulmonary disease but remain a marker for mortality risk
Journal of the American Society of Cytopathology (2017) xx, 1e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jascyto.org/
Herpes simplex virus infections in pulmonary cytology rarely represent pulmonary disease but remain a marker for mortality risk Andrew A. Renshaw, MDa,*, Ming Jin, MD, PhDb, Paul E. Wakely Jr., MDb, Edwin W. Gould, MDa a b
Department of Pathology, Baptist Hospital and Miami Cancer Institute, Miami, Florida Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
Received 7 May 2017; received in revised form 7 June 2017; accepted 8 June 2017
KEYWORDS Cytology; Pulmonary; Herpes simplex virus; HSV; Immunohistochemistry; Therapy; Prognosis
Introduction Herpes simplex virus (HSV) infection can be diagnosed in pulmonary cytology specimens. We sought to determine the clinical significance of this finding. Methods Our medical records were searched for cases of HSV infection diagnosed in cytology specimens and the results compared with those in the literature. Results In our sample, 9 patients had HSV inclusions. All patients had pulmonary disease, 8 of 9 had multi-organ system disease, and 8 of 9 had been treated with either steroids or chemotherapy. Patients were either not treated with antiviral therapy (6 of 9) or treated for oral with or without cutaneous disease only (3 of 9). Two patients died; pulmonary infection was confirmed in only 1 patient. Compared with prior series, the number of cases with 10 or fewer cells with inclusions was significantly higher (89% versus 17%, P < 0.001). Conclusions Compared with prior series, most patients with HSV inclusions in pulmonary cytology specimens have fewer cells with inclusions, have oral and or cutaneous disease as well, and are not treated for pulmonary HSV. Nevertheless, this finding is associated with a risk of death, from both pulmonary infection and/or comorbid disease. Ó 2017 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.
Introduction
*Corresponding author: Andrew A. Renshaw, MD; Baptist Hospital, 8900 N Kendall Dr, Miami, FL 33156; Tel.: 786 596 6525; Fax: 786 596 5986. E-mail address: [email protected] (A.A. Renshaw).
Herpes simplex virus (HSV) infection of the respiratory tract can occur anywhere from the mouth to the alveoli,1 and both radiographic evaluation and bronchoscopy can be of value in identifying the site of infection.2 Patients with immunocompromised status, prolonged intubation,3 burns,4 and
2213-2945/$36 Ó 2017 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jasc.2017.06.003
2
A.A. Renshaw et al.
neoplasia5 are at increased risk for infection, but potentially anyone,6 including neonates and children7-9 is at risk.2 The presence of HSV in the lung may be associated with poorer clinical outcome.3 The diagnosis of HSV infection can be made on a variety of respiratory specimens, including tracheobronchial aspirates,7 sputum, brushings, washings and bronchoalveolar lavages, and can be based on cytologic features, immunocytochemistry, molecular methods and culture.10,11 In the cytology literature, the largest series (21 patients12) suggests that the cells with cytologic inclusions are relatively plentiful (mean: 131 cells), and thus would be presumably easy to identify. This has not been our experience, where cells with diagnostic inclusions are usually rare. In addition, when identified in pulmonary cytologic specimens, some older studies suggest that this most likely represents pulmonary infection, with a death rate of nearly 30%12; but more recent studies suggest that some of these patients may have oral disease only.3 To further investigate this, we compared our series of HSV in pulmonary specimens with series in the literature.
Methods The cytology records of Baptist Hospital (Miami, Fla.), Homestead Hospital (Homestead, Fla.), and the Ohio State University Wexner Medical Center (Columbus, Ohio) from January 2005 to August 2015 were reviewed for cases in which a diagnosis of HSV infection was made in a pulmonary specimen. Only cases in which the original cytologic specimens were available were included. In the cases with available material, all cases were confirmed by immunohistochemistry for HSV (HSV1 and HSV2, Cellmarque, Rockland, Calif., undiluted). Clinical information was obtained from the medical record. Sputum, washings, and bronchoalveolar lavage specimens all had either cytospins or liquid-based preparations with or without a cell block. Brushings consisted of two Table 1
alcohol-fixed slides. All specimens were stained with either hematoxylin and eosin or Papanicolaou stain. Cytologic inclusions consisted of ground glass chromatin with or without multi-nucleation. Statistical analysis was performed using a two-tailed Fisher’s exact test and a threshold of 0.05 was considered significant.
Results The results are summarized in Table 1. Nine patients were identified, 8 of 9 (89%) of whom were at least 60 years of age, all with pulmonary disease. Additionally 8 of 9 (89%) had multiorgan system disease, and 8 of 9 had been treated with steroids and or chemotherapy. Inclusions were identified in 2 sputums, 2 washings, and 5 bronchoalveolar lavage. In all but one case, fewer than 10 cells with cytologic inclusions were identified (Fig. 1). Multinucleated cells were not identified in 2 of the 9 cases. One patient had a positive HSV culture. The mean number of cells with cytologic inclusions in this study was 18.8 39.9, compared with 131.5 220.4 in the largest prior study.12 The number of cases with 10 or fewer cells with intranuclear inclusions in the current study was 89%, compared with only 17% in the prior study12 (P < 0.001). Multinucleate cells were absent. Three patients were treated for the clinical diagnosis of oral (with or without cutaneous) herpes and not pulmonary herpes. Two patients died within 1 week of the diagnosis, neither were treated with antiviral therapy. One of these patients had pulmonary herpes infection confirmed on autopsy and one did not have herpes infection on autopsy. A third patient was transferred to another facility for progressive deterioration based on multiorgan system failure.
Discussion Our results are similar to and different from those of prior studies. As other studies have shown, HSV infection can be
Clinical summary of herpes simplex virus infection.
Case no.
Age
Sex
Pulmonary Dx
Multi-organ system disease
Steroid/ chemotherapy Rx
Antiviral Rx
Specimen
No. cells
1 2 3 4 5 6 7 8 9
77 78 74 60 79 62 37 69 71
F F F M M M M F M
COPD, DADa CA COPD, mucus plug COPD COPD Bacterial pneumonia Bacterial pneumonia Bacterial pneumoniad Herpetic pneumoniad
Yes Yes Yes Yes Yes Yes Yes No Yes
Yes Yes Yes Yes Yes Yes No Yes Yes
No Yesb No Topical only No No No Yesc No
BAL Sputum Washings Sputum Washing BAL BAL BAL BAL
4 10 125 8 2 5 2 5 8
Abbreviations: Dx, diagnosis; COPD, chronic obstructive pulmonary disease; DAD, diffuse alveolar damage; CHF, congestive heart failure; CA, pulmonary carcinoma; BAL, bronchoalveolar lavage. a Confirmed on open lung biopsy. b No fever or infiltrate, oral lesions only clinically. c Clinical skin rash. d Confirmed on autopsy.
HSV in pulmonary cytology
3
Figure 1 A, Herpes virus infection in a bronchial washing showing a binucleate cell with ground glass chromatin (hematoxylin and eosin stain, cell block, 1000). B, HSV-2 immunohistochemistry (cell block, 1000).
identified in pulmonary cytology specimens by the identification of intranuclear cytologic inclusions, and this can be confirmed by immunohistochemical evaluation. Most of the patients in our series were elderly, had both pulmonary and multiorgan system disease, and had undergone either steroid treatment or chemotherapy. In addition, the finding of HSV in a pulmonary cytology specimen was associated with a rate of death (22%) that was similar to that in prior studies (30%).3,12 Unlike these prior studies, however, the number of cells with inclusions were relatively few, and usually less than 10. One patient had 125 inclusions, though the reason for this remains unclear. Thus, the task of identifying these cells may be more challenging than in earlier studies. In addition, multinucleate cells were not always present, forcing the cytologist to make the diagnosis on single nuclei alone. As a result, it would seem very possible to misinterpret the cytologic features as degenerative in nature rather than viral. In addition, despite the availability of antiviral therapy, the majority of patients in this series were not treated with this, and when they were treated with antiviral therapy it was for oral or cutaneous disease rather than the clinical diagnosis of pulmonary infection. Whether the patients with oral disease represent contamination of the pulmonary specimen or coexistent disease in 2 sites is not known. This may partially explain why the number of cells with inclusions was so much lower than in prior studies, in which the clinical diagnosis appears to have been pulmonary involvement, at least in some cases.12 Nevertheless, this finding still remained associated with a mortality rate of 22%, and the patients who died did so in less than a week and had not received antiviral therapy. Although at least one case was due to pulmonary infection, the frequent comorbidity may also have played a role in these deaths. This suggests that patients with herpes viral cytopathic inclusions in pulmonary specimens remain at high risk of death, and antiviral therapy may not necessarily reduce this risk. There are limitations to the current study. This is not a case control study, and whether the finding of HSV in the pulmonary specimens changed the clinical outcome is not clear. In addition, only 2 patients had autopsies, 1 an open lung biopsy, and 1 culture to confirm the cytologic
diagnosis. Finally, the decision to treat with antiviral medications was made on a clinical basis and its impact cannot be assessed. In conclusion, compared with prior series, patients with HSV inclusions in cytology specimens have fewer cells with inclusions, commonly have only oral and or cutaneous disease, and are usually not treated for pulmonary HSV. Nevertheless, this finding is associated with a relatively high risk of death in a short time period, which may represent both pulmonary infection or comorbid disease.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest disclosures The authors have no conflicts of interest and nothing to disclose.
References 1. Nash G, Foley FD. Herpetic infection of the middle and lower respiratory tract. Am J Clin Pathol. 1970;54:857e863. 2. Graham BS, Snell Jr JD. Herpes simplex virus infection of the adult lower respiratory tract. Medicine (Baltimore). 1983;62:384e393. 3. Luyt CE, Combes A, Deback C, et al. Herpes simplex virus lung infection in patients undergoing prolonged mechanical ventilation. Am J Respir Crit Care Med. 2007;175:935e942. 4. Byers RJ, Hasleton PS, Quigley A, et al. Pulmonary herpes simplex in burns patients. Eur Respir J. 1996;9:2313e2317. 5. Maounis N, Blana A, Ellina E, et al. Simultaneous cytological diagnosis of herpes simplex virus infection and primary lung cancer: report of two cases. Diagn Cytopathol. 2008;36:818e822. 6. Reyes CV, Bolden JR. Herpes simplex virus type-1 pneumonitis in immunocompetent young woman. Heart Lung. 2009;38:526e529. 7. Drut RM, Drut R. Congenital herpes simplex virus infection diagnosed by cytology of aspirated tracheobronchial material. Acta Cytol. 1985; 29:712e713. 8. Benjamin DR. Herpes simplex tracheobronchitis and pneumonitis. Pediatr Pathol. 1989;9:773e777.
4 9. Drut R. Neonatal herpes simplex virus infection diagnosed by cytology of tracheobronchial aspirates. Diagn Cytopathol. 1992;8: 91e92. 10. Strickler JG, Manivel JC, Copenhaver CM, Kubic VL. Comparison of in situ hybridization and immunohistochemistry for detection of cytomegalovirus and herpes simplex virus. Hum Pathol. 1990;21:443e448.
A.A. Renshaw et al. 11. Crosby JH, Pantazis CG, Stigall B. In situ DNA hybridization for confirmation of herpes simplex virus in bronchoalveolar lavage smears. Acta Cytol. 1991;35:248e250. 12. Frable WJ, Frable MA, Seney Jr FD. Virus infections of the respiratory tract cytopathologic and clinical analysis. Acta Cytol. 1977;21: 32e36.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jascyto.org/
Herpes simplex virus infections in pulmonary cytology rarely represent pulmonary disease but remain a marker for mortality risk Andrew A. Renshaw, MDa,*, Ming Jin, MD, PhDb, Paul E. Wakely Jr., MDb, Edwin W. Gould, MDa a b
Department of Pathology, Baptist Hospital and Miami Cancer Institute, Miami, Florida Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
Received 7 May 2017; received in revised form 7 June 2017; accepted 8 June 2017
KEYWORDS Cytology; Pulmonary; Herpes simplex virus; HSV; Immunohistochemistry; Therapy; Prognosis
Introduction Herpes simplex virus (HSV) infection can be diagnosed in pulmonary cytology specimens. We sought to determine the clinical significance of this finding. Methods Our medical records were searched for cases of HSV infection diagnosed in cytology specimens and the results compared with those in the literature. Results In our sample, 9 patients had HSV inclusions. All patients had pulmonary disease, 8 of 9 had multi-organ system disease, and 8 of 9 had been treated with either steroids or chemotherapy. Patients were either not treated with antiviral therapy (6 of 9) or treated for oral with or without cutaneous disease only (3 of 9). Two patients died; pulmonary infection was confirmed in only 1 patient. Compared with prior series, the number of cases with 10 or fewer cells with inclusions was significantly higher (89% versus 17%, P < 0.001). Conclusions Compared with prior series, most patients with HSV inclusions in pulmonary cytology specimens have fewer cells with inclusions, have oral and or cutaneous disease as well, and are not treated for pulmonary HSV. Nevertheless, this finding is associated with a risk of death, from both pulmonary infection and/or comorbid disease. Ó 2017 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.
Introduction
*Corresponding author: Andrew A. Renshaw, MD; Baptist Hospital, 8900 N Kendall Dr, Miami, FL 33156; Tel.: 786 596 6525; Fax: 786 596 5986. E-mail address: [email protected] (A.A. Renshaw).
Herpes simplex virus (HSV) infection of the respiratory tract can occur anywhere from the mouth to the alveoli,1 and both radiographic evaluation and bronchoscopy can be of value in identifying the site of infection.2 Patients with immunocompromised status, prolonged intubation,3 burns,4 and
2213-2945/$36 Ó 2017 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jasc.2017.06.003
2
A.A. Renshaw et al.
neoplasia5 are at increased risk for infection, but potentially anyone,6 including neonates and children7-9 is at risk.2 The presence of HSV in the lung may be associated with poorer clinical outcome.3 The diagnosis of HSV infection can be made on a variety of respiratory specimens, including tracheobronchial aspirates,7 sputum, brushings, washings and bronchoalveolar lavages, and can be based on cytologic features, immunocytochemistry, molecular methods and culture.10,11 In the cytology literature, the largest series (21 patients12) suggests that the cells with cytologic inclusions are relatively plentiful (mean: 131 cells), and thus would be presumably easy to identify. This has not been our experience, where cells with diagnostic inclusions are usually rare. In addition, when identified in pulmonary cytologic specimens, some older studies suggest that this most likely represents pulmonary infection, with a death rate of nearly 30%12; but more recent studies suggest that some of these patients may have oral disease only.3 To further investigate this, we compared our series of HSV in pulmonary specimens with series in the literature.
Methods The cytology records of Baptist Hospital (Miami, Fla.), Homestead Hospital (Homestead, Fla.), and the Ohio State University Wexner Medical Center (Columbus, Ohio) from January 2005 to August 2015 were reviewed for cases in which a diagnosis of HSV infection was made in a pulmonary specimen. Only cases in which the original cytologic specimens were available were included. In the cases with available material, all cases were confirmed by immunohistochemistry for HSV (HSV1 and HSV2, Cellmarque, Rockland, Calif., undiluted). Clinical information was obtained from the medical record. Sputum, washings, and bronchoalveolar lavage specimens all had either cytospins or liquid-based preparations with or without a cell block. Brushings consisted of two Table 1
alcohol-fixed slides. All specimens were stained with either hematoxylin and eosin or Papanicolaou stain. Cytologic inclusions consisted of ground glass chromatin with or without multi-nucleation. Statistical analysis was performed using a two-tailed Fisher’s exact test and a threshold of 0.05 was considered significant.
Results The results are summarized in Table 1. Nine patients were identified, 8 of 9 (89%) of whom were at least 60 years of age, all with pulmonary disease. Additionally 8 of 9 (89%) had multiorgan system disease, and 8 of 9 had been treated with steroids and or chemotherapy. Inclusions were identified in 2 sputums, 2 washings, and 5 bronchoalveolar lavage. In all but one case, fewer than 10 cells with cytologic inclusions were identified (Fig. 1). Multinucleated cells were not identified in 2 of the 9 cases. One patient had a positive HSV culture. The mean number of cells with cytologic inclusions in this study was 18.8 39.9, compared with 131.5 220.4 in the largest prior study.12 The number of cases with 10 or fewer cells with intranuclear inclusions in the current study was 89%, compared with only 17% in the prior study12 (P < 0.001). Multinucleate cells were absent. Three patients were treated for the clinical diagnosis of oral (with or without cutaneous) herpes and not pulmonary herpes. Two patients died within 1 week of the diagnosis, neither were treated with antiviral therapy. One of these patients had pulmonary herpes infection confirmed on autopsy and one did not have herpes infection on autopsy. A third patient was transferred to another facility for progressive deterioration based on multiorgan system failure.
Discussion Our results are similar to and different from those of prior studies. As other studies have shown, HSV infection can be
Clinical summary of herpes simplex virus infection.
Case no.
Age
Sex
Pulmonary Dx
Multi-organ system disease
Steroid/ chemotherapy Rx
Antiviral Rx
Specimen
No. cells
1 2 3 4 5 6 7 8 9
77 78 74 60 79 62 37 69 71
F F F M M M M F M
COPD, DADa CA COPD, mucus plug COPD COPD Bacterial pneumonia Bacterial pneumonia Bacterial pneumoniad Herpetic pneumoniad
Yes Yes Yes Yes Yes Yes Yes No Yes
Yes Yes Yes Yes Yes Yes No Yes Yes
No Yesb No Topical only No No No Yesc No
BAL Sputum Washings Sputum Washing BAL BAL BAL BAL
4 10 125 8 2 5 2 5 8
Abbreviations: Dx, diagnosis; COPD, chronic obstructive pulmonary disease; DAD, diffuse alveolar damage; CHF, congestive heart failure; CA, pulmonary carcinoma; BAL, bronchoalveolar lavage. a Confirmed on open lung biopsy. b No fever or infiltrate, oral lesions only clinically. c Clinical skin rash. d Confirmed on autopsy.
HSV in pulmonary cytology
3
Figure 1 A, Herpes virus infection in a bronchial washing showing a binucleate cell with ground glass chromatin (hematoxylin and eosin stain, cell block, 1000). B, HSV-2 immunohistochemistry (cell block, 1000).
identified in pulmonary cytology specimens by the identification of intranuclear cytologic inclusions, and this can be confirmed by immunohistochemical evaluation. Most of the patients in our series were elderly, had both pulmonary and multiorgan system disease, and had undergone either steroid treatment or chemotherapy. In addition, the finding of HSV in a pulmonary cytology specimen was associated with a rate of death (22%) that was similar to that in prior studies (30%).3,12 Unlike these prior studies, however, the number of cells with inclusions were relatively few, and usually less than 10. One patient had 125 inclusions, though the reason for this remains unclear. Thus, the task of identifying these cells may be more challenging than in earlier studies. In addition, multinucleate cells were not always present, forcing the cytologist to make the diagnosis on single nuclei alone. As a result, it would seem very possible to misinterpret the cytologic features as degenerative in nature rather than viral. In addition, despite the availability of antiviral therapy, the majority of patients in this series were not treated with this, and when they were treated with antiviral therapy it was for oral or cutaneous disease rather than the clinical diagnosis of pulmonary infection. Whether the patients with oral disease represent contamination of the pulmonary specimen or coexistent disease in 2 sites is not known. This may partially explain why the number of cells with inclusions was so much lower than in prior studies, in which the clinical diagnosis appears to have been pulmonary involvement, at least in some cases.12 Nevertheless, this finding still remained associated with a mortality rate of 22%, and the patients who died did so in less than a week and had not received antiviral therapy. Although at least one case was due to pulmonary infection, the frequent comorbidity may also have played a role in these deaths. This suggests that patients with herpes viral cytopathic inclusions in pulmonary specimens remain at high risk of death, and antiviral therapy may not necessarily reduce this risk. There are limitations to the current study. This is not a case control study, and whether the finding of HSV in the pulmonary specimens changed the clinical outcome is not clear. In addition, only 2 patients had autopsies, 1 an open lung biopsy, and 1 culture to confirm the cytologic
diagnosis. Finally, the decision to treat with antiviral medications was made on a clinical basis and its impact cannot be assessed. In conclusion, compared with prior series, patients with HSV inclusions in cytology specimens have fewer cells with inclusions, commonly have only oral and or cutaneous disease, and are usually not treated for pulmonary HSV. Nevertheless, this finding is associated with a relatively high risk of death in a short time period, which may represent both pulmonary infection or comorbid disease.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest disclosures The authors have no conflicts of interest and nothing to disclose.
References 1. Nash G, Foley FD. Herpetic infection of the middle and lower respiratory tract. Am J Clin Pathol. 1970;54:857e863. 2. Graham BS, Snell Jr JD. Herpes simplex virus infection of the adult lower respiratory tract. Medicine (Baltimore). 1983;62:384e393. 3. Luyt CE, Combes A, Deback C, et al. Herpes simplex virus lung infection in patients undergoing prolonged mechanical ventilation. Am J Respir Crit Care Med. 2007;175:935e942. 4. Byers RJ, Hasleton PS, Quigley A, et al. Pulmonary herpes simplex in burns patients. Eur Respir J. 1996;9:2313e2317. 5. Maounis N, Blana A, Ellina E, et al. Simultaneous cytological diagnosis of herpes simplex virus infection and primary lung cancer: report of two cases. Diagn Cytopathol. 2008;36:818e822. 6. Reyes CV, Bolden JR. Herpes simplex virus type-1 pneumonitis in immunocompetent young woman. Heart Lung. 2009;38:526e529. 7. Drut RM, Drut R. Congenital herpes simplex virus infection diagnosed by cytology of aspirated tracheobronchial material. Acta Cytol. 1985; 29:712e713. 8. Benjamin DR. Herpes simplex tracheobronchitis and pneumonitis. Pediatr Pathol. 1989;9:773e777.
4 9. Drut R. Neonatal herpes simplex virus infection diagnosed by cytology of tracheobronchial aspirates. Diagn Cytopathol. 1992;8: 91e92. 10. Strickler JG, Manivel JC, Copenhaver CM, Kubic VL. Comparison of in situ hybridization and immunohistochemistry for detection of cytomegalovirus and herpes simplex virus. Hum Pathol. 1990;21:443e448.
A.A. Renshaw et al. 11. Crosby JH, Pantazis CG, Stigall B. In situ DNA hybridization for confirmation of herpes simplex virus in bronchoalveolar lavage smears. Acta Cytol. 1991;35:248e250. 12. Frable WJ, Frable MA, Seney Jr FD. Virus infections of the respiratory tract cytopathologic and clinical analysis. Acta Cytol. 1977;21: 32e36.