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LIESEGANG BODIES IN A SOLID RENAL MASS: MISDIAGNOSIS AS PARASITIC OVA
0022-5347/00/1632-0540/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 163, 540 –541, February 2000 Printed in U.S.A.
Case Reports LIESEGANG BODIES IN A SOLID RENAL MASS: MISDIAGNOSIS AS PARASITIC OVA JO ELLEN KRUEGER, T. SPARK CORWIN, R. CORWIN
AND
M. HOSSEIN SABOORIAN
From the Departments of Urology and Pathology, University of Texas Southwestern Medical School, Dallas, Texas
We report on a patient with a hemorrhagic renal cyst containing numerous concentrically lamellar precipitations initially misdiagnosed as parasitic ova. Although Liesegang bodies are known to the pathology community, they can still be misdiagnosed as parasitic ova. Therefore, it is important for urologists to remember this entity when an unexpected diagnosis of parasitic infection is rendered.
CASE REPORT
An 81-year-old man without significant medical history presented with vague abdominal discomfort several months in duration. Abdominal computerized tomography showed a simple cyst of the right kidney and a 3 cm. solid mass arising from the upper pole of the left kidney (fig. 1). All laboratory studies were unremarkable and the patient was otherwise in good health. He subsequently underwent left partial nephrectomy for the solid renal mass. Histopathological examination of the mass was initially thought to reveal ova of Ascaris lumbricoides but the patient denied any travel to endemic areas except for a day in the Yucatan nearly 30 years before the onset of symptoms. Because of the problematic nature of the pathological diagnosis, the slides were referred for a second opinion. Histological examination of the specimen revealed fragments of organizing hemorrhage associated with a fibrous cyst wall. Within the hemorrhagic cyst contents numerous concentrically laminated acellular spherical bodies of different morphological sizes and shapes were identified. They were nonpolarizable and demonstrated amorphous cores
with fine radial striations characteristic of Liesegang bodies (fig. 2). No internal features suggestive of parasitic organisms could be identified. DISCUSSION
Liesegang rings are formed by alternating cycles of subsaturation and supersaturation of an insoluble product in a colloidal system, resulting in concentrically lamellar precipitations around a central nidus. They occur naturally in limestone and have been induced by various chemical reactions in vitro. Although the exact mechanism by which the precipitation is initiated remains unclear, factors that undoubtedly have a role in the formation of these bodies include electrical charge, chemical concentration, pH, temperature and impurities. Liesegang rings in vivo are rare but have been described in association with neoplastic processes, inflamed tissues and cysts from sites, such as the breast, kidney and synovium.1 As in our case, Liesegang bodies are most often found within the central portion of the cyst, in conjunction with organizing hemorrhagic debris. Their differential diagnosis includes concentrically laminated intracellular entities, such as corpora amylacea or Michaelis-Guttman bodies of malakoplakia, as well as extracellular entities, such as crystals, calcium deposits and hyaline globules.2 More importantly, as in our case Liesegang rings may be mistaken for parasitic ova, although they are more often thought to resemble the giant
Accepted for publication September 24, 1999.
FIG. 1. Abdominal computerized tomography shows solid renal mass in left upper pole 540
FIG. 2. Liesegang bodies. H & E, reduced from 340
541
LIESEGANG BODIES IN SOLID RENAL MASS
kidney worm Dioctophyma renale rather than Ascaris lumbricoides.3
ate the need for further unnecessary treatment or surgical intervention.
CONCLUSIONS
REFERENCES
Liesegang bodies are acellular, concentrically laminated bodies that may be associated with neoplastic and nonneoplastic processes of the kidney, particularly in hemorrhagic renal cysts. Although there are reports in the literature, these bodies are still relatively unknown to pathologists and urologists. Familiarity with Liesegang rings, particularly in association with hemorrhagic cysts and inflammatory processes of the kidney, would preclude misdiagnosis and obvi-
1. Glazier, D. B., Murphy, D. P., Cummings, K. B. et al: Liesegang rings. J Urol, 157: 940, 1997 2. Raso, D. S., Greene, W. B., Finley, J. L. et al: Morphology and pathogenesis of liesegang rings in cyst aspirates: report of two cases with ancillary studies. Diag Cytopathol, 19: 116, 1998 3. Tuur, S. M., Nelson, A. M., Gibson, D. W. et al: Liesegang rings in tissue. How to distinguish Liesegang rings from the giant kidney worm, Dioctophyma renale. Am J Surg Pathol, 11: 598, 1987
Vol. 163, 540 –541, February 2000 Printed in U.S.A.
Case Reports LIESEGANG BODIES IN A SOLID RENAL MASS: MISDIAGNOSIS AS PARASITIC OVA JO ELLEN KRUEGER, T. SPARK CORWIN, R. CORWIN
AND
M. HOSSEIN SABOORIAN
From the Departments of Urology and Pathology, University of Texas Southwestern Medical School, Dallas, Texas
We report on a patient with a hemorrhagic renal cyst containing numerous concentrically lamellar precipitations initially misdiagnosed as parasitic ova. Although Liesegang bodies are known to the pathology community, they can still be misdiagnosed as parasitic ova. Therefore, it is important for urologists to remember this entity when an unexpected diagnosis of parasitic infection is rendered.
CASE REPORT
An 81-year-old man without significant medical history presented with vague abdominal discomfort several months in duration. Abdominal computerized tomography showed a simple cyst of the right kidney and a 3 cm. solid mass arising from the upper pole of the left kidney (fig. 1). All laboratory studies were unremarkable and the patient was otherwise in good health. He subsequently underwent left partial nephrectomy for the solid renal mass. Histopathological examination of the mass was initially thought to reveal ova of Ascaris lumbricoides but the patient denied any travel to endemic areas except for a day in the Yucatan nearly 30 years before the onset of symptoms. Because of the problematic nature of the pathological diagnosis, the slides were referred for a second opinion. Histological examination of the specimen revealed fragments of organizing hemorrhage associated with a fibrous cyst wall. Within the hemorrhagic cyst contents numerous concentrically laminated acellular spherical bodies of different morphological sizes and shapes were identified. They were nonpolarizable and demonstrated amorphous cores
with fine radial striations characteristic of Liesegang bodies (fig. 2). No internal features suggestive of parasitic organisms could be identified. DISCUSSION
Liesegang rings are formed by alternating cycles of subsaturation and supersaturation of an insoluble product in a colloidal system, resulting in concentrically lamellar precipitations around a central nidus. They occur naturally in limestone and have been induced by various chemical reactions in vitro. Although the exact mechanism by which the precipitation is initiated remains unclear, factors that undoubtedly have a role in the formation of these bodies include electrical charge, chemical concentration, pH, temperature and impurities. Liesegang rings in vivo are rare but have been described in association with neoplastic processes, inflamed tissues and cysts from sites, such as the breast, kidney and synovium.1 As in our case, Liesegang bodies are most often found within the central portion of the cyst, in conjunction with organizing hemorrhagic debris. Their differential diagnosis includes concentrically laminated intracellular entities, such as corpora amylacea or Michaelis-Guttman bodies of malakoplakia, as well as extracellular entities, such as crystals, calcium deposits and hyaline globules.2 More importantly, as in our case Liesegang rings may be mistaken for parasitic ova, although they are more often thought to resemble the giant
Accepted for publication September 24, 1999.
FIG. 1. Abdominal computerized tomography shows solid renal mass in left upper pole 540
FIG. 2. Liesegang bodies. H & E, reduced from 340
541
LIESEGANG BODIES IN SOLID RENAL MASS
kidney worm Dioctophyma renale rather than Ascaris lumbricoides.3
ate the need for further unnecessary treatment or surgical intervention.
CONCLUSIONS
REFERENCES
Liesegang bodies are acellular, concentrically laminated bodies that may be associated with neoplastic and nonneoplastic processes of the kidney, particularly in hemorrhagic renal cysts. Although there are reports in the literature, these bodies are still relatively unknown to pathologists and urologists. Familiarity with Liesegang rings, particularly in association with hemorrhagic cysts and inflammatory processes of the kidney, would preclude misdiagnosis and obvi-
1. Glazier, D. B., Murphy, D. P., Cummings, K. B. et al: Liesegang rings. J Urol, 157: 940, 1997 2. Raso, D. S., Greene, W. B., Finley, J. L. et al: Morphology and pathogenesis of liesegang rings in cyst aspirates: report of two cases with ancillary studies. Diag Cytopathol, 19: 116, 1998 3. Tuur, S. M., Nelson, A. M., Gibson, D. W. et al: Liesegang rings in tissue. How to distinguish Liesegang rings from the giant kidney worm, Dioctophyma renale. Am J Surg Pathol, 11: 598, 1987