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The median age of the HR-HPV–positive patients was approximately 11 years younger than the HPV-negative group, and pregnant patients were also more apt to be HPV positive. In cases diagnosed as ASCUS, there are certain cytologic features and patient types that are more likely to be associated with HR-HPV positivity. In 2001, the ALTS trial demonstrated the effectiveness of high-risk human papillomavirus (HR- HPV) testing in the triage of patients with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). Certain behavioral, clinical and socioeconomic risk factors have been identified in association with HR-HPV infection and the development of cervical neoplasia. The ALTS trial showed that the cytologic features associated with LSIL had a high correlation with HR-HPV positivity (83%).
The correlation between HPV and the development of cervical neoplasia has been well established.
Several studies have investigated additional methods of resolving ASCUS, but none have been met with widespread acceptance. Certain nonclassical cytomorphologic characteristics are associated with positive HR-HPV–DNA status.
Shew ML, Fortenberry JD, Tu W, Juliar BE, Batteiger BE, Qadadri B, Brown DR: Association of condom use, sexual behaviors, and sexually transmitted infections with the duration of genital human papillomaviral infection among adolescent women. Smith EM, Johnson SR, Jiang D, Zaleski S, Lynch CF, Brundage S, Anderson RD, Turek LP: The association between pregnancy and human papilloma virus prevalence. Lu DW, Pirog EC, Zhu X, Wang HL, Pinto KR: Prevalence and typing of HPV DNA in atypical squamous cells in pregnant women.
Schneider A, Meinhardt G, De-Villiers EM, Gissmann L: Sensitivity of the cytologic diagnosis of cervical condyloma in comparison with HPV-DNA hybridization studies.
Bollmann M, Bánkfalvi A, Trosic A, Speich N, Schmitt C, Bollmann R: Can we detect cervical human papillomavirus (HPV) infection by cytomorphology alone?
Zhao FH, Forman MR, Belinson J, Shen YH, Graubard BI, Patel AC, Rong SD, Pretorius RG, Qiao YL: Risk factors for HPV infection and cervical cancer among unscreened women in a high-risk rural area of China.
Viikki M, Pukkala E, Nieminen P, Hakama M: Gynaecological infections as risk determinants of subsequent cervical neoplasia. Saccomanno G, Saunders RP, Ellis H, Archer VE, Wood BG, Beckler PA: Concentrations of carcinoma or atypical cells in sputum.
Presented as a poster at the 53rd Annual Meeting of the American Society of Cytopathology, San Diego, California, November 6, 2005. Financial Disclosure: The authors have no connection to any companies or products mentioned in this article. He has lost 60 pounds recently on a weight reduction diet and vitamin pills that he is now taking.
Your patient recently underwent a DEXA SCAN of the spine, hip and forearm on the Hologic 4500. Acute hemorrhagic edema of infancy is a cutaneous leukocytoclastic vasculitis, clinically characterized by the acute development of peripheral edema and targetoid purpuric lesions on the face and extremities. Introduction Acute hemorrhagic edema in infancy (AHEI) of the skin is a benign cutaneous leukocytoclastic vasculitis of infancy[1].
Case Presentation A five-month–old boy presented with symmetrical, erythematous, and edematous purpuric plaques on the face, buttocks, and distal part of the limbs.
His medical history revealed postnatal icterus of one month duration that improved without treatment. On dermatologic examination, there were symmetrical, erythematous, and edematous purpuric plaques on the face, buttocks, and distal part of the limbs (Figs.
Results of histologic examination of a plaque showed perivascular neutrophilic infiltration, eosinophilic fibrinoid change of vessel walls and nuclear debris in upper and mid dermis (Fig. Fig 3: Perivascular neutrophilic infiltrate, eosinophilic fibrinoid change of vessel walls and nuclear debris. Clinical, histological and biologic features of the patient were consistent with acute infantile hemorrhagic edema. Discussion Acute hemorrhagic edema of infancy is a variant of leukocytoclastic vasculitis that presents clinically as painful petechiae and ecchymoses that become edematous and develop a targetlike appearance[5].
Bacterial or viral infections, drugs, and less frequently, immunization, have been suggested to be the likely triggering mechanisms4. First lesions appear on the skin in the form of urticarial plaques, hyperemia or small macules and papules.
The typical histological appearance of the skin lesions in AHEI is leukocytoclastic vasculitis[7] presenting as a perivascular infiltrate of polymorphonuclear cells and lymphocytes with nuclear debris. Acute hemorrhagic edema of infancy should especially be distinguished from HSP, acute febrile neutrophilic dermatosis, meningococcemia, septicemia, purpura fulminans, child abuse, Kawasaki disease, and other diseases leading to cockade eruptions, such as erythema multiforme and urticaria[5,7,8].
Some authors have speculated that hemorrhagic edema and HSP are separate entities, whereas others believe that they are different expressions of the same disorder and that the unifying factor is a hypersensitivity vasculitis[5].
The differences between AHEI and HSP begin with the age of the patients: typically, the former affects children aged 4 months to 2 years, and the latter affects children aged 3 to 6 years. The prognosis of the disease is usually benign and the evolution is self-limited, lasting from one to three weeks[4].
We believe that this relatively unrecognized entity must be kept in mind by pediatricians and dermatologists to make an early diagnosis and thereby avoid unnecessary treatment and concern.
Fisher’s Exact test (2-tailed) was used to calculate the exact probability of obtaining results by chance. Atypical cells in greater numbers and in groups as opposed to single cells correlated more often with HR-HPV–positive individuals.
Although certain criteria have been established for making this diagnosis, this determination remains very subjective and hence problematic.
Additionally, this study assessed the utility of retrospective HPV-DNA testing on Pap test specimens as a method of evaluating individual and laboratory ASCUS reporting rates and performance improvement. Cytology slides were retrospectively reviewed by 5 cytotechnologists (CTs) as part of a site-specific quality improvement indicator in the laboratory, and an information grid was completed on each case.
Seventy-three cases (49%) were HR-HPV positive, 75 (51%) were negative; 2 were equivocal and excluded from the study.


The average age of patients with a positive HR-HPV result was 28 years and of those with a negative result was 39 years. The significant cytoplasmic changes in the HR-HPV–positive cases were koilocytelike changes and parakeratosis, as shown in Figures 5 and 6, respectively. Some evidence exists that atypical cells deserve even closer scrutiny in pregnancy as the risk of HPV infection may actually be increased. ASCUS cases were positive for HR-HPV approximately 50% of the time.1 Various studies, including ours, suggest that it may be possible to further define the cytologic characteristics found in ASCUS that are most strongly associated with HR-HPV.
A study by Schneider et al9 showed that the most significant correlation was with mild koilocytosis, mild hyperkeratosis, hyperchromatic nuclei, binucleation or multinucleation, and cleared cytoplasm.
Many studies have suggested that other infections, especially those involving the female reproductive tract, are also involved in the development of cervical neoplasia. A study utilizing this method found an association with increased DNA content and HR-DNA–positive ASCUS having similar biologic features as HSIL.
These findings demonstrate acceptable individual and laboratory reporting rates and show that HR-HPV DNA testing can serve as a reliable tool for retrospective assessment of laboratory and individual reporting practices.
In particular, koilocytelike changes, parakeratosis and increased numbers of cells with these and other mildly atypical findings are most significant. Diagnostic value of non-classic cytological signs of HPV effect in minimally abnormal Pap tests. Steinman was Fellow in Cytopathology, and currently is Staff Pathologist, Department of Laboratory Medicine, UPMC Mercy Hospital, Pittsburgh, Pennsylvania. Mody is Medical Director of Cytopathology, The Methodist Hospital, and Professor, Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, Houston, Texas.
The clinical picture has a violent onset with a short benign course followed by spontaneous complete recovery. In the family history, his mother had developmental dysplasia of the hip, and his father had Behcet disease.
The patient was treated with oral hydroxyzine, which resulted in rapid fading of the lesions and complete recovery within five days. In our patient, both cellulitis in front of the tragus and antibiotic treatment with ceftriaxone preceded the appearance of AHEI by a few days. Within a few days these lesions grow in size and spread to 1-5 cm in diameter, and are round with sharp edges. Immunohistochemical studies demonstrated deposits of immune complexes and complement in and around vessel walls in some but not all cases[5].
In contrast to AHEI, the skin lesions of HSP are more polymorphic and the fluorescence staining pattern of HSP mainly contains IgA, C3 and fibrin.
Koilocytelike changes and parakeratosis were more frequently associated with HR-HPV, but the presence of Trichomonas was usually a negative predictor. Monitoring individual and laboratory ASCUS rates with HR-HPV positivity can be an important quality improvement indicator. First, the many variations in cellular abnormalities associated with ASCUS allows great differences in opinion between pathologists. In the negative cases, the significant changes were cell enlargement (both nuclear and cytoplasmic) and small halos (Figure 4). However, at the time of interpretation, the background information is limited to the patient age, menstrual status, significant past gynecologic history and hormonal status. Smith et al5 compared 69 pregnant and 54 nonpregnant age-frequency–matched women for the presence of HR-HPV DNA. In our study, the most significant cytologic characteristics associated with HR-HPV–positive ASCUS were the presence of parakeratosis and koilocytelike changes (Figures 5 and 6). This study also stressed that the total number of features was an important factor in distinguishing HPV-positive cases from HPV-negative cases.
Samoff et al12 reported a relationship with HPV persistence and Chlamydia trachomatis infection, but not with Neisseria gonorrhoeae or Trichomonas vaginalis.
Additional disposable items would be required such as glass slides, test tubes, disposable pipettes, fixative vials and necessary reagents.
The benefit of this particular method is in sorting HR-positive cases that may progress to invasive carcinoma from those that may resolve. Based on the deviation from the laboratory mean, certain thresholds could be set up and the rates monitored. Our study suggests that screening for these characteristics in the initial cytologic examination coupled with patient profiling can help select those cases needing a further workup.
We describe a five-month-old boy with acute hemorrhagic edema, in whom the disease appeared after antibiotic treatment for a cellulitis in front of the tragus. AHEI is characterized by fever, acral edema, and rosette-shaped purpuric plaques that show leukocytoclastic vasculitis of small dermal vessels on histologic examination[2].
He had been taking ceftriaxone (1 g) for about five days for the cellulitis in front of the tragus. They finally turn into homogeneous or dark-centered palpable non-pruritic hemorrhagic purpura[8]. Our patient’s histopathology was consistent with leukocytoclastic vasculitis, and direct immunofluorescence was negative. AHEI classic features do not include symptoms such as vomiting, abdominal pain or renal alterations like in HSP[4]. Systemic corticosteroids and antihistamines do not seem to improve the course of the disease[1].
Second, the current criteria do not distinguish cellular abnormalities that are more suggestive of HPV infection from those that are not. Seven different PTs signed out these cases, and the HR-HPV positivity rates of 6 were within 10% of the laboratory average HR-HPV rate, with 1 who was 20% higher. The focus of our study was to identify the cytologic characteristics and pertinent background information available at the time of interpretation, which would maximize the screening power of the Pap test in the most cost-effective and time-efficient manner. Additionally, many atypical cells, whether singly or in groups, and increased numbers of atypical groups of cells were also associated with increased incidence of HR-HPV (Table I).


Another study, by Zhao et al,13 found no relationship between trichomoniasis and cervical neoplasia but did find a possible correlation with tuberculosis infection. While this technique is reportedly successful at sorting 60% of cases diagnosed as ASCUS into either LSIL or HSIL, it does involve additional cost, time and manpower. This technique may be useful after the diagnosis of HR DNA–positive ASCUS has been rendered, but with the additional cost incurred for this procedure, it is less desirable as a universal screening option. Individuals with significant departure from the laboratory mean or laboratories with significant departure from national reporting rates could trigger closer examination of their interpretive and reporting rates.
Obtaining more patient information, such as smoking history, may be additional data to be used for future studies. AHEI has common clinical features with Henoch- Schonlein purpura (HSP), and is considered by some authors to be a variant of this syndrome[3]; others regard it as a distinct clinical entity[2,4]. All patients have been infants and young children, with a majority younger than two years of age[7]. Although antihistaminic was given to our patient, we are not convinced that this treatment influenced the outcome of the disease. And finally, although reflex HR-HPV DNA testing is the preferred management option in the diagnosis of ASCUS, it does add an extra cost for the patient. The grid consisted of patient information: age, pregnancy status as available on the requisition, cell morphology, cell patterns, original cytologic diagnosis by pathologist (PT) and CT, and quality control review diagnosis. The average age of the pregnant patients was 31 years, with an age range of 16–35 years. Therefore, we used patient age and pregnancy status in our patient profiles because this information could be obtained from the specimen requisition form as it is a required field. Although increased numbers of atypical cells correlated with an increased incidence of HR-HPV infection, the converse did not prove to be true.
In contrast to these findings, a longitudinal cohort study performed by Viikki et al14 involving several different infectious agents showed that both T vaginalis and Herpes simplex were possible additional predictors of cervical neoplasia. No information is given concerning cost-effectiveness as compared to reflex HR-HPV DNA testing. Our study also affirms that HR-HPV DNA testing results can be used for retrospective analysis of laboratory and individual reporting practices and could be incorporated into the laboratory quality improvement program. Herein, we present a child with AHEI in whom the cutaneous eruption appeared after antibiotic treatment for a cellulitis in front of the tragus. If the criteria used in the initial diagnosis of ASCUS could be better defined and made more specific, the Pap test might be a more powerful tool. For the 5 CTs who screened these cases, the original laboratory statistics for 4 were within 10% of the laboratory average, with the exception of 1 CT, who was 20% lower on the positive HR-HPV rate. These findings suggest that hormonal or other effects of pregnancy may be associated with an increased risk of HPV infection.
A study by Cecchini et al10 evaluated these same nonclassical findings and also found a significant association with HPV infections.
Surprisingly, our study not only showed a lack of correlation but also a lower incidence of trichomoniasis in the HPV-positive group as compared with the HPV-negative group. Nuclear enlargement was defined as a nucleus 2–3 times the size of an intermediate cell nucleus. The review done by CTs as part of this project would have upgraded 32% of the cases to low grade squamous intraepithelial lesions (LSIL) or ASC-H (ASC, cannot rule out HSIL) and downgraded 24% to NILM (negative for intraepithelial lesion or malignancy). In our study, the 25 pregnant patients (16%) were found to have a higher percentage of positive HR-HPV results than the other women in the study (75% and 25%, respectively, Table I).
This suggests that while increased numbers of atypical cells or groups of cells may increase suspicion for HR-HPV infection, fewer numbers of cells are not a reliable negative indicator. In summary, the body of evidence for the correlation of specific infectious agents, particularly T vaginalis, and the development of cervical neoplasia is inconclusive at this point. Food and Drug Administration–approved method of processing cervical cytology specimens. Koilocytelike changes were defined as changes in cells that had some cytoplasmic and nuclear features suggestive of koilocytes but were qualitatively short of a diagnosis of koilocyte. Finally, 7 cases sent for HR-HPV testing were from the negative quality control rescreens as mandated under CLIA ’88. Hyperchromasia and nuclear enlargement were nonspecific findings in our study, while cells that demonstrated both nuclear and cytoplasmic enlargement were most often associated with HPV-negative cases. They may represent an actual increase in infection, but the possibility that this is an age-related finding cannot be dismissed. Fishers’s Exact test (2-tailed) was used to calculate the exact probability of obtaining results by chance. Our study differed from these other studies in that we did not separate cytomorphologic characteristics according to HR vs. However, even in this study, the pregnant population had a 4.8% higher HPV-positive rate, but whether this increase is significant is not known. We also evaluated total number of cells with changes rather than total number of features present. Subsequent reporting rates and HR-HPV positivity rates continue to be monitored as part of the laboratory’s quality improvement program. In contrast to the Bollmann study, we did not find that fewer cells or minimally abnormal Pap tests were reliable in ruling out a case for further triage. Acute hemorrhagic oedema of infancy (AHEI) - a variant of Henoch-Schonlein purpura or a distinct clinical entity?.



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Comments to «Herpes skin infection on stomach»

  1. Nomre_1 writes:
    Episode can, at occasions, be so gentle as to pass unnoticed.
  2. JESSICA writes:
    Must have Pap smears extra often accidentally says.