Cytologic Diagnosis of Malacoplakia

Abstract

Malacoplakia is a rare chronic inflammatory process characterized histologically by the collection of histiocytes with acidophilic granular cytoplasm, so-called von Hansemann cells, some of them rounded lamellar basophilic inclusions in the cytoplasm called Michaelis-Gutmann bodies or calcospherites. In 1902, Michaelis and Gutmann described malacoplakia in the urinary tract and until the last two decades, it was thought to be confined to the urinary tract, when cases in other sites were reported. The exact etiology of malacoplakia is not known but an acquired defect of intracellular degradation of ingested bacteria, usually gram negative coliform bacilli, by phagocytes has been postulated as an etiologic factor. 1 Twenty-two cases of malacoplakia affecting the genital tract have been previously reported, but only in two cases, cytologic analysis has been included. We reported the cytological findings in a case of malacoplakia involving the vagina, cervix, endometrium, parametrium, one adnexa and the skin.A 50-year-old Saudi female, Para 9, Gravida 10, 11 years postmenopausal, was referred to the Maternity and Childrens Hospital (Riyadh) because of sluggish vaginal bleeding associated with lower abdominal pain for one year. On admission, she was a thin female, with a temperature of 39°C, BP of 130/80. Physical examination was noncontributory except for a hard, painful mass in the lower abdomen. Gynecological examination revealed an enlarged uterus, a necrotic polypoid mass at the cervix and vaginal vault and an irregular nodular mass on the right side of the uterus. Biopsy and cytologic smear from the vaginal lesion were obtained.The cervical smear showed an inflammatory exudate made up of histiocytes with polymorphonucleocytes (PMN) associated with a scanty number of epithelial cells as expected in postmenopausal Papanicolaou smear.In addition to the increased number of histiocytes with fine granular cytoplasm and intracytoplasmic bacteria, a thin layer of capillary blood vessels lined by endothelial cells was present. Occasional target-like inclusions of Michaelis-Gutmann bodies were observed (Figure 1). A cytologic diagnosis of malacoplakia was made. This was later confirmed by the biopsy obtained from the vaginal mass (Figure 2). Subsequent total hysterectomy revealed that the process was extensively involving the cervix, endometrium, parametrium and one adnexa also.The clinical presentation in this patient is the classic manifestation of malacoplakia involving the genital system. The patients are 50 years old or older and the main complaint is usually vaginal bleeding because the vagina is the most commonly affected organ.5 Clinical diagnosis of carcinoma also is frequently made when the lesion is affecting the cervix. 4,6 The cervical smear revealed an inflammatory process with PMN and histiocytes associated with strings of capillary structures and postmenopausal epithelial changes. The histiocytes were filled with bacteria and a few Michaelis-Gutmann bodies were present in the histiocytes.Cytologic diagnos...