Tularemia: potential role of cytopathology in differential diagnosis of cervical lymphadenitis: Multicenter experience in 53 cases and literature review

Abstract

Tularemia is a zoonosis caused by Francisella tularensis. Tularemia outbreaks occurred in Central Anatolia during 2009 and 2011. We evaluated the clinical characteristics and cytomorphologies of fine needle aspirations (FNAs) from cervical lymph nodes in serologically confirmed tularemia cases. To our knowledge, this is the first large series concerning FNA morphology of Tularemia. FNA smears of 53 patients of the 290, diagnosed by microagglutination tests and PCR, were evaluated at three Pathology centers. FNAs were performed by cytopathologists or ear-nose-throat surgeons. Of all patients, 17 had also lymph node resections. FNAs showed the presence of suppuration and abscess. Rare epithelioid histiocytes and granulomas, seldom phagocytosed bacilli-like microorganisms were observed. On histopathology; granulomas, necrosis, and suppurative inflammation extending extracapsular areas were seen. Tularemia is endemic in certain areas of the Northern Hemisphere. The benefit from cytopathology is limited and cytological suspicion should be confirmed by serology. However FNA cytology is helpful in differential diagnosis of tularemia and other diseases presented with suppurative, granulomatous cervical lymphadenitis. It is also useful in providing the material for PCR and culture in early phase when the serology is negative and the treatment is more effective.

A Suppurative Granulomatous Lymphadenitis Agent: Tularemia, Case Report

“…Tularemia is seen most commonly in the Black Sea and Marmara regions of Turkey (4) . There are six clinical forms of Tularemia in humans: oropharyngeal, glandular, ulceroglandular, oculoglandular, pneumonic, and typhoidal (2,4,6,8) . Among all of the outbreaks in Turkey, the oropharyngeal form was the most common (2) .…”

“…However, for the diagnosis of tularemia, FNA is not a useful method per se. FNA may raise the suspicion and should be supplemented by serology (6) .…”

“…Differential diagnosis of suppurative granulomatous lymphadenitis in cervical lymph nodes mainly includes tularemia and CSD. The absence of the history of a cat-contact and a visible injury site on the skin helps excluding the diagnosis of CSD and also the identification of microorganism is necessary for the diagnosis (6) .…”

“…It causes granulomatous and suppurative lesions especially in the affected regional lymph nodes and various organs (5) . Histopathological findings in affected lymph nodes have been found as ranged from well-defined acute inflammation and necrosis located within the outer cortex to generalized necrosis that obliterated the node with rare granulomatous inflammation (6) . We report a case of oropharyngeal tularemia in a patient who presented with cervical lymphadenopathy that can have similar clinical findings with metastatic carcinomas and lymphomas and we suggest to keep in mind cervical granulomatous lymphadenitis in differential diagnosis of cervical lymphadenopathies.…”

Early Diagnosis of Tularemia by Flow Cytometry, Czech Republic, 2003–20151

“…No clinical or laboratory manifestations are pathognomonic for tularemia; preliminary diagnosis is based on exposure risk and compatible clinical presentation ( 5 ). Clinical manifestations include the ulceroglandular, glandular, oroglandular, and oculoglandular forms; septicemic (typhoidal) form; and respiratory form ( 6 , 7 ).…”