Utility of urinary cytology for diagnosing human polyoma virus infection in transplant recipients: a study of 37 cases with electron microscopic analysis.

Human polyoma virus (HPOV) infection is associated with hemorrhagic cystitis, tubulointerstitial nephritis, and renal transplant dysfunction/allograft loss. We evaluated the utility of cytologic examination to detect HPOV infection in 37 urinary cytology (UC) samples (3 bladder washings, and 34 voided samples) from 29 transplant patients, compared to electron microscopic studies (EMS). Evidence of viral infection was found in 11 specimens (30%). Five cases were diagnosed as HPOV by both UC and EMS. One was positive for HPOV by EMS only. Two cases diagnosed as HPOV by UC were demonstrated to be adenovirus (AV) with EMS. Two cases diagnosed as cytomegalovirus (CMV) by EMS had negative UC. One was called HPOV by UC; EMS in this case was negative. Compared to EMS, the sensitivity and specificity of UC for detecting HPOV were 83% and 90%, respectively, with a positive predictive value of 63% and a negative predictive value of 96%. We conclude that UC is a relatively sensitive and specific method for detecting active HPOV infection in transplant patients, and is important in light of the clinical significance of HPOV infection in transplant recipients. The sensitivity and accuracy of UC for diagnosing HPOV can be increased by adding EMS.     

Cytologic detection of concurrent infectious agents in urines from renal transplant patients

Cytology is a well recognized and utilized method for the detection of polyomavirus in urine specimens from renal transplant patients. The purpose of this 5 year 6 month retrospective study (January 1, 2003–June 30, 2008) was to report on the additional infectious agents detected in these specimens. Of the 7,116 urine samples from renal transplant patients that were processed for the detection of polyoma (BK) virus, 1,399 (19.7%) were positive for BK viral inclusions and 5,717 (80.3%) were negative. In addition, 347 specimens (4.8%) contained infectious agents including HPV (1.6%), Candida (3.2%), Herpes virocytes (0.03%), cytomegalovirus (CMV; 0.03%), and trichomonads (0.03%) either alone or in combination. Follow‐up cervical, vaginal, and/or vulvar biopsies were available in six (5%) of the 115 specimens with cellular changes consistent with low‐grade HPV infection: three showed high‐grade squamous intraepithelial lesions, two showed low‐grade squamous intraepithelial lesions, and one showed both types of lesions. Urinary cytology plays a role not only in the detection of BK virus but also other infectious agents, which have an impact on follow‐up patient management. Diagn. Cytopathol. 2010;38:549–550. © 2009 Wiley‐Liss, Inc.     

Microfilaria in urine cytology: Report of three cases with review of literature

Lymphatic filariasis is a major public health problem in the developing countries. In India, around 90% of the cases are attributed to Wuchereria bancrofti species morphologically identified as sheathed parasites with tail tip free of nuclei. Microfilariae have been described in urine specimens from patients with chylous and achylous hematuria as well as in a spectrum of other body fluids. Case reports describe their presence in aspirates from numerous neoplasms. However, their association with urothelial carcinoma in urine sediment has been rather rare with only three cases described previously. We report three cases of filariasis in urine cytology, one of which was associated with atypical urothelial cells. Our aim is to stress on the possibility of concomitant filariasis in body fluids and aspirates with other significant findings, especially in endemic areas. Identification of the same renders complete diagnosis and proper treatment to the patient.     

Atypical cells in a voided urine cytology specimen in a renal transplant recipient

Voided urine is routinely collected from renal transplant patients to screen for polyomavirus. In rare cases, atypical lymphoid cells can be detected in voided urine and raise the suspicion of post‐transplant lymphoproliferative disorder (PTLD). However, further immunohistochemistry of the cell block and flow cytometry is frequently limited by the low cellularity and poor preservation of voided urine. Therefore, PTLD of the renal allograft is usually diagnosed from tissue biopsy or nephrectomy specimens. Herein, we report a rare case of atypical cells in a voided urine cytology specimen from a kidney transplant recipient. Needle core biopsy of the renal allograft showed monomorphic PTLD. Diagn. Cytopathol. 2017;45:69–72. © 2016 Wiley Periodicals, Inc.     

Decoy cells and malignant cells coexisting in the urine from a transplant recipient with BK virus nephropathy and bladder adenocarcinoma

The search for decoy cells (DC) in urine is widely used as screening for BK virus (BKV) reactivation in transplant recipients. BKV cytopathic effect of DC must not be confused with high-grade urothelial carcinoma. This report presents a case of coexistence of DC and malignant cells in the urine from a transplant recipient with BKV-associated nephropathy (BKVN) and bladder adenocarcinoma. A 38-year-old female with type 1 diabetes mellitus and end-stage renal disease underwent a simultaneous pancreas and kidney transplant. Four years post-transplantation, BK virus studies were performed for renal dysfunction. Isolated DC and DC in casts were identified in urine. Also, the tests for BKV DNA were positive in serum and renal allograft biopsy. BKVN was treatment-resistant and the patient returned to hemodialysis. A kidney transplant nephrectomy was performed 2 years later. The next urine cytology showed, in addition to DC, other distinct cells with nuclear atypia highly suggestive of malignancy. Some cells showed both, malignant and DC features. A bladder adenocarcinoma was diagnosed on biopsy and BKV proteins were demonstrated on tumor cells, supporting a possible role for BKV in the oncogenic pathway in this clinical setting. The presence of DC in the urine from a transplant recipient is the hallmark of BKV activation, but it does not exclude the existence of carcinoma. Furthermore, the presence of highly atypical cells should raise, not eliminate, the possibility of neoplastic transformation of the bladder.     

Human papillomavirus infection in urine samples from male renal transplant patients

Renal allograft recipients have a well‐documented increased incidence of human papillomavirus (HPV)‐related malignancies and preventive strategies should be specifically implemented. While in females the use of the Papanicolau test and HPV detection assay are used currently as a screening test for cervical cancer, no diagnostic procedures have been implemented to monitor HPV infection in males. The aim of this study was to test for HPV infection and to determine the spectrum of viral genotypes in urine samples of men with renal transplants. The study included 88 patients who underwent kidney transplantation between 1999 and 2005. HPV sequences were detected by nested PCR, using the broad‐spectrum consensus‐primer pairs MY09/MY11 and the new MGP system, and characterized by nucleotide sequence analysis. Overall, 43 (48.9%) samples were found positive for HPV sequences and the most common genotypes were HPV 16 (53.5%) and HPV 54 (9.3%) followed by HPV 6, 53, 56, 58, 66, 11, 12, 20, 45, 62, and 71, in descending order of prevalence. The majority of HPV 16 isolates were classified as European and only one as African‐1 variant on the basis of nucleotide signature present within the MGP L1 region. The high prevalence of HPV 16 among renal allograft recipients suggests that an HPV‐16‐based preventive or therapeutic vaccine may be effective for prevention or treatment of HPV‐related neoplasia in this group of immune compromised patients. J. Med. Virol. 82:1179–1185, 2010. © 2010 Wiley‐Liss, Inc.     

Negative-staining electron microscopy of the urine for the detection of polyomavirus infections

Negative-staining electron microscopy (EM) has played a pivotal role in diagnostic virology. It is a rapid technique for viral detection in the urine and can provide an easy means for monitoring viral activity and productive infections. EM of urine for the detection of polyomaviruses has hitherto not been systematically evaluated as a screening tool for renal transplant patients at risk for BK polyomavirus nephropathy (BKN). Here, the authors discuss technical aspects of negative-staining EM of urine (n = 76 samples) and present a simple and rapid protocol for the semiquantitative evaluation of patient samples. In two patient populations (either with (n = 15 samples) or without (n = 15 samples) an established diagnosis of BKN), EM results were compared with two previously established techniques for monitoring polyomavirus activation: (1) cytology for the quantitation of decoy cells, and (2) quantitative PCR assays for the detection of BK virus DNA load levels. In both patient groups, the dynamics of decoy cell shedding by urine cytology closely paralleled free viral particle shedding by EM, and viral load levels as measured by PCR. A trend toward higher readings was observed in patients with BKN (median values, control versus BKN groups: decoy cells 21 versus 50/slide; free virions by EM: 32 versus 66 viral particles/10 high-power fields; PCR: 3.5 × 10⁸ versus 5.4 × 10⁸ BK virus copies/ml; all differences not statistically significant). The authors conclude that negative-staining EM and the semiquantitative assessment of free viral particles in the urine can be a useful clinical method to identify patients at increased risk for BKN. EM can be used alone or in combination with urine cytology or PCR assays.     

Direct detection of the human papovavirus BK in urine of bone marrow transplant recipients: comparison of DNA hybridization with ELISA

Urine specimens from bone marrow transplant (BMT) recipients and from controls were directly tested for BK virus (BKV) DNA sequences by dot hybridization and for BKV antigen by a double-antibody indirect ELISA. A total of 158 specimens from 55 BMT patients (57 collected prior to or at the time of transplantation and 101 in the posttransplant period) and single urines from 125 control subjects were examined by both methods. A molecularly cloned, 32P-labelled BKV probe was hybridized with urine sediments that were spotted directly on nitrocellulose filters and denatured in situ. BKV DNA sequences were detected in 1 (1.8%) pretransplant and 22 (21.8%) posttransplant urines of BMT patients, and in none of control urines. In ELISA of urine supernatants, BKV antigen was detected in 1 (1.8%) pretransplant and 21 (20.8%) posttransplant urines of BMT patients and in 1 (0.8%) of the control urines. The results of the two tests correlated as follows: 16 urines were positive and 253 urines negative by both methods; seven specimens were positive by DNA hybridization only and seven were positive by ELISA alone. Virus excretion in urine was demonstrated in 20 (36.4%) patients by DNA hybridization, in 19 (34.5%) patients by ELISA, in 15 (27.3%) patients by both methods, and in 24 (44%) patients by at least one of the two tests.     

Diagnosis of histoplasmosis in urine cytology: reactive urothelial changes, a diagnostic pitfall. Case report and literature review of urinary tract infections

Histoplasmosis not uncommonly causes systemic infection, particularly in immunocompromised patients. In systemic infection, the urinary tract is often involved, although the diagnosis of histoplasmosis in urine cytologic specimens has never been reported. Urinary tract histoplasmosis may present with gross hematuria, raising clinical suspicion for malignancy. The index case presented with intermittent gross hematuria, suprapubic pain, significant weight loss, hoarse voice, and a painful tongue ulcer. Examination of the patient revealed an ulcerated tongue lesion, an anal ulcer, a polypoid lesion on the vocal cord, and cystoscopic examination of the urinary bladder revealed erythematous patchy areas. Surgical biopsy sections from the vocal cord and tongue lesion were diagnostic of histoplasma infection. Urine cytologic examination showed atypical urothelial cells suspicious for malignancy. However, fungal stains performed on the urine specimen showed histoplasma organisms. We conclude that with a high index of suspicion, and the use of special stains, histoplasma organisms can be identified in urine.     

Cytokeratin-20 immunocytochemistry in voided urine cytology and its comparison with nuclear matrix protein-22 and urine cytology in the detection of urothelial carcinoma

This study was done on 59 subjects (42 urinary bladder carcinoma patients and 17 non‐neoplastic controls). Urine cytology and bladder chek NMP22 test was done on all cases. CK20 immunostaining was performed on archived papanicolaou stained urine cytology smears in 34 cases (27 bladder carcinoma and 7 negative controls). Results of all three tests (cytology, NMP22, and CK20 immunostaining) were compared with histopathology to evaluate the accuracy of individual test. The combination of cytology and NMP22 was compared with combination of cytology and CK20 immunostaining for detection of bladder carcinoma. NMP22 had sensitivity of 92.9% and specificity of 70.6%, as compared with voided urine cytology (sensitivity of 76.2% and specificity of 76.5%) and CK20 immunostaining (sensitivity of 70.4% and specificity of 71.4%). Combination of cytology and NMP22 gave better results (sensitivity of 88.1% and specificity of 88.2%) than combination of cytology and CK20 immunostaining or any other test in isolation. Diagn. Cytopathol. 2012. © 2011 Wiley Periodicals, Inc.     

Polyomavirus disease in renal transplantation: review of pathological findings and diagnostic methods

Up to 10% of renal transplant recipients can develop polyomavirus nephropathy (PVN) in the allograft, leading to premature graft failure. Recent studies have shown that early diagnosis of PVN before there is irreversible damage to the kidney can result in marked improvement of outcome with resolution of the infection in a large proportion of patients. Early histopathologic diagnosis is complicated by the subtle beginning of the infection and its multifocal nature. This review presents a comprehensive set of guidelines for the effective clinical use of urine cytology and quantitation of viruria and viremia in conjunction with the renal biopsy findings. The morphological features of PVN are presented with specific emphasis on the patterns of PVN that are based on the histological progression of the disease and that correlate with clinical outcome. Also discussed in the context of their clinical significance are the main virological and epidemiological aspects of the BK, JC, and SV40 polyomavirus infections.     

Use of ThinPrep monolayer technique and cytospin preparation in urine cytology: a comparative analysis

We compared the ThinPrep (TP) technique to the cytospin (CS) preparation in the cytological diagnosis of urine by processing 79 specimens by these two techniques. Ten cases were positive for malignancy (six high grade (HG)/carcinoma in situ; four low grade (LG) transitional cell carcinomas (TCC)). Forty-eight cases were within normal limits (59%) and 21 cases had atypical cytological features (19%). The TP technique was better in terms of a cleaner background with fewer obscuring inflammatory cells and blood and with a more even distribution of cells. In general, the cytomorphology was comparable in both techniques. However, in cases with malignancy, CS was relatively superior in the cytomorphologic details; in TP, the diagnostic cells were mostly dispersed as single cells with loss of architectural features and were difficult to find. Artifactual empty spaces and air-drying were more frequently present in TP. In cases contaminated with squamous cells, the urothelial cells were difficult to find in TP. Screening time was comparable for both techniques. In conclusion, to avoid false-negative diagnosis, CS would be complementary to the TP technique in malignant cases and, in particular, those with low cellularity.     

Rare subtypes of BK virus are viable and frequently detected in renal transplant recipients with BK virus-associated nephropathy

BK virus-associated nephropathy (BKVN) occurs in up to 5% of kidney transplants and is a significant cause of graft loss. Four major subtypes of BKV have been described, with the vast majority of individuals persistently infected with BKV Type I (> 80% of the population). Sequencing of BKV isolates subcloned from BKVN patients revealed a high percentage of variants in the urine (40%) in the VP1 subtyping region. In vitro analysis of several viral variants revealed that all variants recovered from the urine of BKVN patients produced infectious viral particles and were replication competent in cell culture while some of the variants induced cytopathic changes in infected cells when compared to the major BKV subtype, VP1 Type I. These results suggest that rare BKV VP1 variants are more frequently associated with disease and that some variants could be more cytopathic than others in renal transplant recipients.     

Urine cytology in renal glomerular disease and value of G1 cell in the diagnosis of glomerular bleeding

The objectives of the present study were to evaluate the cytology of urine sediments in patients with glomerular diseases, as well as the value of G1 dysmorphic erythrocytes (G1DE) or G1 cells in the detection of renal glomerular hematuria. Freshly voided urine samples from 174 patients with glomerular diseases were processed according to the method used for semiquantitative cytologic urinalysis. G1DEs (distorted erythrocytes with doughnut-like shape, target configuration with or without membranous protrusions or blebs), non-G1DEs (distorted erythrocytes without the above-mentioned morphologic changes), normal erythrocytes (NEs), and renal tubular cells (RTCs) were evaluated. Erythrocytic casts (ECs) were counted and graded as abundant (>1 per high-power field) or rare (1 per 5 high-power fields). G1DE/total erythrocyte ratios were calculated by counting 200 erythrocytes including G1DEs, non-G1DEs, and NEs. Only abundant NEs were found in 13 cases; abundant G1DEs, non-G1DEs, NEs, and no ECs in 95 cases; abundant NEs, non-G1DEs, and ECs and no G1DEs in 31 cases; and abundant NEs, G1DEs and non-G1DEs, and rare ECs in 35 cases. In 130 cases in which G1DEs were present, the G1DE/total erythrocyte ratios varied from 10% to 100%. This parameter was greater or equal to 80%, 50%, 20%, and 10% in 58 (44.6%), 29 (22.3%), 28 (21.5%), and 15 (11.5%) patients, respectively. In all cases, the number of RTCs was within normal limits or slightly increased, and a variable number of non-G1DEs were present in 161 cases. Thus, abundant ECs and/or G1DEs with a G1DE/total erythrocyte ratio of 10-100% proved to be specific urinary markers for renal glomerular diseases.     

Penoscrotal transposition and associated anomalies: Report of five new cases and review of the literature

We present the largest single series of cases (n = 5) of penoscrotal transposition (PST) with carefully documented nongenitourinary/anal anomalies, none of which fell into categories of known syndromes, associations, sequences or chromosome disorders. Several unexpected anomalies were observed including coloboma of the iris and retina, hydrocephalus, microcephaly, diaphragmatic hernia, tracheo-esophageal fistula/esophageal atresia and cleft palate. The most frequent anomalies other than PST were renal defects (100%) such as renal agenesis and dysplasia, imperforate anus (60%), central nervous system anomalies (60%) and preaxial upper limb defects (40%). Cardiovascular defects (atrial septal defect, double aortic arch with vascular ring) were noted in only one case. The surviving patients (3/5) had postnatal growth failure and mental retardation. Our 5 PST patients are compared to 16 well-documented cases from the literature. The overall incidence of various extragenital abnormalities were: renal (90%), mental retarardation (60%), imperforate anus (33%), central nervous system (CNS) anomalies (29%), vertebral defects (29%), preaxial limb defects (24%) and congenital heart disease (19%). PST is a rare heterogenous anomaly, the detection of which should warrant careful clinical evaluation to rule out other anomalies, especially of the urinary system, gastrointestinal tract, upper limbs, craniofacial region and central nervous system. PST may be a localized field defect involving the genitourinary system; however, the wide variety of more distant defects noted in our series and the literature would raise doubt about that assumption. The high frequency of growth deficiency and mental retardation has also not been given due respect as accompanying problems associated with PST. © 1995 Wiley-Liss, Inc.     

Myeloid leukemia in a urine specimen: A case report and review of the literature

Urinary tract cytology has a long history of utilization for the diagnosis and follow‐up of tumors involving the urothelial tract. As expected, the most common tumor encountered in exfoliative urine cytology is urothelial carcinoma. While the sensitivity of urinary tract cytology for the diagnosis of low‐grade urothelial carcinomas is low, its sensitivity and accuracy for high grade urothelial carcinomas is much higher. However, nonurothelial malignancies, such as hematopoietic malignancies, can also be encountered in urine specimens. Leukemic cells in urine can be diagnosed readily by cytological examination in cases where more invasive procedures are difficult to perform. Additionally, cell block sections can be utilized to determine the immunocytochemical profile of the tumor cells to confirm the diagnosis. Herein we report a case of a 75‐year‐old man with a past medical history of acute myeloid leukemia (AML), who presented with congested heart failure and painless macroscopic hematuria. AML relapse was diagnosed. Cytological examination of the urine using a ThinPrep® smear, cytospin preparation, and immunohistochemical stains performed on the cell block sections were examined. Findings were consistent with leukemic cells of myeloid origin in the bladder washing specimen. Diagn. Cytopathol. 2014;42:700–704. © 2013 Wiley Periodicals, Inc.     

Mammary myofibroblastoma: report of two cases with fine-needle aspiration cytology and review of the cytology literature

Fine-needle aspirates from two histologically, immunohistochemically, and ultrastructurally confirmed mammary myofibroblastomas (MM) of two elderly women revealed abundant, randomly arranged single and clustered benign spindle-shaped mesenchymal cells with scant cytoplasm and elongated or oval nuclei displaying a finely granular chromatin pattern and inconspicuous nucleoli. In one case a few cells showed inconspicuous nuclear grooves. The aspirated tumor cells from the other case stained positively with desmin and CD34 antibodies and negatively with cytokeratin and S-100 protein antibodies, in keeping with an MM. A review of the literature was briefly presented.     

The detection of antibodies to cytomegalovirus in the sera of renal transplant patients by an igm antibody capture assay

An IgM antibody capture assay for detection of cytomegalovirus (CMV) IgM antibody (MACRIA) was developed. It was shown to be of similar sensitivity to the indirect immunofluorescence test but has the advantage that rheumatoid factor does not react in it and pretest fractionation of serum is not required. It does, however, give false results with some Paul Bunnell-positive sera. The assay was used to measure the IgM response in 28 renal transplant patients followed prospectively. Seven patients (100%) with primary infections and six of 13 (46%) patients with secondary infections developed IgM by MACRIA. Nine of 13 (69%) patients with CMV IgM-positive sera had symptoms other than pyrexia associated with CMV infections, while only one of seven (14%) IgM-negative infections were symptomatic. Four of seven irreversible rejection episodes were associated with CMV IgM. The possible significance of CMV IgM production is discussed.