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STUDY OF SPUTUM CYTOLOGYIN CHEST DISEASES
Jg Saluja*, Ms Ajinkya**, Bhavana Khemani***
*Assoc. Prof and Head of Pathology; **Assoc. Prof. of Pathology; ***Chief Technician; CMPH Medical College and Mumbadevi Homoeopathic Hospital, Vile Parle (W), Mumbai - 400 056.
Sputum is pathologic material expectorated from lungs and bronchi, in the strict sense, and it consists of saliva and secretion from nasal, laryngeal and mouth cavities in different proportions when evacuated from the mouth. Sputum material collected should show the presence of alveolar macrophages, as macrophages have not been reported in the secretion of upper respiratory tact. The positive predictive value of sputum cytology in chest diseases depends on its reliability, sensitivity and specificity. We describe the data studied in 40 patients of chest diseases at Shri Mumbadevi Hom. Hospital and CMPH Medical College. Since 1960, little data is found in literature regarding sputum cytology in lung tuberculosis. In our study of sputum cytology, we did find epithelioid cells, giant cells in tuberculosis lung pathology as compared to non tuberculosis lesion of lung assuming that the exfoliation of chronic inflammatory cells were more in cavitatory lesion and the sensitivity when the cavity is in direct connection with bronchioles/bronchi. Finally repeated findings of epithelioid cells and Langhan cells in the sputum excludes the possibility that cytological abnormality is due to transient response to irritation in the subject with non tuberculous lung disease.
INTRODUCTION
Sputum is pathologic material expectorated from lungs and bronchi, in the strict sense, and it consists of saliva and secretion from nasal, laryngeal and mouth cavities in different proportions when evacuated from the mouth.
A spot specimen may be collected under supervision or an overnight collection be used for examination. Specimen is collected preferably in the early hours of morning before a meal is taken. Patients must be properly instructed to rinse the mouth before collection to avoid food and other particles. Specimen collected should not be exposed to direct sunlight as tubercle bacilli are highly sensitive. Sputum material collected should show the presence of alveolar macrophages; macrophages have not been reported in the secretion of the upper respiratory tract. Its presence is especially important as to specimen adequacy for cytology.
The positive predictive value of sputum cytology [3] in chest diseases depends on its reliability, sensitivity and specificity. The reliability of a test is defined as its precision. A reliable test is one which when applied repeatedly to same specimen or patient will produce same or similar result. Test reliability is commonly expressed in terms of its reproducibility. Test sensitivity is defined as the proportion of persons with a given disease to give a positive response to the test.
The specificity of a test is defined as the proportion of persons without the disease who give a negative response to the test. The false positive rate is the proportion of persons without the disease, who give positive response to the test. The false positive rate=I - specificity.
The epithelioid cells, giant 1-2 cells are ordinarily not expectorated in sputum but looked for in fine needle aspiration or bronchial brushing.
We describe the data studied in 40 patients of chest diseases at Shri Mumbadevi Hom. Hospital and CMPH Medical College.
MATERIAL
Forty patients were selected having various chest diseases in the age group 25-70 years. There were 26 males and 14 females. Males were working in cotton mill factory and few of them staying near industrial areas.
The presenting complaints was classified as follows :
Symptoms Males Females Pat No. Per cent Pat No. Per cent Cough with expectoration 28 11.2 6 2.4 Dyspnoea 12 4.8 3 1.3 Weight loss 15 6.0 15 6.0 Fever 20 8.0 9.0 3.6 Cough not responding to treatments 6.0 2.4 3.0 1.2 Past history Males Females Pat No. Per cent Pat No. Per cent Maltreated pulmb TB 19 7.6 6.0 2.4 Smoking 30 12 5.0 2.0 Bronchial asthma 2.0 0.8 0 0 Allergic diathesis 1.0 0.4 1.0 0.4 Diabetes mellitus 2.0 0.8 1.0 0.4 HIV status +ve 0 0 2.0 0.8 Family history No. of cases Per cent Mother diabetic 3.0 1.2 Father diabetic 3.0 1.2 Mother pulm TB 2.0 0.8 Father pulm TB 4.0 1.6
All the patients were subjected to investigations viz. CBC, ESR, sputum cytology, plasma glucose, HIV (ELISA) and X-ray chest.
The results are tubulated as follows (Tables 1-6).
TABLE 1
X-ray chest PA viewParticulars No of cases Per cent Cavity 10.00 25 Infiltration with cavity 7.0 17 Infiltrating lesion
- Apical
- Lower lobe10.0
6.0
4.025
15
10Bronchopneumonia 1.0 2.5 Bronchiectasis
-Tubercular
- Non tubercular4.0
2.0
2.010
5.0
5.0BVM and pulm fibrosis 3.0 7.5 Pleural effusion with infiltration 3.0 7.5
TABLE 2
Sputum cytology (H and E stain)Findings of SputumPatients showing X-ray findings CytologyCavity and Infiltration Number Per cent - Epithelioid cells 17.0 42.5 - Degenerated epithelioid cells 2.0 5.0 - Multinucleated giant cells 5.0 12.5 - Degenerated giant cells 7.0 17.5 - No specific cells 9.0 22.5 - Malignant cells 2.0 5.0
TABLE 3
Detection of acid fast bacilli (ZNCF modified method cool technique)Positive No of cases Per cent + 10.0 25 ++ 4.0 10 +++ 2.0 5.0 ++++ 1.0 2.5 Negative 23.0 57.5
Number of bacilli seen in a smear Result reported No AFB per 100 oil immersion fields 0 1-9 AFB per 100 oil immersion fields Scanty 10-99 AFB per 100 oil immersion fields + 1-10 AFB per oil immersion fields ++ 10 AFB per oil immersion fields +++ More than 10 AFB per oil immersion fields ++++
DISCUSSION
We searched the literature since 1960 for data of sputum cytology in lung tuberculosis, there is little to be found. There were studies carried out by Nasiell. M and Roger V in the year 19721 they found that sputum and bronchial secretions showed giant cells and epitheliod cells in chronic non-tuberculous inflammatory lung diseases and in bronchogenic carcinoma. Nasiell et al mentioned that the population of these were more marked in tuberculosis lung disease as compared to chronic non-tuberculous lung disease.
In our study of sputum cytology we did find epitheliod cells, degenerated epitheliod cells, giant cells as well as degenerated giant cells significantly more in tuberculous lung pathology as compared to non-tuberculous lesion of lung. This is probably due to the caseous necrosis [8] and affection of bronchial wall or mucosa which makes it comprehensible that epitheliod cells and langhan cells would be found in sputum cytology examination.
The variability of results in our study could be probably related to location [4-7] of tuberculosis. E.g. intrabronchial tuberculous cavitation, infiltration of lung tissue. Various ‘irritation’ forms of the bronchial epithelium may occur in response to pathogens or irritants and atypical cells have been observed in sputum from patients with bronchial asthma, bronchiectasis, acute and chronic respiratory infection and prior radiotherapy.
Sensitivity [3] increases with repeated examination and is highest in patients having cavitatory lesion as compared to infiltration of lung parenchyma. Assuming that the exfoliation of chronic inflammatory cells were more in cavitatory lesion and the sensitivity improved when the cavity is in direct connection with bronchioles / bronchi. One should screen the population at risk, for sputum cytological examination in order to catch the tuberculous disease process at the earliest to prevent complications and multidrug resistance. Finally repeated findings of epitheliod and langhan cells in the sputum excludes the possibility that the cytological abnormality is due to transient response to irritation in subject with non-tuberculous lung disease
TABLE 4 HIV status (Elisa) No. of cases Per cent Positive 2.0 5 Negative 38 95 Both females One female HIV + Sputum cytology Negative and ESR 12 mm at the end of one hour Second female HIV + Sputum cytology Epitheliod cells giant cells ESR : - 40 mm at the end of one hour ESR (Westergren’s)
TABLE 5 Haematology No. of cases Percent Leucocytosis 8.0 20 Normal leucocyte count 32.0 80 Normal range 4,000-11,000 Haemoglobin Normal 24.0 60 Low Normal range 11.0 - 16.0 gms/dl Low range 8.0 - 12.0 gms/dl Erythrocyte sedimentation rate (ESR) (Westergren’s) Males No. of cases Per cent 20 - 30 mm 12.0 30 40 - 50 mm 7.0 17.5 50 - 100 mm 7.0 17.5 Below 20 mm 1.0 2.5 Females No. of cases Per cent 20 - 40 mm 6.0 15 40 - 100 mm 7.0 17.5 Below 20 mm 0 0 Normal range Males 0-15 mm at the end of one hour
Females 0 - 20 mm at the end of one hour
TABLE 6 Plasma glucose No of cases Per cent Fasting Pl Glucose 3.0 1.2 Range 200-220 mg/dl Post lunch Pl glucose Range 286-300 mg/dl Method : GOD POD
ACKNOWLEDGEMENT
We thank the Dean Dr. SK Goel for giving permission to publish the study.
REFERENCES :
1.Nasiell M, Roger V, et al. A cytologic findings indicating pulmonary tuberculousis. The diagnostic significance of epitheliod cells and langhan giant cells in sputum or bronchial secretions. Acta Cytol 1972; 16 : 646.
2.Roger V, Nasiell M, Hjerper A. A cytologic findings indicating pulmonary tuberculosis. The occurrence in sputum of epitheliod cells and multi-nucleated giant cells in pulmonary tuberculosis, chronic non-tuberculous inflammatory lung disease and bronchogenic carcinoma. Acta Cytol 1972; 16 : 538.
3.Dr. J Benhassal predictive value to sputum cytology. Thorax 1987; 42 : 165-72.
4.Jay SJ, Smith AL, et al. Diagnostic sensitivity and specificity of pulmonary cytology. Acta Cytol 1980; 24 : 304-12.
5.Ng ABP, Horak GC. Factors significant in the diagnostic accuracy of pulmonary cytology. Acta Cytol 1983; 27 : 397-406.
6.Evans DMD, Shelley G. Respiratory cytodiagnosis study in observer variation and its relation to quality of material. Thorax 1982; 37 : 259-63.
7.Johnson WW, et al. The cytopathology of respiratory tract A review. Am J Pathol 1976; 84 : 372-424.
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