7 year old male with pericardial effusion on cytology examination, plenty of eosinophil is noted.

1. SLIDE PRESENTATION
FLUID CYTOLOGY
Sansar Babu Tiwari, MBBS, PGY I
Department of Pathology
TUTH
20-02-2020
1

2. Slide Details
• One Giemsa stained and another Pap stained smear
of pericardial fluid
• 7 Years old male child

3. Description:
• Effusion smears from the pericardial fluid show
mostly eosinophils with lymphocytes, scattered
neutrophils and macrophages along with few
reactive mesothelial cells in a proteinaceous
background.
• Abundant extracellular and few phagocytosed
Charcot Leyden crystals are also seen.
• Parasites are not seen in the examined smears.
• Atypical cells are not seen.

4. Description:
• PBS findings:
• HB: 12.7 gm/dl
• WBC: 10300
• N 46 L 30 M 04 E 20
• Platelet: 297000

5. Olympus, X100

6. Olympus, X400

7. Olympus, X100

8. Olympus, X400

9. DIAGNOSIS:
DIAGNOSIS: EOSINOPHIL RICH EFFUSION.
Differentials:
1. Parasitic infections:
• Filariasis
• Hydatid Disease
2. Allergic or Hypersensitivity:
• Drug induced (Ceftriaxone)
• Food allergy
3. Autoimmune Disorders:
• Eosinophilic Granulomatosis with Polyangitis (EGPA)
4. Clonal proliferation:
• Chronic Eosinophilic leukemia
• T-cell Lymphoma
5. Idiopathic

10. BODY CAVITIES: Embryology

11. BODY CAVITIES: Embryology

12. BODY CAVITIES: Embryology

13. BODY CAVITIES: Embryology

14. BODY CAVITIES: Anatomy

15. BODY CAVITIES: Histology
• Although mesothelial cells are derived from
mesoderm, they demonstrate many
morphological and biological features of
epithelial cells.

16. BODY CAVITIES: Histology

17. BODY CAVITIES: Cytology
• Mesothelial cells round-up and appear
polyhedral after exfoliation due to surface
tension of the surrounding fluid.
• 1.5 to 2 times the size of the neutrophils.
• When the differential is performed, all
nucleated cells are counted, including
mesothelial cells and malignant cells

18. BODY CAVITIES: Cytology
• With pericardial fluid, a WBC count of
greater than 1000 cells/µl is suggestive of
pericarditis.
• Pleural fluids:
• Neutrophils predominate in 90% of acute
inflammation.
• Lymphocytes in TB, neoplasms and systemic
diseases.
• Peritoneal fluids:
• Neutrophils predominate in 25%
• Lymphocytes in TB, neoplasms and lymphatic
obstruction.

19. BODY CAVITIES: Cytology
• Pericardial fluids:
• Differential is seldom performed as it has little
diagnostic value.
• Overall the cell types are:
• Neutrophils
• Eosinophils
• Lymphocytes
• Monocytes
• Macrophages
• Plasma cells
• Mesothelial cells
• Malignant cells

20. BODY CAVITIES: Cytology

21. BODY CAVITIES: Cytology

22. BODY CAVITIES: Cytology

23. BODY CAVITIES:
• Lined by a thin layer of connective tissue
composed of flat mesothelial layer.
• The cavity fluid is created and maintained
through plasma ultrafiltration in the parietal
membrane and absorption by the visceral
membrane.
• Serous fluid have a composition similar to
that of serum.

24. BODY CAVITIES:
• Normally serous fluids do not contain blood
or fibrinogen
• But a traumatic puncture procedure,
hemorrhagic effusion, or an active bleed
(e.g., from a ruptured blood vessel) can
result in serous fluid that appears bloody and
clots spontaneously.
• Therefore, to prevent clot formation and
entrapment of cells and micro-organisms,
EDTA is preferred.

25. BODY CAVITIES:
• Refrigeration ( 4 to 8°c) adversely affects the
viability of microorganisms and should not
be used for serous fluid specimens.
• However, serous fluid samples intended for
cytology examination can be refrigerated at
4°c when storage is necessary.

26. BODY CAVITIES:

27. BODY CAVITIES:

29. BODY CAVITIES:
• Mesothelial cells can vary in appearance,
such as appearing singly or in clumps, can be
multi-nucleated, and can show reactive or
degenerative changes, mesothelial cells can
be difficult to differentiate from malignant
cells and macrophages.

30. BODY CAVITIES:

31. BODY
CAVITIES:

32. BODY
CAVITIES:

33. BODY CAVITIES: Mesothelial markers
• Positive markers:
• Calretinin
• D2-40 (podoplanin)
• CK 5/6
• WT1
• Negative markers:
• Ber-EP4
• mCEA
• MOC-31
• BG-8
• B72.3

34. BODY CAVITIES: Mesothelial markers

35. BODY CAVITIES: LYMPHOCYTE RICH EFFUSION

36. Hyper-eosinophilia:
• HE in a peripheral blood is defined as an
absolute eosinophil count (AEC) > 1500/µL)
on two examinations separated in time by at
least one month and/or pathological
confirmation of tissue HE.
• Tissue HE is defined by:
• On bone marrow, eosinophil percentage that
exceeds 20% of all nucleated cells and/or
• Tissue infiltration that is extensive in the opinion
of pathologist and/or
• Marked deposition of eosinophil granule
proteins in tissue (demonstrated by IF)

37. Hyper-eosinophilic Syndrome:
• HES is defined by the association of HE with
eosinophil mediated organ damage and/or
dysfuntion, provided other potential causes
for the damage have been excluded.
• Restrictive cardiac disease occurring in the setting of
parasitic infections. [Loefflers endocarditis]
• In contrast Persistent HE and thoracic pain secondary to
coronary artery occlusion shouldn't be diagnosed as
HES.

38. Hyper-eosinophilic Syndrome:
•Primary HES (Neoplastic)
•Secondary (Reactive)
•Parasitic infestations
•Solid tumors
•T cell lymphoma
•Idiopathic HES

39. HES: Pathophysiology
• Mechanism of eosinophil overproduction:
• Clonal eosinophilic proliferation as a result of
primary molecular defect involving
hematopoietic stem cells
FIP1LI-PDGFRA
PDGFRB
FGFR1
PCM1-JAK2
• Overproduction of eosinophilic cytokines such
as IL-5
Lymphocytic variant HES (L-HES): CD3- CD4+
phenotype of T cell

40. Organ-restricted HES
• Blood eosinophilia > 1500/µl in the setting of
single organ involvement.
• Eosinophilic gastrointestinal diseases
• Chronic eosinophilic pneumonia
• Well’s syndrome

41. HES: Clinical features
A retrospective multicenter study on 188
patients:
• Dermatological (rash) 37 %
• Pulmonary (cough and breathlessness) 25 %
• GI 14%
• Cardiac 5%
• Neurologic 4%

42. HES: Clinical features

43. HES: Pathophysiology
• Cardiac Diseases:
• Eosinophilic myocarditis is a major cause of morbidity
and mortality in HES
• PDGFRA associated HES has more predilection to heart
• The severity of cardiac injury does not correlate with the
degree of peripheral eosinophilia.
• In EGPA: cardiac involvement of the myocardium and
pericardium is due to small vessel vasculitis that impairs
cardiac function without the development of
endomyocardial thrombi and fibrosis.

44. HES: Pathophysiology
• Cardiac Diseases:
• Three stages:
• Acute necrotic stage: Endocardial damage, myocardial
infiltration with eosinophils and lymphocytes, myocardial
necrosis (Usually clinically silent). Trop I can be used as a
indicator of damage in HES and EGPA. ECHO may be normal.
Endomyocardial biopsy can be done with MBP-1 immunostain
even if eosinophils are not seen in the sections examined.
• Thrombus formation: Eosinophil peroxidase forms
hypothiocyanous acid which inturn induces tissue factor
expression. Embolic stroke can be the presentation.
• Fibrotic stage: Fibro-inflammatory remodeling can lead to
rupture of chordae tendinae or fusion of valves to the
endocardial surface. Dyspnea, chest pain, MR, TR,
cardiomegaly, restrictive cardiomyopathy can occur.

45. HES: Pathophysiology

46. HES: Pathophysiology

47. Pericardial effusion: Causes
• Normal fluid volume is 10-50 ml.
• Causes:
• Infection
• Malignancy
• Trauma
• Uremia
• Hypothyroidism
• Autoimmune disorders
Exudates
Transudates

48. Pericardial effusion: Significance

49. Pericardial effusion: Eosinophilia
• > 10% eosinophil is considered pleural and
pericardial fluid eosinophilia.
• Pericardial fluid eosinophilia is a rare entity
and correlates with disease severity and
mortality.
• Causes:
• Trauma (Haemothorax and pneumothorax)
• Allergic reactions
• Parasitic infections

52. B

53. Eosinophilic Effusion: Case Series of 12 cases
• 2005-2018 (13 years)
• Retrospective study
• Rashid Hospital, UAE (Dubai)
• 12 patients who demonstrated eosinophilic fluids
• Constituted
• 0.5% of 2305 total serous body cavity effusion fluids.
• 0.7% of 1800 nonmalignant effusions.
• 5 pleural, 5 peritoneal and 2 pericardial.
• 4 ( >95%), 2 (> 50%) and 6 (<50%).
• 1 case without peripheral blood eosinophilia.
• 2 cases showed Charcot-Leyden crystals (Galectin-10).

54. Eosinophilic Effusion: Case Series of 12 cases
• The higher the fluid eosinophilia the less likely the
cause to be malignancy or tuberculosis.
• Pleural eosinophilia is frequently associated with
traumatic pleural effusions making the assumption
that introduced air and blood act as a stimulant for
eosinophilic pleuritic.
• This is also unlikely in pericardial and peritoneal EEs
since most are spontaneous.
• The significant presence of lymphocytosis in
eosinophilic fluids may suggest a role played by T
helper lymphocytes and their interleukins in
inducing eosinophilia.

55. Eosinophilic Effusion: Case Series of 12 cases
• Eosinophilic pericardial effusions may indicate a
life-threatening complication of eosinophilic
pericarditis secondary to eosinophilic myocarditis
due to hypereosinophilic syndrome.

57. Pericardial Eosinophilia: Case Report
• 16 Years-old girl
• Chest pain, palpitations, dyspnea, dizziness,
nausea, low-grade fever, vomiting and
fatigue for 2 days
• An allergy to seafood, similar episode 1
month earlier
• No history of asthma, drugs intake, skin rash
or diarrhea
• Initial impression: Food poisoning, lung
infection, tuberculosis or gastritis

58. Pericardial Eosinophilia: Case Report
• Chest X-ray showed marked pericardial
effusion with clear lungs
• USG showed mild to moderate pleural
effusion and ascites
• WBC: 14200 (Eosinophils: 5600 i.e. 40%)
• PBS: Mild reactive eosinophilia without blast
cells
• LFT, RFT, TFT, ESR and CRP normal

59. Pericardial Eosinophilia: Case Report
• Serological tests for viruses, mycoplasma,
brucella, toxoplasma, parasites and
autoantibodies for autoimmune diseases
were negative.
• Mantoux test negative
• Stool and urine test for parasites, ova,
eosinophils and crystals are negative

60. Pericardial Eosinophilia: Case Report
• Developed cardiac tamponade and heart
failure
• Pericardiocentesis was performed and a 250
ml of cloudy bloody fluid was aspirated
• Cytological examination of the pericardial
fluid revealed a mixed inflammatory infiltrate
and florid reactive mesothelial hyperplasia
• Predominantly eosinophils with small
lymphocytes, macrophages, and neutrophils.
• Diamond shaped crystals were also seen.

61. Pericardial Eosinophilia: Case Report
• Pleural fluid showed reactive mesothelial
cells, small lymphocytes and macrophages
without eosinophils and neutrophils.
• The clinical diagnosis of eosinophilic
myopericarditis of the restrictive
cardiomyopathy type in a setting of hyper-
eosininophilic syndrome.
• Churg-Strauss syndrome was excluded
because the patient had no history of
asthma, no evidence of clinical
manifestations of vasculitis, pulmonary
infiltrate and paranasal sinus polyps.

62. Pericardial Eosinophilia: Case Report
• The patient improved after pericardial
drainage and systemic steroid therapy. The
patient was asymptomatic and the
pericardial effusion and peripheral
eosinophilia improved after 6 weeks follow
up.
• D/D:
• Parasitic infestations
• Drugs
• HES
• Churg-Strauss syndrome
• Restrictive cardiomyopathy.

63. TAKE HOME MESSAGE
1. Serous lining is developed from mesoderm
but resembles that of epithelial lining.
2. Obstruction of drainage of serous fluid lead
to lymphocyte rich effusion.
3. Pericardial fluid eosinophilia is a rare entity.
4. Charcot-leyden crystals are formed by
combinations of galectin-10 proteins from
eosinophils.
5. Cardiac involvement in HES usually occurs
in FIP1LI-PDGFRA1.
6. Microfilariae and hooklets can be seen.

64. Thankyou!!!!