The spectrum of pathologic lesions in spleen in patients with acquired immunodeficiency syndrome: Autopsy report of 257 patients.

BACKGROUND: Human immunodeficiency virus (HIV) infection continues to persist in India over the past three decades. The involvement of the spleen in these patients has a wide array of differentials with opportunistic infections and malignancies. The spectrum of splenic lesions in patients with HIV/AIDS has not been described in the Indian literature. MATERIALS AND METHODS: A retrospective study was designed to understand the spectrum of splenic pathology in patients with HIV/AIDS. The specimens of the spleen obtained at autopsy in 257 patients over a period of 29 years were systematically analyzed. RESULTS: Among 257 patients, 197 (77%) were males and 60 (23%) were females with a heterosexual route of transmission in 246 (96%) patients. There were 236 (92%) patients from the pre-highly active anti-retroviral therapy era, while 21 (8%) patients had received highly active anti-retroviral therapy for a short duration. The most frequent splenic pathology identified was tuberculosis, noted in 135 (52%) patients, manifesting as military lesions (119 patients, 46%), tuberculous abscesses (13 patients, 5%), and tuberculosis associated with splenic infarcts (03, 1%) patients. The other pathologies noted were cryptococcosis in 17 (7%) patients, malarial infection in 13 (5%) patients, and cytomegalovirus infection in 01 (0.5%) patient. The other findings identified were chronic passive venous congestion, perivascular fibrosis, hemosiderosis, and amyloidosis. In addition, absence or depletion of lymphocyte was noted in 98 (38%) patients and in 4 (1.5%) patients diffuse large B-cell lymphoma was found. CONCLUSIONS: Patients with HIV/AIDS presenting with splenic lesions have a wide array of differentials, such as tuberculosis, opportunistic infection, and the lymphoma. This study provides a better insight into the splenic lesions in patients with AIDS in India.

Comparison of visual inspection with acetic acid and cervical cytology to detect high-grade cervical neoplasia among HIV-infected women in India.

Human immunodeficiency virus (HIV)-infected women in India and other developing country settings are living longer on antiretroviral therapy, yet their risk for human papillomavirus (HPV)-induced cervical cancer remains unabated because of lack of cost-effective and accurate secondary prevention methods. Visual inspection after application of dilute acetic acid on the cervix (VIA) has not been adequately studied against the current standard: conventional cervical cytology (Pap smears) among HIV-infected women. We evaluated 303 nonpregnant HIV-infected women in Pune, India, by simultaneous and independent screening with VIA and cervical cytology with disease ascertainment by colposcopy and histopathology. At the cervical intraepithelial neoplasia (CIN2+) disease threshold, the sensitivity, specificity and positive and negative predictive value estimates of VIA were 80, 82.6, 47.6 and 95.4% respectively, compared to 60.5, 59.6, 22.4 and 88.7% for the atypical squamous cells of undetermined significance or severe (ASCUS+) cutoff on cytology, 60.5, 64.6, 24.8 and 89.4% for the low-grade squamous intraepithelial cells or severe (LSIL+) cutoff on cytology and 20.9, 96.0, 50.0 and 86.3% for high-grade squamous intraepithelial lesion or severe (HSIL+) cutoff on cytology. A similar pattern of results was found for women with the presence of carcinogenic HPV-positive CIN2+ disease, as well as for women with CD4+ cell counts <200 and <350 µL(-1) . Overall, VIA performed better than cytology in this study with biologically rigorous endpoints and without verification bias, suggesting that VIA is a practical and useful alternative or adjunctive screening test for HIV-infected women. Implementing VIA-based screening within HIV/acquired immunodeficiency syndrome care programs may provide an easy and practical means of complementing the highly anticipated low-cost HPV-based rapid screening tests in the near future, thereby contributing to improve program effectiveness of screening.

Study of a manual method of liquid-based cervical cytology.

We report a study of a manual liquid-based cytology (MLBC) method. Slides are prepared by using a polymer solution and allowing it to dry, forming a membrane. The aims of the study were to prepare cervical cytology smears using the manual method, observe morphology, compare with direct scrape smears and correlate with histopathology wherever possible. Out of 105 cases, the membrane was intact, indicating a good MLBC preparation, in 97 cases. Simultaneous conventional smears were taken in 81 patients. There was an 88.8% agreement in the diagnoses of general category in both groups. The diagnosis of negative for intraepithelial lesion or malignancy (NILM) in both groups was made in 70 cases. The MLBC preparation was unsatisfactory in two cases which showed high grade squamous intraepithelial lesion and low grade squamous intraepithelial lesion, respectively, on the conventional smear. One MLBC smear diagnosed as atypical squamous cells of undetermined significance was reported as NILM on conventional smear. Cytohistologic correlation was done in nine cases, all of which showed cervicitis on histopathology. The MLBC method was found to be comparable to the conventional scrape smear. Further study of this method as a cost-effective alternative to the mechanized methods would be worthwhile.

Fine-needle aspiration cytology in lymphadenopathy of HIV-positive patients.

Fine-needle aspiration cytology (FNAC) of 32 HIV-positive cases presenting with lymphadenopathy was performed to evaluate its role in this group of patients. For each case air-dried smears were stained with Leishman, hematoxylin and eosin, and Zeihl-Neelsen stains for acid fast bacilli (AFB). The results were tuberculous (TB) lymphadenopathy (15), reactive lymphadenopathy (10), acute lymphadenitis/abscess (5), and suspected malignancy (2). In seven cases of TB lymphadenitis findings were suggestive of TB since no AFB was demonstrable on the cytology smears. In TB lymphadenitis, two additional patterns besides necrotising granulomatous (4) and granulomatous (2) were observed. These were necrotising (6) and necrotising suppurative (3) patterns. FNAC is a simple, inexpensive, rapid investigative procedure which can reduce surgical excisions and provide definite guidelines about further management.

Prevalence and predictors of colposcopic-histopathologically confirmed cervical intraepithelial neoplasia in HIV-infected women in India.

BACKGROUND: Prevalence estimates of cervical intraepithelial neoplasia (CIN) among HIV-infected women in India have been based on cervical cytology, which may have underestimated true disease burden. We sought to better establish prevalence estimates and evaluate risk factors of CIN among HIV-infected women in Pune, India using colposcopy and histopathology as diagnostic tools. METHODOLOGY: Previously unscreened, non-pregnant HIV-infected women underwent cervical cancer screening evaluation including standardized diagnostic colposcopy by a gynecologist. Histopathologic confirmation was conducted among consenting women with clinical suspicion of CIN. The prevalence of CIN was evaluated by a composite diagnosis based on colposcopy and histopathology results. Multivariable ordinal logistic regression analysis was conducted to determine independent predictors of increasing severity of CIN. RESULTS: The median age of the n = 303 enrolled HIV-infected women was 30 years (interquartile range, 27-34). A majority of the participants were widowed or separated (187/303, 61.7%), more than one-third (114/302, 37.7%) were not educated beyond primary school, and nearly two-thirds (196/301, 64.7%) had a family per capita income of <1,000 Indian Rupees ( approximately US$22) per month. Cervical high-risk HPV-DNA was detected in 41.7% (124/297) of participants. The composite colposcopic-histopathologic diagnoses revealed no evidence of CIN in 220 out of 303 (72.6%) women, CIN1 in 33/303 (10.9%), CIN2 in 31/303 (10.2%), CIN3 in 18/303 (5.9%) and 1 (0.3%) woman was diagnosed with ICC. Thus, over a quarter of the participants [83/303: 27.7% (95% CI: 22.7-33.1)] had > or =CIN1 lesions and a sixth [50/303: 16.5% (95% CI: 12.2-21.9)] had evidence of advanced (> or =CIN2) neoplastic disease. The independent predictors of increasing severity of CIN as revealed by a proportional odds model using multivariable ordinal logistic regression included (i) currently receiving antiretroviral therapy [adjusted odds ratios (aOR): 2.24 (1.17, 4.26), p = 0.01] and (ii) presence of cervical high-risk HPV-DNA [aOR: 1.93 (1.13, 3.28), p = 0.02]. CONCLUSIONS: HIV-infected women in Pune, India have a substantial burden of cervical precancerous lesions, which may progress to invasive cervical cancer unless appropriately detected and treated. Increased attention should focus on recognizing and addressing this entirely preventable cancer among HIV-infected women, especially in the context of increasing longevity due to antiretroviral therapy.

Study of a manual method of liquid-based cervical cytology.

We report a study of a manual liquid-based cytology (MLBC) method. Slides are prepared by using a polymer solution and allowing it to dry, forming a membrane. The aims of the study were to prepare cervical cytology smears using the manual method, observe morphology, compare with direct scrape smears and correlate with histopathology wherever possible. Out of 105 cases, the membrane was intact, indicating a good MLBC preparation, in 97 cases. Simultaneous conventional smears were taken in 81 patients. There was an 88.8% agreement in the diagnoses of general category in both groups. The diagnosis of negative for intraepithelial lesion or malignancy (NILM) in both groups was made in 70 cases. The MLBC preparation was unsatisfactory in two cases which showed high grade squamous intraepithelial lesion and low grade squamous intraepithelial lesion, respectively, on the conventional smear. One MLBC smear diagnosed as atypical squamous cells of undetermined significance was reported as NILM on conventional smear. Cytohistologic correlation was done in nine cases, all of which showed cervicitis on histopathology. The MLBC method was found to be comparable to the conventional scrape smear. Further study of this method as a cost-effective alternative to the mechanized methods would be worthwhile.