Correlation of Microbiologic Culture and Fine-Needle Aspiration Cytology: A 14-Year Experience at a Single Institution

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1 Original Article Correlation of Microbiologic Culture and Fine-Needle Aspiration Cytology: A 14-Year Experience at a Single Institution Cecilia G. Clement, MD; Natalie M. Williams-Bouyer, PhD; Ranjana S. Nawgiri, MD; and Vicki J. Schnadig, MD BACKGROUND: Fine-needle aspiration (FNA) is an important tool for the diagnosis of infectious disease. FNA material should be appropriately submitted for cultures when indicated by preliminary findings. Correlation of cytologic diagnoses with culture results are important quality assurance tools. The current study reviewed 14 years of FNA-culture correlation. METHODS: FNA cytology-culture correlation records from the years 1996 through 2007 and 2010 through 2011 were retrieved from electronic databases compiled for histology and culture correlation. Correlation was limited to those cases for which material was submitted for culture from the FNA sample. Culture results were retrieved from the laboratory or hospital information system. RESULTS: Correlative data included 770 cases. Cytology, culture, or both were positive for microbes in 416 of 770 samples (54%), excluding cultured bacterial skin contaminants. Among the 204 bacteria cases, 93 (46%) were identified by cytology and culture, 92 (45%) were identified by culture only, and 19 (9%) were identified by cytology only. Among the 16 cases of Actinomycetales, 8 (50%) were identified by cytology and culture, 5 (31%) were identified by culture only, and 3 (19%) were identified by cytology only. Of the 129 cases of mycobacteria, 63 (49%) were identified by cytology and culture, 44 (34%) were identified by culture only, and 22 (17%) were identified by cytology only. Among the 67 cases of fungi, 34 (51%) were identified by cytology only, with 15 of these 34 cases being fungal hyphae; 25 cases (37%) were identified by cytology and culture, with a 100% concordance between the cytology diagnosis and culture result; and 8 cases (12%) were identified by culture only. CONCLUSIONS: FNA cytology-culture correlation is a valuable tool with which to assess the efficacy and limitations of the direct diagnosis of infectious agents, and to identify types of infections that may be negative on culture but positive on cytology diagnosis. Cancer (Cancer Cytopathol) 2015;123: VC 2015 American Cancer Society. KEY WORDS: correlation; culture; cytology; microbiology; quality assurance. INTRODUCTION The use of fine-needle aspiration (FNA) biopsy for the diagnosis of infectious disease has been reported since the late 19th century. In 1883, Leyden described the use of transthoracic aspiration biopsy for the diagnosis of bacterial pneumonia. 1 Later, in 1904, Grieg and Gray used needle aspiration of lymph nodes for the diagnosis of African trypanosomiasis, 2 and in 1921, Guthrie identified cases of syphilis and tuberculosis using lymph node aspirations. 3 Recently, the use of FNA for the diagnosis of infections has been amplified, parallel to the increasing need for the rapid diagnosis of opportunistic infectious diseases in immunocompromised patients. 4 FNA is a safe, minimally invasive procedure that allows for triage into infectious/inflammatory versus neoplastic categories by rapid onsite evaluation (ROSE). In addition, FNA can provide material for microbiologic culture. Culture is considered the gold standard for the diagnosis of infections. However, in some cases, days to weeks Corresponding author: Vicki J. Schnadig, MD, Department of Pathology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX ; Fax: (409) ; vschnadi@utmb.ed. Department of Pathology, The University of Texas Medical Branch, Galveston, Texas Received: May 9, 2015; Revised: June 22, 2015; Accepted: June 29, 2015 Published online August 4, 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: /cncy.21590, wileyonlinelibrary.com 612 Cancer Cytopathology October 2015

2 Microbiologic Culture and FNA Cytology/Clement et al TABLE 1. Selected Examples From the Cytology-Microbiology Database Source Diagnosis Microbiology Diagnosis Soft tissue Bacterial infection consistent with actinomycosis Actinomyces meyeri Ovary Abscess Bacteroides fragilis Soft tissue Infected epidermal cyst Clostridium species Lymph node Fungal infection consistent with histoplasmosis Histoplasma capsulatum Lung Granuloma and caseous-like necrosis Mycobacterium avium complex Lymph node Mycobacterial lymphadenitis Mycobacterium tuberculosis Arm Infection consistent with Nocardia or Mycobacterium fortuitum Nocardia farcinica Lymph node Inflammation and gram-positive cocci in chains Streptococcus group B Lymph node Noncaseating granuloma (clinically consistent with sarcoid) Negative are required for the recovery and identification of the pathogen by culture. Occasionally, cultures prove negative and cytomorphologic diagnosis of the infectious pathogen provides the only means for presumptive diagnosis and appropriate therapy. At the study institution, FNA of palpable lesions is usually performed by a cytopathologist. FNA of deep-seated or nonpalpable lesions is performed by an interventional radiologist under ultrasound or computed tomography guidance. In both instances, ROSE is performed to provide a preliminary classification of the disease and predict the need for ancillary studies. When microorganisms and/or purulent exudate, granuloma, amorphous, caseous-type necrosis, and diffuse histiocytic exudate are noted, dedicated FNA passes are made for culture. Aspirates for bacterial cultures are submitted either in blood culture bottles (preferred by the pathologists at the study institution) or in vials appropriate for aerobic and anaerobic cultures. Aspirated material, with or without a sterile saline rinse, is placed in a sterile container for mycobacterial and fungal cultures. In the current study, we report a 14-year review of FNA specimens from infectious or inflammatory conditions in which FNA material was submitted for both cytological examination and microbial culture. The FNA cytology diagnoses and culture results were correlated to assess the efficacy and limitations of the direct diagnosis of infectious agents and to identify types of infections that may be culture negative and cytology diagnosis positive. MATERIALS AND METHODS At the study institution, since 1996, FNA cytology diagnoses and corresponding microbial culture results have been kept in computer databases along with data correlating FNA diagnoses with surgical resections. An example of part of a database is illustrated in Table 1. Accession numbers of cytology specimens and microbiology samples (both of which are recorded in the actual databases) and cytology-histology data have been omitted. The databases were constructed by querying the computerized laboratory information system to obtain FNA diagnoses. In cases in which the diagnosis indicated the identification of an infectious organism or inflammatory condition, either the laboratory information system or the electronic medical record were used to obtain the results of microbial cultures performed from material obtained from the same FNA sample. Cases in which both the FNA cytological diagnosis and corresponding culture results were available for the years 1996 through 2007 and 2010 through 2011 were analyzed. The years of 2008 and 2009 were not included because of microbiology laboratory restrictions caused by Hurricane Ike. Databases included accession numbers of all positive cultures. In this manner, one could determine whether bacterial cultures were grown from a sample submitted fresh or in blood culture bottles (BAC- TEC; Becton, Dickinson and Company, Franklin Lakes, NJ). Microbe identification was determined by the microbiology laboratory via microscopic (Gram stain, Kinyoun stain, or Auramine O stain), macroscopic (observations on plated culture media), and biochemical testing. Cases with microorganisms identified by cytology only, culture only, or both cytology and culture were assigned to 1 of 4 categories: bacteria, Actinomycetales, mycobacteria, or fungi. Actinomycetales, although a subset of bacteria, was considered separately due to its characteristic morphology. Included were the genera Actinomyces, Nocardia, and Rhodococcus. Routine cytology stains include Romanowsky and Papanicolaou. At least 1 special stain was performed for the majority of FNA samples in which microorganisms were cytologically identified. Special stains for the diagnosis of infectious agents performed in the cytopathology laboratory include the Cancer Cytopathology October

3 Original Article TABLE 2. FNA Sources (770 Cases) FNA Source No. (%) Lymph node 244 (31.6) Soft tissue 210 (27.2) Lung 153 (19.8) Breast 72 (9.4) Liver 21 (2.7) Bone 18 (2.3) Salivary gland 14 (1.8) Kidney 11 (1.6) Vertebral disc 8 (1.0) Spleen 4 (0.5) Pancreas 3 (0.4) Sinus 2 (0.3) Ovary 2 (0.3) Adrenal gland 2 (0.3) Others a 6 (0.8) Abbreviation: FNA, fine-needle aspiration. a Includes gallbladder, knee joint, thyroid, pelvis, and vitreous humor. classic Gram, Weigert-Gram, Kinyoun acid-fast, modified Kinyoun acid-fast, and microwave Gomori/Grocott methenamine silver stains. One or more of these are typically used as determined by clinical information and cytomorphologic findings. FNA diagnoses of inflammation without the presence of identifiable organisms were classified by the predominant inflammatory pattern as purulent, granuloma, or nonspecific. Purulent indicates a predominance of neutrophils and macrophages. Granuloma indicates the presence of epithelioid macrophages in sheets or aggregates with or without associated necrosis. A nonspecific inflammatory pattern includes mixed inflammation with or without necrosis. RESULTS FNA cytology and microbial culture results from 770 cases were correlated. FNA was obtained from superficial and deep-seated lesions from a wide variety of sites. Lymph nodes, soft tissues, and lung together comprised approximately 80% of the FNA sources, as shown in Table 2. Microorganisms were identified by cytology and/ or culture in 416 of 770 samples (54%), excluding 46 samples (6%) with cultured bacterial skin contaminants such as coagulase-negative staphylococci. The 416 cases were categorized as bacteria in 204 cases (49%), mycobacteria in 129 cases (31%), fungi in 67 cases (16%), and Actinomycetales in 16 cases (4%). No microorganisms were identified by either cytology or culture in 308 of the 770 total cases (40%) analyzed. Of the 204 bacteria cases, 93 (46%) had bacteria identified by cytology and culture, 92 (45%) by culture only, and 19 (9%) by cytology only. Therefore, 83% of cases with non-actinomycete bacteria seen on the FNA sample had positive cultures. Of the 185 cases with positive bacterial cultures, 57 (31%) were submitted in blood culture bottles and 128 (69%) were submitted in sterile cups and anaerobic standard transport media. Among the 57 positive cultures by BACTEC, 44 were gram-positive cocci (31 cases of Staphylococcus aureus, 12 cases of Streptococcus spp., and 1 case of Enterococcus spp.), 8 were mixed anaerobes, 4 were gram-negative bacilli, and 1 was grampositive bacillus. The 128 isolates obtained by conventional culture included 78 gram-positive cocci (60 Staphylococcus aureus, 16 Streptococcus spp., and 2 Enterococcus spp.), 25 gram-negative bacilli, 13 mixed anaerobes, 10 mixed bacteria, and 2 gram-positive bacilli. Because of the habitual use of blood culture bottles for pathologistperformed FNAs only, the majority of FNA samples were submitted for culture in sterile cups and anaerobic transport media. These findings suggest that both methods are effective, in that a similar spectrum of bacteria was cultured from each. Actinomycetales were identified in 16 cases: 8 (50%) by culture and cytology (6 Nocardia, 1 Rhodococcus, and 1 Actinomyces), 5 (31%) by culture only (4 Actinomyces and 1 Nocardia), and 3 (19%) by cytology only (3 Actinomyces). Among the 8 cases identified by cytology and culture, the cytology-culture correlation was excellent. It should be noted that Nocardia spp. and Mycobacterium fortuitum complex have morphologic features that cannot be distinguished by direct examination alone, although the clinical findings do allow one to favor one or the other. Both are long, beaded, and branching acid-fast bacilli (Fig. 1), and often colorize preferentially with modified acid-fast stains. The reports favor Nocardia or M. fortuitum complex based on the clinical setting, and this differential is discussed in the report comment. Nocardia has generally been isolated from the FNA sample in patients who have undergone transplantation and developed pneumonia, whereas M. fortuitum complex is more commonly isolated from patients with the acquired immunodeficiency syndrome with lymphadenopathy at the study institution. Mycobacteria were identified in 129 samples: 63 (49%) by culture and cytology, 44 (34 %) by culture only, and 22 (17%) by cytology only. Therefore, of the 85 cases in which acid-fast bacilli were observed on the smear, culture was positive in 63 cases (74%). The 44 cases in 614 Cancer Cytopathology October 2015

4 Microbiologic Culture and FNA Cytology/Clement et al Figure 1. (A) Modified acid-fast stain of a fine-needle aspiration (FNA) specimen from a 72-year-old male patient who underwent a heart transplantation and had multiple pulmonary nodules. Branching, weakly acid-fast, slender bacilli were noted. The FNA culture grew Nocardia farcinica. (B) Modified acid-fast stain from an FNA specimen from a necrotic para-aortic lymph node from a 38-year-old male patient with the acquired immunodeficiency syndrome demonstrating branching acid-fast bacilli similar to that of Nocardia FNA culture grew M. fortuitum (31500). TABLE 3. Mycobacteria Identified by Cytology, Culture, or Both Organism Isolated Cytology Positive/ Culture Positive Cytology Negative/ Culture Positive G N P Cytology Positive/ Culture Negative Total Mycobacteria Mycobacterium tuberculosis complex Mycobacterium avium complex 23 3 a Mycobacterium fortuitum complex 3 b Mycobacterium marinum Mycobacterium kansasii Total Abbreviations: G, granuloma; N, nonspecific inflammation; P, purulent. a Cytology was negative for acid-fast bacilli but positive for budding yeast consistent with Cryptococcus in one case. b Cytology was positive for acid-fast bacilli, favored M. fortuitum in 3 cases. which no organism was observed in the cytology preparations were classified by the predominant inflammatory pattern, with granuloma being the most frequent pattern (Table 3). There was an interesting cytology-culture discrepancy noted in one case that is illustrated in Figure 2. This figure depicts the findings of an FNA from the supraclavicular lymph node in a 20-year old patient who was positive for the human immunodeficiency virus (HIV) who presented with lymphadenitis. Numerous budding yeasts, morphologically consistent with Cryptococcus, were identified in cytology smears. Although budding yeasts were also observed in the mycology laboratory wet preparation, culture was negative for fungi. However, mycobacterial culture was found to be positive for M. avium complex. This patient had a positive blood culture for Cryptococcus neoformans 1 year before undergoing FNA and, at the time the FNA was performed, her CD4 T-cell counts had been increasing. Retrospectively, we suspect that patient had cryptococcal immune reconstitution inflammatory syndrome, which involves reconstitution of T-cell immunity with improvement in CD4 T-cell counts after therapy for HIV and the development of an inflammatory response to microbial antigens, either as intact or dead organisms. 5 A summary of the fungal culture findings is shown in Table 4. Among the 67 cases in the fungi category, 34 (51%) were diagnosed by cytology only, and 15 of these 34 cases were mycelial fungi. The positive culture rate for Cancer Cytopathology October

5 Original Article Figure 2. Supraclavicular lymph node fine-needle aspiration specimen containing yeast forms consistent with Cryptococcus. (A) Round to oval, focally budding yeasts of various sizes (methenamine silver stain, 3600). (B) Black-pigmented, melanin-like material in a yeast cell wall (Fontana-Mason stain, 3600). TABLE 4. Fungal Organisms Identified by Cytology, Culture, or Both Organism Total Cytology Positive/ Culture Positive Cytology Negative/ Culture Positive G P N Cytology Positive/ Culture Negative Total Histoplasma H. capsulatum Candida 1 1 C. albicans C. parapsilosis C. glabrata Cryptococcus C. neoformans Coccidioides C. immitis 4 a Zygomycetes Non-zygomycetes Fungal yeast Hormonema dematioides Total Abbreviations: G, granuloma; N, nonspecific inflammation; P, purulent. a Cytology showed 1 case with scanty spherule-like cells suggestive of fungal infection (Coccidioides vs Blastomyces in differential). yeast-like fungi noted on cytology was much higher (58%) than for mycelial fungi (0%). Mycelial fungi were categorized as Zygomycetes (3 cases) and non- Zygomycetes (12 cases) based on the morphologic characteristics of their hyphae. Usually, these 2 fungal categories can be readily distinguished in Papanicolaou-stained cytology slides because of the dense, often yellow-brown, staining of Zygomycetes compared with other hyphal fungi and the thickness of cytologic preparations that allow one to observe more of the hyphal fragments (Fig. 3). In thin histologic sections, this may be problematic. For non-zygomycetes cytological diagnoses, a descriptive interpretation rather than a specific organism is generally reported. For example, fungal hyphae or fungus ball alone is reported, usually with a comment. Fusarium and other fungi with septate hyphae have a similar appearance in tissue samples. Identification to the genus or species level can only be achieved when conidiation (fruiting head formation) is present. There were 25 cases (37%) diagnosed by culture and cytology, all of 616 Cancer Cytopathology October 2015

6 Microbiologic Culture and FNA Cytology/Clement et al Figure 3. Illustrations from autopsy and older cases not included in the database. (A) Postmortem scraping of a lung nodule from a patient with severe neutropenia. The culture grew Aspergillus glaucus. (B) Fine-needle aspiration of a kidney lesion. The culture grew Rhizopus species. Note the more narrow, pale purple hyphae of Aspergillus compared with the broader, more dense staining hyphae of Rhizopus (Papanicolaou stain, 3600). which were yeast-like organisms, with 100% concordance between the cytology diagnosis and culture result. Eight cases (12%) were identified by culture only. DISCUSSION FNA is a well-established diagnostic procedure that can be used for the diagnosis of both neoplasms and infectious diseases. 4 An aliquot of the FNA material should be submitted for microbiologic culture confirmation after rapid on-site identification of microorganisms or inflammatory reactions. Although a dedicated pass for culture is recommended, one can pool aliquots of aseptically obtained needle passes that have been triaged by ROSE to ensure the best material is submitted for culture. Correlation of cytopathology diagnoses with culture results and close communication with microbiology personnel are valuable tools for patient care, education, and quality control purposes. Not only should the submission of FNA samples from suspected infections be routine, but there should be a culture of close communication between microbiology laboratory professionals and the cytopathologists. Microbiologists can provide important feedback regarding methods for collection and submission to the laboratory. Similarly, the cytopathologist can guide laboratory procedures based on what type of organisms are suspected. For example, when organisms morphologically consistent with Actinomyces species are found, the microbiologists are informed of the suspicion, and the anaerobic culture is held for a minimum of 1 week. To the best of our knowledge, the current study is the largest study to date correlating FNA cytological diagnoses and microbiologic culture results, with 770 cases analyzed. The current study was limited because it was based on data gathered over a long period of time with diagnoses by different pathologists, and changes in culture techniques that may have occurred. In addition, chart review to determine causes of cytology-positive/culturenegative cases was not performed. Nevertheless, we believe that important information was gleaned from this analysis, as discussed below. The spectrum of aerobic and anaerobic organisms isolated from samples submitted in blood culture bottles was similar to that of samples submitted in sterile cups and anaerobic transport media. Direct inoculation into blood culture bottles is preferred by the pathologists at the study institution because it is easy and immediately places material in culture media. Others have found blood culture bottles comparable to conventional methods for the culture of sterile body fluids. 6,7 Although there are pitfalls in the morphologic diagnosis of fungal pathogens by histology and cytology, 8 we found a high degree of concurrence (100%) between Cancer Cytopathology October

7 Original Article cytodiagnosis and culture for cases in which yeast-like fungi were identified by both cytology and culture. High positive culture rates likely relate to the relatively high number of immunosuppressed patients undergoing diagnostic FNA. Presumptive diagnoses based on morphology of yeast, such as Candida, Histoplasma, Coccidioides, and Cryptococcus spp., can be performed accurately in the majority of cases, especially when combinations of stains are used and the observer is experienced. The morphologic identification of Histoplasma is facilitated by the use of Romanowsky stain and the characteristic diagnostic features of Coccidioides and Blastomyces are best observed using Papanicolaou stain Fontana-Masson stain can contribute to the identification of capsule-deficient Cryptococcus. 13 Pitfalls do exist, especially when one depends on methenamine silver stains alone. Immature Coccidioides spherules can be mistaken for Blastomyces 11,12 (or Paracoccidioides in endemic areas) and Candida blastoconidia can be confused with Histoplasma. The use of Romanowsky staining on smears or cytospin preparations is usually helpful for visualizing the typical features of Histoplasma, Cryptococcus, and Candida. Cell block preparations are not typically used for the diagnosis of infectious disease in the study laboratory. Cultures were all negative in cases in which hyphal fungi were noted on cytology. Others have noted this finding and questioned the usefulness and costeffectiveness of fungal culture in FNA specimens because fungi were often identified by morphology and special stains. 14,15 Lack of sporulation because of conditions such as the presence of nonviable fungus balls and traumatization of cultured material during processing may contribute to poor culture results. 16 We believe that attempting to culture organisms is warranted when fungal hyphae are identified during ROSE because mycelial fungi lacking fruiting heads cannot be identified to the genus level on the basis of morphology whereas cultures occasionally will be productive. We have isolated significant mycelial fungal pathogens from non-fna respiratory sites. The use of immunohistochemistry and molecular techniques may be able to compensate for culture insensitivity if these techniques become more specific and widely available. We typically use cytomorphology to distinguish Zygomycetes (mucormycosis agents) from non-zygomycetes and use the clinical and radiologic findings to describe the likely type of infection (ie, fungus ball, chronic necrotizing, or disseminated infection). The direct identification of acid-fast bacilli can be very useful to clinicians while they await culture results. Based on our experience, the use of FNA smears or cytospin preparations is superior to cell block or core needle biopsies for the identification of mycobacteria. On occasion, simply letting the clinician know that mycobacteria are present is valuable in that it eliminates (or greatly reduces) the probability of neoplasia or other types of infection. We rely on the clinical microbiology laboratory to verify our results, but because sampling discrepancies exist, we do not believe that all special stains should be deferred to the clinical microbiology laboratory. Teamwork and the communication of results is recommended. Culture is of course of primary importance for determining the antimicrobial sensitivity of bacteria and mycobacteria. Using clinical information, a modified acid-fast stain, and morphology, the accuracy for diagnosing infections with actinomycetes can be very good. Rhodococcus pulmonary or soft tissue infection is suspected on the basis of clinical information (usually immunosuppression in our population), the presence of gram-positive coccobacilli with narrow capsules, and occasionally weak acid-fast staining with modified acid-fast stain. Pulmonary and mediastinal infections are often characterized by malakoplakia, in which foamy macrophages and occasional Michaelis-Gutmann bodies are seen. 17 Actinomyces species usually can be distinguished from Nocardia infections using a combination of clinical information, morphology, and modified acid-fast stain. In the United States, actinomycosis is often associated with mycetoma formation, and the granules of bacteria, occasionally with presence of a Splendore-Hoeppli reaction, can be noted in Papanicolaou-stained slides. Gram or Weigert-Gram stains and modified acid-fast stains also are helpful. It should be noted that Actinomyces are often associated with a mixture of both other anaerobic and facultative bacteria that may overgrow them in culture. The growth of other organisms does not exclude actinomycosis. We habitually tell our microbiology colleagues to hold anaerobic cultures for Actinomyces. Communication, along with a dedicated microbiology technologist, can lead to very favorable results. Nocardia infections in immunosuppressed patients in the United States (Nocardia mycetomas are common in some other parts of the world) usually lack granules and are accompanied by necrotizing purulent inflammation. Modified acid-fast stain is useful for 618 Cancer Cytopathology October 2015

8 Microbiologic Culture and FNA Cytology/Clement et al distinguishing Nocardia from Actinomyces, but its distinction from M. fortuitum complex is not always possible. A clinical history of immunosuppressive therapy for patients with a history of transplantation and necrotizing pneumonia favor Nocardia, whereas HIV infection and lymphadenopathy favor M. fortuitum. Many years ago, we first recognized M. fortuitum as a cause of lymphadenitis in patients with HIV by correlating our misinterpretation of Nocardia infection with the culture results. 18 FNA cytology-culture correlation adds to our knowledge of the efficacy and limitations of both cytomorphology and culture. Among the information gleaned from the current study data are: 1) confirmation by culture is high for bacteria (83%) and mycobacterial (74%) pathogens visualized by cytologic evaluation but is poor (0%) for hyphal fungi such as Aspergillus and Zygomycetes (cytology-microbiology correlation for yeast-like fungi is excellent in immunosuppressed patients); 2) blood culture bottles and standard transport media appear to be equivalent for bacterial culture; 3) the limitations of culture indicate the need to explore molecular methods for the diagnosis of infectious diseases; and 4) communication and collaboration between members of the cytopathology and microbiology divisions is essential and teamwork and the correlation of results should be practiced. FUNDING SUPPORT No specific funding was disclosed. CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures. REFERENCES 1. Webb AJ. Through a glass darkly. (The development of needle aspiration biopsy). Bristol Med Chir J. 1974;89: Greig ED, Gray AC. Note on the lymphatic glands in sleeping sickness. Br Med J. 1904;1: Guthrie CG. Gland puncture as a diagnostic measure. Bull Johns Hopkins Hosp. 1921;32: Silverman JF, Gay RM. Fine-needle aspiration and surgical pathology of infectious lesions. Morphologic features and the role of the clinical microbiology laboratory for rapid diagnosis. Clin Lab Med. 1995;15: Skiest DJ, Hester LJ, Hardy RD. Cryptococcal immune reconstitution inflammatory syndrome: report of four cases in three patients and review of the literature. J Infect. 2005;51:e289 e Cetin ES, Kaya S, Demirci M, Aridogan BC. Comparison of the BACTEC blood culture system versus conventional methods for culture of normally sterile body fluids. Adv Ther. 2007;24: Akcam FZ, Yayli G, Uskun E, Kaya O, Demir C. Evaluation of the Bactec microbial detection system for culturing miscellaneous sterile body fluids. Res Microbiol. 2006;157: Sangoi AR, Rogers WM, Longacre TA, Montoya JG, Baron EJ, Banaei N. Challenges and pitfalls of morphologic identification of fungal infections in histologic and cytologic specimens: a ten-year retrospective review at a single institution. Am J Clin Pathol. 2009; 131: Schnadig VJ. Cytopathology of infectious and inflammatory diseases. In: Kradin RL, ed. Diagnostic Pathology of Infectious Disease. Boston, MA: Saunders Elsevier; 2010: Sanders JS, Sarosi GA, Nollet DJ, Thompson JI. Exfoliative cytology in rapid diagnosis of pulmonary blastomycosis. Chest. 1977;72: Sarosi GA, Lawrence JP, Smith DK, Thomas A, Hobohm DW, Kelley PC. Rapid diagnostic evaluation of bronchial washings in patients with suspected coccidioidomycosis. Semin Respir Infect. 2001;16: Powers CN. Diagnosis of infectious diseases: a cytopathologist s perspective. Clin Microbiol Rev. 1998;11: Kwon-Chung KJ, Hill WB, Bennett JE. New, special stain for histopathological diagnosis of cryptococcosis. J Clin Microbiol. 1981; 13: Krane JF, Renshaw AA. Relative values and cost-effectiveness of culture and special stains in fine needle aspirates of the lung. Acta Cytol. 1998;42: Granville LA, Laucirica R, Verstovsek G. Clinical significance of cultures collected from fine-needle aspiration biopsy. Diagn Cytopathol. 2008;36: Tarrand JJ, Lichterfeld M, Warraich I, et al. Diagnosis of invasive septate mold infections. A correlation of microbiological culture and histologic or cytologic examination. Am J Clin Pathol. 2003; 119: Kwon KY, Colby TV. Rhodococcus equi pneumonia and pulmonary malakoplakia in acquired immunodeficiency syndrome. Pathologic features. Arch Pathol Lab Med. 1994;118: Smith M, Schnadig VJ, Boyars MC, Woods GL. Clinical and pathologic features of Mycobacterium fortuitum infections. An emerging pathogen in patients with AIDS. Am J Clin Pathol. 2001; 116: Cancer Cytopathology October