Materials and Methods: Tzanck TZANCK PREP PART 1: VIRUSES 2/28/19. Bedside Diagnos,cs: Beyond the Tzanck. Introduced in 1947 by Arnault Tzanck

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1 I do not have any relevant rela,onships with industry. Bedside Diagnos,cs: Beyond the Tzanck PART 1: VIRUSES I will be discussing off-label use of medica,ons. *SPECIAL THANKS TO DR KAROLYN WANAT* Travis Vandergriff, MD Director of Dermatopathology UT Southwestern Medical Center Dallas, Texas TZANCK PREP Introduced in 1947 by Arnault Tzanck cytodiagnosis based on cytology Mul,ple dermatologic uses: blistering diseases, infec,ons, cutaneous neoplasia Materials and Methods: Tzanck Slide, 15 blade, stain(s), microscope 1

2 1. Select the best lesion -intact vesicles or pustules, 1-2 days old -avoid ulcerated, eroded or crusted lesions 2. Clean area with isopropyl alcohol or chlorhexidine 3. Use a 15 blade to incise the roof of the vesicle or pustule 4. Scrape the sides and base of the blister with a 15 blade, and transfer the contents to a dry glass slide 2

3 5. Allow slide to air dry, then apply stain, rinse with tap water, allow to air dry, then cover with coverslip Many opoons for staining May-Grunwald-Giemsa: more intense colora,on, can take a longer,me to perform Wright-Giemsa: methylene blue, eosin, azure blue, Giemsa Diff-Quik stain TM : modified Wright-Giemsa stain Quik-Dip stain TM : Methylene Blue/Azure A stains, Eosin Y, fixa,ve Papanicolaou Other varia,ons on: Hematoxyllin and eosin, Gram, ACF, methylene blue, toluidine blue, PAS, GMS STAINING Wright-Giemsa Quik-Dip Stain TM 3

4 CASE 62 y/o woman with painful lesions on her right shoulder and neck for last 2 days. Tzanck performed Which of the following features are diagnosoc? A. Purple cells B. Margina,on of the nuclear contents with nuclear molding C. Smaller cells D. Leukocytes E. No diagnos,c features are present DETECTION Diagnosis depends on visualiza,on of: Kera,nocyte ballooning Acantholy,c cells/ sync,um of cells Mul,nuclea,on Nuclear margina,on Ballooning AcantholyOc keraonocytes 4

5 DETECTION Diagnosis depends on visualiza,on of: MulOnucleated cells DETECTION Diagnosis depends on visualiza,on of: Margination of chromatin Acantholy,c cells/ sync,um of cells Kera,nocyte ballooning Mul,nucleated cells Nuclear margina,on Ballooning Acantholy,c cells/ sync,um of cells Kera,nocyte ballooning Mul,nucleated cells Nuclear margina,on DETECTION Diagnosis depends on visualiza,on of: Acantholy,c cells/ sync,um of cells Kera,nocyte ballooning Mul,nucleated cells Nuclear margina,on Margination of chromatin CASE 40 y/o paraplegic man admifed for pneumonia with pain on his back for the last 5 days. 5

6 Which of the following is true? A. Choosing the oldest lesion is best and will give the highest yield B. Tzanck smear will be able to dis,nguish between HSV or VZV C. If Tzanck is nega,ve, then addi,onal tes,ng is necessary to confirm herpe,c infec,on D. Viral culture should be performed as it is the most sensi,ve test Advantages Simple Inexpensive Rapid Non-invasive Tzanck Disadvantages Cannot specify between certain viral infec,ons Best with newer, vesicular lesion Less sensi,ve for crusted, older lesions Tzanck vs PCR Tzanck vs PCR Int J Dermatol Nov;46(11): Int J Dermatol. 2007;46(11):

7 Test CharacterisOcs: Depend on age of lesion! Tzanck DFA PCR Biopsy Culture SensiOvity % 50-85% up to 100% 94.9% 52-93% Specificity 98-99% 99% % 95% 100% Cost $5 $30 $80 $70 $65 Time to 1 day to 1 1 to 3 over one Immediate 1 to 3 days Results week days week Tips for the Tzanck: 1) Earlier, vesicular lesions (1-2 days old) 2) Prac,ce on lesions you know are herpes Future Virology. 2014;9(8): JAMA Feb 3;251(5):633-5 J Am Acad Dermatol Dec;59(6): Int J Dermatol. 2007;46(11): CASE 32 y/o man with untreated HIV presents with numerous umbilicated papules on his face, neck. Tzanck smear is performed 7

8 Which of the following is the most likely diagnosis? A. Cryptococcus B. Herpes simplex virus C. Histoplasmosis D. Molluscum contagiousum Molluscum contagiosum Tzanck smear from central core Inclusion bodies: Henderson-Paferson bodies μm Virally transformed kera,nocytes Ovoid, homogenous, basophilic bodies 4. Hand Foot Mouth Disease Syncy,al nuclei Other Viruses Orf Guarnieri body: eosinophilic inclusions Acantholy,c cells Inflammatory cells TZANCK PREP PRACTICAL CONSIDERATIONS CPT code: Medicare reimbursement: approximately $66 CLIA: Moderate complexity, NOT provider performed microscopy (PPM) J Am Acad Dermatol Dec;59(6):

9 QUESTIONS? 9