PART TWO
Diagnostic Cytology
Fig. 19.56 Numerous leukocytes, not identifiable as to type, contain neatly
round, cyanophilic particles formed by disintegrating nuclei. The patient had
rheumatoid pleuritis. Such cells have been referred to (inappropriately) as
either "ragocytes” or "RA cells.” Smear of pleural effusion (Papanicolaou x OI).
experience and by other reports in the literature.21,95 We are una-
ware of any recorded example of rheumatoid peritonitis with
effusion showing the cytologic picture of rheumatoid disease,
although the possibility of such a case exists because rheuma-
toid nodules have been described on the peritoneum.97,98
Almost all of the patients whose pleural or pericardial fluid
showed the cytologic picture of rheumatoid disease had clear
clinical evidence of rheumatoid arthritis. Because the pleural
manifestations of rheumatoid disease may precede the arthral-
gia,99,100 the possibility exists of diagnosing rheumatoid pleu-
ritis or pericarditis by cytologic examination of serous fluid
before
a patient develops rheumatoid arthritis. In the series of
Boddington and co-workers, pericardial effusion showing cyto-
logic evidence of rheumatoid disease developed in one patient
2 months before the onset of arthritis.101
Any account of the pathognomonic cytologic picture of rheu-
matoid pleural and pericardial effusion requires mention of
the so-called ragocyte and rheumatoid arthritis (RA) cell. The
term ragocyte was coined by Delbarre and colleagues to refer
to small, spherical cytoplasmic inclusions in neutrophils and
occasionally in monocytes in
unstained wet films
of cells from
synovial fluid from patients with various types of arthritis.102
These investigators observed that ragocytes were most likely
to be found in synovial fluids from patients with rheumatoid
arthritis, an observation confirmed by Astorga and Bollet and
by Hollander and associates, who adopted the term RA cells for
these inclusion-bearing leukocytes.103,104
Such cells were subsequently described in pleural and peri-
cardial fluids from patients with rheumatoid effusions.105-109 The
inclusions are easily seen in toluidine blue-stained wet films and
give the staining reaction for neutral fat.101 Neutrophilic leuko-
cytes and histiocytes containing fat droplets are certainly com-
mon in rheumatoid pleural effusion; however, they may be seen
in effusions caused by various other conditions, including effu-
sions caused by malignant neoplasms.28-30 It is a mistake to rely
on the presence of so-called RA cells in pleural and pericardial
fluids to confirm or even suggest the diagnosis of rheumatoid
disease.
The pleural fluid of 5 of our 24 cases of cytologically diag-
nosable rheumatoid pleuritis contained cholesterol crystals (see
Fig. 19.57 Pleural effusion of a patient with rheumatoid pleuritis.
The white flocculent sediment consists of the necrotic cellular background
material seen in smears of patients with rheumatoid pleuritis. This fluid
was shaken up only a few minutes before the photograph was taken;
spontaneous sedimentation took place very rapidly.
Fig. 19.10), a manifestation of the breakdown of cell membranes
caused by widespread necrosis of macrophages and other cells
in an effusion of long duration. Cell-block preparations from
such fluids may exhibit acicular clefts (see Fig. 19.16), denoting
the presence of cholesterol crystals that were dissolved when the
specimen was processed.
Unless the full-blown cytologic picture of rheumatoid pleu-
ritis is present, it is easy to overlook the significance of partial
cytologic evidence, which is what initially happened in our own
laboratory. It is important to diagnose rheumatoid pleuritis or
pericarditis cytologically; otherwise, patients may be subjected
to useless investigation, including thoracotomy, to find out the
cause of their effusion, or they may be subjected to useless ther-
apy, such as therapy against tuberculosis, as happened with some
of our patients. It is also important to note the gross appearance
of a specimen of serous fluid. Figure 19.57 depicts a specimen
of pleural fluid that contained a thick flocculent deposit, which
when suspended rapidly sank to the bottom of the container.
The flocculent deposit consisted of all the cytologic components
of a typical rheumatoid effusion.
538
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