Tzanck test

Last updated
Tzanck test
Tzanck test.png
A positive Tzanck test, showing three multinucleated giant cells ("Tzanck cells") in center.
Purposediagnosis of varicella-zoster virus and herpes

In dermatopathology, the Tzanck test, also Tzanck smear, is scraping of an ulcer base to look for Tzanck cells. It is sometimes also called the chickenpox skin test and the herpes skin test. It is a simple, low-cost, and rapid office based test. [1]

Contents

Tzanck cells (acantholytic cells) are found in:

Arnault Tzanck did the first cytological examinations in order to diagnose skin diseases. [3] To diagnose pemphigus, he identified acantholytic cells, and to diagnose of herpetic infections he identified multinucleated giant cells and acantholytic cells. He extended his cytologic findings to certain skin tumors as well.

Even though cytological examination can provide rapid and reliable diagnosis for many skin diseases, its use is limited to a few diseases. In endemic regions, Tzanck test is used to diagnose leishmaniasis and leprosy. For other regions, Tzanck test is mainly used to diagnose pemphigus and herpetic infections. Some clinics use biopsies even for herpetic infections. [4] This is because the advantages of this test are not well known, and the main textbooks of dermatopathology do not include dedicated sections for cytology or Tzanck smear. [5] A deep learning model called TzanckNet has been developed to lower the experience barrier needed to use this test. [6]

Procedure

  1. Unroof vesicle and scrape base w/ sterile №15 scalpel blade
  2. Smear with cotton stick onto a clean glass slide
  3. Fix w/ gentle heat or air dry
  4. Fix w/ MeOH (Methanol)
  5. Stain w/ Giemsa, methylene blue or Wright’s stain.
  6. Microscopic examination using an oil immersion lens. (Look for multinucleated giant cells) [7]

A modified test can be performed using proprietary agents which requires fewer steps and allows the sample to be fixed quicker.

Cytologic findings

For microscopic evaluation, samples are first scanned with low magnification objectives (X4 and X10) and then examined in detail with the high magnification objective (X100). The X4 objectives are used to select the areas to investigate in detail and to detect some ectoparasites, but the basis of the cytological diagnostic process is the X10 objective. With X10 magnification, the individual characteristics of the cells, the relationship of the cells to each other and the presence of some infection and infestation agents are evaluated. For this reason, most of the cytological examination is spent at this magnification, and most samples are diagnosed at this magnification. The key cytological findings that are observed at low magnification or, in other words, should be investigated according to the clinical characteristics of the patient are as follows: acantholytic cells, tadpole cells, granulomatous inflammation, infectious agents and increases in specific cells.

Major indications, cytologic findings and diagnostic value of Tzanck smear test [8]

DiseasesCytologic findingsDiagnostic value
I. Cutaneous infections
Bacterial infections
Bullous impetigo Dyskeratotic acantholytic cells, abundant neutrophils and clusters of cocci92% sensitive and 100% specific
Staphylococcal scalded skin syndrome (SSSS)Dyskeratotic acantholytic cells, absence of abundant neutrophils and cocciA Tzanck smear may be a rapid test to distinguish toxic epidermal necrolysis from SSSS
Mycobacterial infectionsNegative images of mycobacteriae, acid-fast bacilliMaximum acid-fast bacilli positivity (94%) in cases showing caseation necrosis with or without granulomas
Bacillary angiomatosis Clumps of coccobacilli of B Henselae in Warthin-Starry-stained smears
Fungal infections
Dermatophytic infectionsHyphae and spores
Candidiasis Pseudohyphae and sporesPseudohyphae and spores in 90% of patients with candida folliculitis
Aspergillosis Septate hyphae with 45-degree angle branching and/or aspergillus heads
Blastomycosis Broad-based budding spores57.7 - 93% sensitive
Sporotrichosis Spherical, oval or cigar-shaped yeasts and asteroid bodies84.9% sensitive and 57.9% specific
Viral infections
Herpetic infections Acantholytic cells, multinucleated giant cells and eosinophilic inclusion bodies53.1 - 86% sensitive and 100% specific
Hand, foot and mouth disease Syncytial nuclei, absence of acantholytic cells172% sensitive and 100% specific
Human papillomavirus infections Koilocytes75% sensitive and 100% specific
Molluscum contagiosum Intracytoplasmic inclusion bodies (“Henderson-Patterson’s bodies”)
Milker’s nodule and orfIntracytoplasmic inclusion bodies (“Guarnieri’s bodies”)
Parasitic infections
Leishmaniasis Ellipsoid-shaped Leishman-Donovan bodie30 - 82.6% sensitive and 100% specific
DemodicosisMore than 5 Demodex mites/cm2The diagnostic value of cytology for diagnosing Demodex folliculitis is higher than that of histopathology. The sensitivity of histopathology is 60%, whereas that of cytology is 93.3%
Cutaneous amoebiasis Trophozoites of Entamoeba histolyticaDirect specimens or PAS and acid phosphatase-stained specimens in cases with doubtful direct specimens show trophozoites of Entamoeba histolytica
II. Immunobullous disorders
Pemphigus Acantholytic cells with direct immunofluorescence positivityWith the use of direct immunofluorescence examination, the specificity of cytology for diagnosing pemphigus can be increased from 43% to 100%.
Erythema multiforme, Toxic epidermal necrolysisApoptotic and necrotic cells, absence of acantholytic cellsA Tzanck smear may be a rapid test to distinguish toxic epidermal necrolysis from SSSS
III. Genodermatoses
Hailey-Hailey disease Acantholytic cells without direct immunofluorescence positivityDirect immunofluorescence examination should be made for differentiation from pemphigus.
Darier’s disease Acantholytic cells, corps ronds, grains
IV. Spongiotic dermatitisPresence of more than 10 tadpole cells at x100 magnification
Contact dermatitis Tadpole cells and lymphocytes83% sensitive and 100% specific
V. Granulomatous diseasesGranuloma formation and multinucleated giant cellsThe main purpose of cytological examination in granulomatous dermatitis is to detect infectious agents. Foreign body materials are very specific for foreign body granuloma.
Granuloma annulare Palisading granuloma and mucin
Necrobiosis lipoidica Palisading granuloma and necrobiotic materials
Foreign-body granuloma Foreign body
Juvenile xanthogranuloma Touton type giant cells and foamy cells
VI. Tumoral lesions
Benign tumoral lesions
Mastocytoma Abundant mast cellsTzanck smear test is useful for rapid diagnosis of mastocytoma in children
Sebaceous hyperplasia Clusters of sebocytes
Seborrheic keratosis Hyperkeratosis and horny cysts87.5% sensitive and 80.8% specific
Melanocytic nevi Dermal and epidermal type nevoid cells87.5% sensitive and 100% specific
Eruptive vellus hair cysts Abundant vellus hairs
Malignant tumoral lesionsCellular atypia including mitosis, poikilokaryosis, poikilocytosis, nuclear contour irregularity, prominent nucleoli and nuclear molding
Basal cell carcinoma Clusters of basaloid cellsThe most common reason to use cytological examination in malignant tumoral diseases is to distinguish basal cell carcinoma from other tumors, such as squamous cell carcinoma and melanoma. Tzanck smear test is 97% sensitivity and 86% specificity for the diagnosis of basal cell carcinoma.
Squamous cell carcinoma Cytologic atypia of keratinocytes
Melanoma Atypical melanocytes
Lymphoma Atypical lymphocytes
Paget’s disease Isolated or clusters of Paget’s cells
Kaposi’s sarcoma Cigar-shaped spindle cells

Tzanck smear examples

Related Research Articles

<span class="mw-page-title-main">Pap test</span> Cervical screening test to detect potential cancers

The Papanicolaou test is a method of cervical screening used to detect potentially precancerous and cancerous processes in the cervix or, more rarely, anus. Abnormal findings are often followed up by more sensitive diagnostic procedures and, if warranted, interventions that aim to prevent progression to cervical cancer. The test was independently invented in the 1920s by the Greek physician Georgios Papanikolaou and named after him. A simplified version of the test was introduced by the Canadian obstetrician Anna Marion Hilliard in 1957.

<span class="mw-page-title-main">Pathology</span> Study of the causes and effects of disease or injury, and how they arise

Pathology is the study of disease and injury. The word pathology also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatment, the term is often used in a narrower fashion to refer to processes and tests that fall within the contemporary medical field of "general pathology", an area that includes a number of distinct but inter-related medical specialties that diagnose disease, mostly through analysis of tissue and human cell samples. Idiomatically, "a pathology" may also refer to the predicted or actual progression of particular diseases, and the affix pathy is sometimes used to indicate a state of disease in cases of both physical ailment and psychological conditions. A physician practicing pathology is called a pathologist.

<span class="mw-page-title-main">Cytopathology</span> A branch of pathology that studies and diagnoses diseases on the cellular level

Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Cytopathology is frequently, less precisely, called "cytology", which means "the study of cells".

<span class="mw-page-title-main">Leishmaniasis</span> Disease caused by parasites of the Leishmania type

Leishmaniasis is a wide array of clinical manifestations caused by parasites of the Trypanosomatida genus Leishmania. It is generally spread through the bite of phlebotomine sandflies, Phlebotomus and Lutzomyia, and occurs most frequently in the tropics and sub-tropics of Africa, Asia, the Americas, and southern Europe. The disease can present in three main ways: cutaneous, mucocutaneous, or visceral. The cutaneous form presents with skin ulcers, while the mucocutaneous form presents with ulcers of the skin, mouth, and nose. The visceral form starts with skin ulcers and later presents with fever, low red blood cell count, and enlarged spleen and liver.

<span class="mw-page-title-main">Sputum</span> Mucus that is coughed up from the lower airways

Sputum is mucus that is coughed up from the lower airways. In medicine, sputum samples are usually used for a naked eye examination, microbiological investigation of respiratory infections and cytological investigations of respiratory systems. It is crucial that the specimen does not include any mucoid material from the nose or oral cavity.

<span class="mw-page-title-main">Blood smear</span> Stained blood on microscope slide

A blood smear, peripheral blood smear or blood film is a thin layer of blood smeared on a glass microscope slide and then stained in such a way as to allow the various blood cells to be examined microscopically. Blood smears are examined in the investigation of hematological (blood) disorders and are routinely employed to look for blood parasites, such as those of malaria and filariasis.

<span class="mw-page-title-main">Granuloma</span> Aggregation of macrophages in response to chronic inflammation

A granuloma is an aggregation of macrophages that forms in response to chronic inflammation. This occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate. Such substances include infectious organisms including bacteria and fungi, as well as other materials such as foreign objects, keratin, and suture fragments.

<span class="mw-page-title-main">Pemphigus</span> Blistering autoimmune diseases

Pemphigus is a rare group of blistering autoimmune diseases that affect the skin and mucous membranes. The name is derived from the Greek root pemphix, meaning "blister".

Dermatopathology is a joint subspecialty of dermatology and pathology or surgical pathology that focuses on the study of cutaneous diseases at a microscopic and molecular level. It also encompasses analyses of the potential causes of skin diseases at a basic level. Dermatopathologists work in close association with clinical dermatologists, with many possessing further clinical training in dermatology. The field was founded by German dermatologist and physician Gustav Simon, who published the first textbook on dermatopathology, 'Skin Diseases Illustrated by Anatomical Investigations', in 1848.

WHO Disease Staging System for HIV Infection and Disease in Adults and Adolescents was first produced in 1990 by the World Health Organization and updated in September 2005. It is an approach for use in resource limited settings and is widely used in Africa and Asia and has been a useful research tool in studies of progression to symptomatic HIV disease.

<span class="mw-page-title-main">Herpetic gingivostomatitis</span> Medical condition

Gingivostomatitis is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva. Herpetic gingivostomatitis is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis which is often the subsequent presentations. Primary herpetic gingivostomatitis is the most common viral infection of the mouth.

<span class="mw-page-title-main">Pemphigus vulgaris</span> Medical condition

Pemphigus vulgaris is a rare chronic blistering skin disease and the most common form of pemphigus. Pemphigus was derived from the Greek word pemphix, meaning blister. It is classified as a type II hypersensitivity reaction in which antibodies are formed against desmosomes, components of the skin that function to keep certain layers of skin bound to each other. As desmosomes are attacked, the layers of skin separate and the clinical picture resembles a blister. These blisters are due to acantholysis, or breaking apart of intercellular connections through an autoantibody-mediated response. Over time the condition inevitably progresses without treatment: lesions increase in size and distribution throughout the body, behaving physiologically like a severe burn.

<i>Anaplasma phagocytophilum</i> Species of bacterium

Anaplasma phagocytophilum is a Gram-negative bacterium that is unusual in its tropism to neutrophils. It causes anaplasmosis in sheep and cattle, also known as tick-borne fever and pasture fever, and also causes the zoonotic disease human granulocytic anaplasmosis.

<span class="mw-page-title-main">Herpes</span> Viral disease caused by herpes simplex viruses

Herpes simplex, often known simply as herpes, is a viral infection caused by the herpes simplex virus. Herpes infections are categorized by the area of the body that is infected. The two major types of herpes are oral herpes and genital herpes, though other forms also exist.

<span class="mw-page-title-main">Cold sore</span> Herpes simplex virus infection of the lip

A cold sore is a type of herpes infection caused by the herpes simplex virus that affects primarily the lip. Symptoms typically include a burning pain followed by small blisters or sores. The first attack may also be accompanied by fever, sore throat, and enlarged lymph nodes. The rash usually heals within ten days, but the virus remains dormant in the trigeminal ganglion. The virus may periodically reactivate to create another outbreak of sores in the mouth or lip.

<span class="mw-page-title-main">Post-kala-azar dermal leishmaniasis</span>

Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis (VL); it is characterised by a macular, maculopapular, and nodular rash in a patient who has recovered from VL and who is otherwise well. The rash usually starts around the mouth from where it spreads to other parts of the body depending on severity.

<span class="mw-page-title-main">Arnault Tzanck</span>

Arnault Tzanck was a French physician and a pioneer of blood transfusion. During the First World War, he was a doctor in the military ambulance where he realized the vital role of the blood transfusions.

<span class="mw-page-title-main">Cervical screening</span> Type of medical screening

Cervical cancer screening is a medical screening test designed to identify risk of cervical cancer. Cervical screening may involve looking for viral DNA, and/or to identify abnormal, potentially precancerous cells within the cervix as well as cells that have progressed to early stages of cervical cancer. One goal of cervical screening is to allow for intervention and treatment so abnormal lesions can be removed prior to progression to cancer. An additional goal is to decrease mortality from cervical cancer by identifying cancerous lesions in their early stages and providing treatment prior to progression to more invasive disease.

The mainstay of malaria diagnosis has been the microscopic examination of blood, utilizing blood films. Although blood is the sample most frequently used to make a diagnosis, both saliva and urine have been investigated as alternative, less invasive specimens. More recently, modern techniques utilizing antigen tests or polymerase chain reaction have been discovered, though these are not widely implemented in malaria endemic regions. Areas that cannot afford laboratory diagnostic tests often use only a history of subjective fever as the indication to treat for malaria.

<span class="mw-page-title-main">Herpes simplex keratitis</span> Medical condition

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

References

  1. Durdu M (2019). Cutaneous Cytology and Tzanck Smear Test. Springer International Publishing. ISBN   978-3-030-10721-5.
  2. Folkers E, Oranje AP, Duivenvoorden JN, van der Veen JP, Rijlaarsdam JU, Emsbroek JA (August 1988). "Tzanck smear in diagnosing genital herpes". Genitourinary Medicine. 64 (4): 249–54. doi:10.1136/sti.64.4.249. PMC   1194227 . PMID   3169755.
  3. Tzanck A (1947). "Le cyto-diagnostic immédiat en dermatologie". Presse Médicale.
  4. Horn TD (December 2008). "Commentary: heading the wrong way: the disappearing Tzanck smear". Journal of the American Academy of Dermatology. 59 (6): 965–966. doi:10.1016/j.jaad.2008.08.025. ISSN   1097-6787. PMID   18929430.
  5. Kelly B, Shimoni T (2009-06-01). "Reintroducing the Tzanck Smear". American Journal of Clinical Dermatology. 10 (3): 141–152. doi:10.2165/00128071-200910030-00001. ISSN   1179-1888. PMID   19354329. S2CID   23928319.
  6. Noyan MA, Durdu M, Eskiocak AH (2020-10-27). "TzanckNet: A convolutional neural network to identify cells in the cytology of erosive-vesiculobullous diseases". Scientific Reports. 10 (1): 18314. doi:10.1038/s41598-020-75546-z. PMC   7591506 . PMID   33110197.
  7. Pettit, Normal Microbiota of the Skin, ATSU School of Osteopathic Medicine Arizona, Lecture Slides. Jan 2013.
  8. Durdu M, Seckin D, Baba M (January–February 2011). "The Tzanck Smear Test: Rediscovery of a Practical Diagnostic Tool". Skinmed. 9 (1): 23–32. PMID   21409959 . Retrieved 18 September 2023.