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Year : 2016  |  Volume : 59  |  Issue : 4  |  Page : 557-558
The fire flares which lead to grave


Department of Pathology, TN Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

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Date of Web Publication10-Oct-2016
 

How to cite this article:
Desai HM, Shetty JB, Jashnani KD. The fire flares which lead to grave. Indian J Pathol Microbiol 2016;59:557-8

How to cite this URL:
Desai HM, Shetty JB, Jashnani KD. The fire flares which lead to grave. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Oct 22];59:557-8. Available from: http://www.ijpmonline.org/text.asp?2016/59/4/557/191795


A 35-year-old female came with an anterior neck swelling since 5 years. The swelling was diffuse, measuring 3 cm 3 cm, firm in consistency, and moved with deglutition. Eye signs were positive. Her thyroid profile tests were suggestive of a hyperplastic thyroid (T3, T4 raised and thyroid-stimulating hormone reduced). Ultrasonography (USG) of the neck showed bilaterally enlarged thyroid lobes with a heterogenous echotexture and highly increased vascularity suggestive of either Hashimoto's thyroiditis or hypothyroid phase of Graves' disease. Thyroid scan showed increased trapping function with a cold area in the region of the isthmus. USG-guided fine-needle aspiration cytology (FNAC) was carried out from the isthmus with a 24-gauge needle and 10cc syringe. Smears prepared were stained with both Papanicolaou (PAP) and May-Grunwald-Giemsa (MGG) stains. Smears were cellular and showed benign thyroid follicular cells in clusters and isolated. Individual cells within the clusters had abundant lacy cytoplasm and many of the clusters showed the presence of fire flares on MGG stain suggestive of toxic goitre (Bethesda category II) [Figure 1].
Figure 1: (a-d): Multiple loose clusters of benign thyroid follicular cells showing abundant lacy cytoplasm with homogenous pale pink material (fire flares) around the periphery of all the clusters (May-Grunwald-Giemsa, ×400)

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In Graves' disease, apart from the characteristic clinical and thyroid hormone assays, various cytomorphological features are helpful in diagnosis. One of the characteristic cytological findings is the presence of fire flares/marginal vacuoles (MVs)/soap bubble, colloid suds best identified on MGG-stained smear preparations although they may not be seen in all cases of hyperplasia of the thyroid. [1] They were first described within the cytoplasm of follicular cells in toxic goitres by Söderström et al. in 1979 [2] These MVs are deeply eosinophilic in the periphery and have an unstained central area identified only on MGG stain. [3] Because of their peripheral distribution, they are known as MVs. They are also known as fire flares because they resemble a spreading fire. They are a manifestation of pinocytosis of thyroglobulin present within the thyroid follicles. [1]

It has been proposed that MVs occur because of diffusion of thyroid hormones from the follicular cell basal layer as they reach the interfollicular capillaries. [3] Ultrastructural studies have shown that these MVs are dilated cisternae of the endoplasmic reticulum. [3]

Gupta et al. [4] in their study on the cytomorphological significance of MVs in diffuse toxic goitre found that abundant MVs were found in primary hyperplasia and Hashimoto's thyroiditis (P = 0.01) and were absent in cases of colloid goitre (P = 0.004).

Although highly suggestive of thyrotoxicosis, fire flares have also been reported to occur in Hashimoto's thyroiditis, diffuse goitres and follicular carcinoma although they are more abundant in hyperthyroid aspirates. [3],[4]

In our case, characteristic clinical signs, radiological findings, thyroid hormone assays and FNAC findings supported a diagnosis of toxic goitre (Graves' disease).

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Buley ID. Thyroid gland. In: Gray W, Kocjan G, editors. Diagnostic Cytopathology. 3 rd ed. China: Churchill Livingstone Elsevier; 2010. p. 487-512.  Back to cited text no. 1
    
2.
Söderström N, Nilsson G. Cytologic diagnosis of thyrotoxicosis. Acta Med Scand 1979;205:263-5.  Back to cited text no. 2
    
3.
Das DK. Marginal vacuoles (fire-flare appearance) in fine needle aspiration smears of thyroid lesions: Does it represent diffusing out of thyroid hormones at the base of follicular cells? Diagn Cytopathol 2006;34:277-83.  Back to cited text no. 3
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4.
Gupta A, Singhal M, Kalhan S, Gupta A, Singhal O, Kaur V. Cytomorphologic significance of marginal vacuoles in diffuse thyroid enlargements. J Cytol 2013;30:125-9.  Back to cited text no. 4
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Correspondence Address:
Heena Maulek Desai
Department of Pathology, TN Medical College and BYL Nair Charitable Hospital, Dr. A.L. Nair Road, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.191795

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