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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and Keywords: Tzanck smear, Chickenpox skin test, herpes skin test

Overview

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. The test is named after Arnault Tzanck (1886-1954), a Russian dermatologist. Atypical Tzanck cell is a large round keratinocyte with a hypertrophic nucleus, hazy or absent nucleoli, and abundant basophilic cytoplasm. The basophilic staining is deeper peripherally on the cell membrane due to the cytoplasm's tendency to get condensed at the periphery, leading to a perinuclear halo. Tzanck cells commonly are found in: herpes simplex, varicella, herpes zoster and pemphigus vulgaris.[1]

Historical Perspective

  • Diagnostic cytology is the study of individual cells and their characteristics and functions.
  • George Papanicolaou is considered the father of exfoliative cytology.
  • Cytology technique was first used by Tzanck for the diagnosis dermatological disorders such as herpes and other vesico-bullous lesions.[2]
  • The test is named after Arnault Tzanck (1886-1954), a Russian dermatologist.
  • The different techniques of cytological studies include aspiration cytology, imprint smear, exudate smear, skin scraping smear, and Tzanck smear.

Tzanck Smear

Sample Collection

  • In patients with suspected viral lesions the sample must be collected from fresh vesicular lesions rather than the healing crusted lesions, to have a sample with adequate number of virus infected cells.[3]
  • The vesicle should be un-roofed and the base of the ulcer must be scraped with a scalpel or with a scapula.
  • The obtained material should be then transferred on to a clean glass slide.
  • Care should should be taken that the glass slide is clean and has no finger prints as the specimen will not stay on the glass slide with finger prints.

Fixation of the Smear

  • A fixative fluid contains reactive chemicals and is useful for the preservation of the specimens. The fixative fluid prevents the denaturation of the proteins and autolysis and helps in maintaining the cellular morphology and its contents.
  • Fixatives usually contain chemicals like formalin, glutaraldehyde, methanol, ethanol, acetone, acetic acid, chromates, and picric acid.
  • Once the sample is transferred on to the glass slide it should be fixed immediately using a fixative fluid to prevent drying of the tissue.

Staining of the Smear

Tzanck Smear Findings

  • A typical Tzanck cell is a large round keratinocyte with a hypertrophic nucleus, hazy or absent nucleoli, and abundant basophilic cytoplasm. The basophilic staining is deeper peripherally on the cell membrane due to the cytoplasm's tendency to get condensed at the periphery, leading to a perinuclear halo.

The following are the list of cutaneous diseases which can be differentiated based on the findings on the Tzanck smear:[4]

Category Disease Cytological Findings
Immunobullous Lesions Pemphigus vulgaris Multiple acantholytic cells (Tzanck cells)
Toxic epidermal necrolysis Necrotizing basal cells with scattered inflammatory cells and fibroblasts 
Staphylococcal scalded skin syndrome Dyskeratotic acantholytic cells with few inflammatory cells
Findings are non-specific with no acantholytic cells
Cutaneous Infections Herpes Simplex

Varicella

Herpes Zoster

Multinucleated syncytial giant cells and acantholytic cells 

Intranuclear inclusion bodies surrounded by subtle clear halo is a characteristic of herpetic infection

Molluscum contagiosum Intracytoplasmic molluscum bodies (Henderson-Patterson bodies)
Variable number of acantholytic cells and detached keratinocytes

Eosinophilic cytoplasmic inclusion called "Guarnieri body" may be present

Leishmaniasis Leishman-Donovan (LD) bodies

Wright Cells

Genodermatosis Hailey-Hailey disease[5] Multiple acantholytic cells.
Darier disease "Corps ronds" and "grains" appearance

"Corps ronds" are isolated keratinocytes with a round shape and an acidophilic cytoplasm, the grains are seen as small, hyaline, acidophilic ovoid bodies resembling pomegranate seeds.

Cutaneous Tumors Basal cell epithelioma Clusters of basaloid cells with peripheral palisading
Squamous cell carcinoma Isolated cells with pleomorphism

Presence of nuclear and cytoplasmic changes

Paget's disease Round to oval cells with amphophilic, vacuolated cytoplasm and a hypertrophic nucleolated nucleus
Erythroplasia of Queyrat Polyhedral, spindle-shaped and round cells with "poikilokaryosis" 
Mastocytoma Numerous mast cells
Histiocytosis X Multinucleate atypical Langerhans cells 

References

  1. Schneider WH (2010). "Arnault Tzanck, MD (1886-1954)". Transfus Med Rev. 24 (2): 147–50. doi:10.1016/j.tmrv.2009.11.006. PMID 20303038.
  2. Yaeen A, Ahmad QM, Farhana A, Shah P, Hassan I (2015). "Diagnostic value of Tzanck smear in various erosive, vesicular, and bullous skin lesions". Indian Dermatol Online J. 6 (6): 381–6. doi:10.4103/2229-5178.169729. PMC 4693347. PMID 26751561.
  3. Brodell RT, Helms SE, Devine M (1991). "Office dermatologic testing: the Tzanck preparation". Am Fam Physician. 44 (3): 857–60. PMID 1877427.
  4. Eryılmaz A, Durdu M, Baba M, Yıldırım FE (2014). "Diagnostic reliability of the Tzanck smear in dermatologic diseases". Int J Dermatol. 53 (2): 178–86. doi:10.1111/j.1365-4632.2012.05662.x. PMID 23557278.
  5. de Aquino Paulo Filho T, deFreitas YK, da Nóbrega MT, Lima CB, Carriço BL, Silva MA; et al. (2014). "Hailey-Hailey disease associated with herpetic eczema-the value of the Tzanck smear test". Dermatol Pract Concept. 4 (4): 29–31. doi:10.5826/dpc.0404a04. PMC 4230254. PMID 25396081.



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