BackgroundThe cervical cancer screening recommendation for transgender female‐to‐male (FTM) patients is the same as that for cisgender females. A lack of literature on testosterone‐induced changes in cervical cytology in these patients may result in interpretation errors, especially without a proper clinical history. The aim of this study was to delineate the Papanicolaou (Pap) test findings in this patient population.MethodsA pathology laboratory information system was used to obtain a cohort of FTM transgender patients on testosterone therapy (2009‐2019). A cohort of age‐matched, atrophic, control cisgender female patients (postpartum or menopausal) was selected. A retrospective review of the cytomorphologic findings on cervical Pap smears, pertinent follow‐up, and human papillomavirus (HPV) test results was performed.ResultsFourteen transgender patients (age range, 21‐64 years; mean age, 42.5 years) receiving testosterone therapy with 17 Pap smears were identified. One of the 5 available HPV tests was positive for HPV, and 4 were negative. A Pap smear review revealed the following: negative for intraepithelial lesion (NILM; 82.4%), unsatisfactory (5.9%), atypical squamous cells of undetermined significance (ASCUS; 5.9%), and low‐grade squamous intraepithelial lesion (5.9%). The Pap smears of the atrophic cisgender cohort (102 patients) revealed the following: NILM (92.5%), unsatisfactory (0.9%), ASCUS (5.6%), and high‐grade squamous intraepithelial lesion (0.9%). The difference between the rates of epithelial cell abnormality in the 2 cohorts was not statistically significant. Although atrophy was noted in both groups, cytomorphologic findings of transitional cell metaplasia (TCM; 88.2%) and “small cells” (82.4%) were characteristic of the testosterone‐treated transgender cohort. Histologic correlates of TCM and small cells were noted in hysterectomy specimens from 6 patients.ConclusionsSmall cells and TCM are common cytomorphologic findings in Pap smears of testosterone‐treated transgender (FTM) patients. On the basis of histologic follow‐up, small cells most likely represent atrophic parabasal cells of cervical‐vaginal epithelium.

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Thrombotic microangiopathy (TMA) is a serious and potentially fatal disorder, especially if there is a delay in diagnosis and appropriate treatment. Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are the two main forms of TMA. Although severe acute kidney injury (AKI) is a common manifestation of TMA, it remains rarely described in reported TTP cases. We present a rare case of TTP in a 76-year-old African American male who presented with severe AKI (stage 3) and uremic symptoms. Early diagnosis and prompt treatment of TTP with plasmapheresis followed by rituximab and caplacizumab were associated with the resolution of the AKI and avoidance of hemodialysis. This case highlights the need to consider TTP as a possible diagnosis even in the setting of severe AKI.

A 55-year-old man with a history of pulmonary metastatic disease underwent thoracentesis for evaluation of a pleural effusion. The pH of the pleural fluid sample was measured using an ABL835 blood gas analyzer, which yielded a value of 7.37. As part of new instrument validation, the sample was immediately tested using an ABL90 analyzer, which generated a markedly lower value of 6.71 (Table 1). A sample from a second patient demonstrated similarly discrepant results. The answers are below. ANSWERSInappropriate collection practices resulting in lidocaine HCl contamination have been shown to decrease the reported pH of pleural fluid (1 ). Patient 2's sample was available for follow-up testing using GC-MS, which revealed a lidocaine concentration of 560 g/mL (5.6% contamination with a 10 mg/mL stock solution). Testing of experimental spiked solutions confirmed that both instruments generated decreasing pH results with increasing lidocaine concentration. It is unclear why the ABL90 demonstrated greater susceptibility than the ABL835.