Atypical Squamous Cells in Liquid-Based Cervical Cytology: Microbiology, Inflammatory Infiltrate, and Human Papillomavirus-DNA Testing

OBJECTIVE

The aim of this study was to assess the correlation between atypical squamous cells (ASC) and inflammatory infiltrate and vaginal microbiota using cervical liquid-based cytological (SurePath®) and high-risk human papillomavirus (HR-HPV) tests.

STUDY DESIGN

A cross-sectional study was conducted using a 6-year database from a laboratory in Fortaleza (Brazil). Files from 1,346 ASC cases were divided into subgroups and results concerning inflammation and vaginal microorganisms diagnosed by cytology were compared with HR-HPV test results.

RESULTS

An absence of specific microorganisms (ASM) was the most frequent finding (ASC of undetermined significance, ASC-US = 74%; ASC - cannot exclude high-grade squamous intraepithelial lesion, ASC-H = 68%), followed by bacterial vaginosis (ASC-US = 20%; ASC- H = 25%) and Candida spp. (ASC-US = 6%; ASC-H = 5%). Leukocyte infiltrate was present in 71% of ASC-US and 85% of ASC-H (p = 0.0040), and in these specific cases HR-HPV tests were positive for 65 and 64%, respectively. A positive HR-HPV test was relatively more frequent when a specific microorganism was present, and Candida spp. was associated with HR-HPV-positive results (p = 0.0156), while an ASM was associated with negative HR-HPV results (p = 0.0370).

CONCLUSION

ASC-US is associated with an absence of inflammation or vaginosis, while ASC-H smears are associated with Trichomonas vaginalis and inflammatory infiltrate. A positive HR-HPV is associated with Candida spp. in ASC cytology.

Epigenetics regulates transcription and pathogenesis in the parasite Trichomonas vaginalis

Trichomonas vaginalis is a common sexually transmitted parasite that colonizes the human urogenital tract. Infections range from asymptomatic to highly inflammatory, depending on the host and the parasite strain. Different T. vaginalis strains vary greatly in their adherence and cytolytic capacities. These phenotypic differences might be attributed to differentially expressed genes as a consequence of extra-genetic variation, such as epigenetic modifications. In this study, we explored the role of histone acetylation in regulating gene transcription and pathogenesis in T. vaginalis. Here, we show that histone 3 lysine acetylation (H3KAc) is enriched in nucleosomes positioned around the transcription start site of active genes (BAP1 and BAP2) in a highly adherent parasite strain; compared with the low acetylation abundance in contrast to that observed in a less-adherent strain that expresses these genes at low levels. Additionally, exposition of less-adherent strain with a specific histone deacetylases inhibitor, trichostatin A, upregulated the transcription of BAP1 and BAP2 genes in concomitance with an increase in H3KAc abundance and chromatin accessibility around their transcription start sites. Moreover, we demonstrated that the binding of initiator binding protein, the transcription factor responsible for the initiation of transcription of ~75% of known T. vaginalis genes, depends on the histone acetylation state around the metazoan-like initiator to which initiator binding protein binds. Finally, we found that trichostatin A treatment increased parasite aggregation and adherence to host cells. Our data demonstrated for the first time that H3KAc is a permissive histone modification that functions to mediate both transcription and pathogenesis of the parasite T. vaginalis.

Effect of Anapsos® in a murine model of experimental trichomoniasis

Immunomodulator effect of Anapsos (Polypodium leukotomas extract) in NMRI (US Naval Medical Research Institute) outbred mice infected by the intraperitoneal route with 10(7) Trichomonas vaginalis has been tested. Gross histopathologic changes in abdominal organs and mortality rate, as a consequence of the pathogenicity of the protozoa and the immune response of the host, were evaluated. Among the different treatment regimes assayed, Anapsos at doses of 20 mg/Kg/day administered for 10 days before infection decreases the parasite pathogenicity index (PI) in the treated animals when compared to those of the untreated control group. The immunosuppressor treatments with azathioprine (100 mg/Kg/day x 1), cyclophosphamide (100 mg/Kg/day x 1), and FK-506 (10 mg/Kg/day x 10) significantly decreased the PI, while an immunostimulant treatment with glycophosphopeptical (13 mg/Kg/day x 10) increased it. These assays have shown the usefulness of the murine model of experimental trichomoniasis for the study of immunomodulator activity of natural or synthetic drugs.

Whole Slide Imaging of Pap Cell Block Preparations versus Liquid-Based Thin-Layer Cervical Cytology: A Comparative Study Evaluating the Detection of Organisms and Nonneoplastic Findings

OBJECTIVE

Cervical cancer is one of the most common malignancies worldwide, yet it is preventable by population screening. In a previous study, we confirmed the feasibility of utilizing whole slide imaging (WSI) of cell block (CB) preparations to overcome the limitations of digitizing cytologic samples. In this study, we evaluated the accuracy of WSI in identifying various organisms and nonneoplastic findings.

STUDY DESIGN

A total of 335 WS images from Pap CB preparations were analyzed using the Aperio system. The test performance characteristics of ThinPrep (TP) and WSI samples were compared for adequacy, for the presence of bacterial vaginosis (BV), fungi, Trichomonas vaginalis (TV) and herpes simplex virus (HSV) and for nonneoplastic findings.

RESULTS

The WSI samples contained optimal material from all preparations. BV was diagnosed in 33 WSI versus 36 TP samples. Budding yeasts and/or pseudohyphal forms were noted in 18 WSI versus 19 TP samples. TV organisms (10 of 11 samples) and 1 HSV case were accurately identified in the WSI and TP samples. Squamous metaplasia, keratosis and reactive/reparative and inflammatory changes were easily identified by WSI.

CONCLUSIONS

The concept of WSI from Pap CB preparations is potentially feasible for adoption. Digital remote web-based technology eliminates the need for an individual on site, saving time and resources.

Association of Trichomonas vaginalis and cytological abnormalities of the cervix in low risk women

Objective

Is Trichomonas vaginalis (TV) an inducing factor for the development of (pre-)cancerous lesions of the cervix?

Design

Cross sectional study.

Setting

Screening healthy Belgian women with low infection risk.

Sample

63,251 consecutive liquid based cervical samples.

Methods

Real time quantitative PCR for presence of TV, 18 HPV types and Pap smear analysis of cytologic abnormalities.

Main Outcome Measures

Association of TV and HPV with cervix dysplasia

Results

The overall prevalence of TV DNA was 0.37%, of low risk HPV 2%, of high risk HPV 13.2%, and 8.8 % had cytological abnormalities. Both LR-HPV and HR-HPV were significantly associated with all cytological abnormalities. Presence of TV was associated with LR- and HR-HPV, ASC-US and HSIL, but not with other abnormalities. All women with TV and HSIL also had HR-HPV, while the latter was present in only 59% of women with TV and ASC-US. Amongst HPV negative women, TV was found in 1.3% of women with ASC-US, but only in 0.03% of women with normal cytology (OR 4.2, CL95% 2.1-8.6). In HR-HPV positive women, presence of TV increased the likelihood of cytological abnormalities somewhat (P=0.05), mainly due to an increase in ASC-US and LSIL, but not HSIL.

Conclusions

We conclude that TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. TV is a concomitant STI, but is not thought to be a co-factor in the causation of HSIL and cervical cancer. However, TV may cause false positive diagnoses of ASC-US.

Gardnerella, Trichomonas and Candida in cervical smears of 58,904 immigrants participating in the Dutch national cervical screening program

OBJECTIVE

To report the prevalence of Gardnerella, Trichomonas and Candida in the cervical smears of 9 immigrant groups participating in the Dutch national cervical screening program.

STUDY DESIGN

Cervical smears were taken from 58,904 immigrant participants and 498,405 Dutch participants. As part of the routine screening process, all smears were screened for the overgrowth of Gardnerella (i.e. smears with an abundance of clue cells) and for the presence of Trichomonas and Candida. The smears were screened by 6 laboratories, all of which use the Dutch KOPAC coding system. The odds ratio and confidence interval were calculated for the 9 immigrant groups and compared to Dutch participants.

RESULTS

Immigrants from Suriname, Turkey and the Dutch Antilles have a 2-5 times higher prevalence of Gardnerella and Trichomonas when compared to native Dutch women. Interestingly, the prevalence of Trichomonas in cervical smears of Moroccan immigrants is twice as high, yet the prevalence of Gardnerella is 3 times lower than in native Dutch women.

CONCLUSIONS

Immigrants with a high prevalence of Gardnerella also have a high prevalence of Trichomonas. In the context of the increased risk of squamous abnormalities in smears with Gardnerella, such slides should be screened with extra care.

Morphologic criteria associated with Trichomonas vaginalis in liquid-based cytology

OBJECTIVE

To evaluate the morphologic criteria associated with Trichomonas vaginalis on Cytyc (Marlborough, Massachusetts, U.S.A.) liquid-based cytology and to compare results between 2 types of liquid-based cytology-Cytyc and SurePath (BD Diagnostics-TriPath, Burlington, Vermont, U.S.A).

STUDY DESIGN

Forty thousand Cytyc liquid-based cytology cases were tested between January 2005 and 2008. Among these, 80 cases (0.2%) had aT vaginalis infection without intraepithelial lesions or other associated infectious organism. The 80 ThinPrep (Cytyc) slides were reexamined, and for each case, morphologic characteristics associated with the parasite were listed. Concerning the SurePath technique, only 1 paper has been found in the literature based on 60,104 cases with 88 cases of T vaginalis (0.17%).

RESULTS

Among the 80 T vaginalis patients, the most frequent features associated with the infection were the presence of cannonballs (93%), perinuclear halo (90%), reactive nuclear changes (88%) and attachment of T vaginalis to squamous cells (86%). Moreover, the presence of ghost cells was significantly more frequent in SurePath than Cytyc liquid-based cytology (p = 0.00001), and the presence of neutrophils, reactive nuclear changes, dirty background and karyorrhexis and the predominance of coccobacilli were significantly more frequent in Cytyc than SurePath liquid-based cytology (p < 0.05).

CONCLUSION

On the basis of these results, we conclude that SurePath and Cytyc, which are the both commonly used liquid-based cytologic techniques, are useful and have the same efficacy in the detection of T vaginalis infection (p = 0.99).

Recent diagnostic study for the flagellate protozoan Trichomonas vaginalis

The signs and symptoms of trichomonasis vaginalis are not adequately sensitive or specific for diagnosis as up to 50% being asymptomatic. Parasitologic diagnosis was usually a must. Diagnosis of trichomonasis was traditionally based on demonstration of the parasite in the normal saline wet mounts of vaginal swaps. In this study, 15/167 married women had T. vaginalis. Wet mount preparation showed 38.5% sensitivity, 98.7% specificity, 71.4% positive predictive value and 95% negative predictive value. InPouch TV culture showed 86.7% sensitivity, 100% specificity, 100% positive predictive value and 98.7% negative predictive value. The results were discussed.

Trichomoniasis among women with vaginal discharge in Benghazi city, Libya

From April 2000 to July 2001, clinical and wet-mount examination were performed on 2,450 women attending gynecologic department, El-Keish Polyclinic, Benghazi City. The mean age was 34+/-7 (in years). 328 (13.4%) women were clinically diagnosed as having viginatis. Sterile vaginal swab of the posterior fornix was stained by Giemsa and examined as wet smear for trichomoniasis infection. 29/2450, (1.2%) had T. vaginalis. The infected women suffered vaginalis discharge (93.10%), burning (81.48%), vulvar pruritus (79.39%), dyspareuria (40.47%), dysuria (21.43%) and strawberry appearance (75.86%).

The Occurrence of Vaginal Infections Among HIV-Infected and High-Risk HIV-Uninfected Women

OBJECTIVES

To evaluate changes over time in rates of bacterial vaginosis (BV), trichomoniasis (TV), and yeast vaginitis (YV) among HIV-infected and similar HIV-uninfected women.

METHODS

Two thousand fifty-six HIV-infected women and 554 HIV-uninfected women were evaluated semiannually from 1994 until March 2003 in a prospective cohort study. BV was diagnosed by Gram stain, TV by wet mount, and YV by symptoms with microscopically visible hyphae or positive culture. Trends were assessed using Poisson models.

RESULTS

At baseline, BV was present in 42.8% and 47.0% of HIV-infected and uninfected women (P = 0.21), TV in 6.1% and 7.8% (P = 0.17), and YV in 10.0% and 3.8% (P < 0.001). Over time, rates of BV and TV decreased significantly in both groups, whereas rates of YV declined only among HIV-infected women. Risk of BV was not associated with HIV status, whereas HIV-infected women had a lower risk of TV. Highly active antiretroviral therapy (HAART) use was associated with decreased risk of all 3 infections.

CONCLUSIONS

: Declines in BV, TV, and YV represent decreased morbidity for HIV-infected women and, potentially, decreased risk of transmission of HIV, because each has been associated with increased genital detection of HIV.

[Molecular and chemical mechanism of Trichomonas vaginalis-induced contact-dependent cytotoxicity]

Trichomonas vaginalis parasitizes in human genitourinary tract. The protozoon adhering to target cell plays a critical role in its contact-dependent cytotoxicity. The enzymes synthesized by T.voginalis can hurt vaginalis epithelial cells (VECs) directly. The focal immune reaction in the location parasitized by the parasite may provide an immunologic protection. Meanwhile, inflammatory factors and immune cells may aggravate the situation. In general, the T. vaginalis-induced contact-dependent cytotoxicity is a result of the involvement of some molecular and chemical factors.

Nitric oxide radicals in leucocytes and vaginal washes of Trichomonas vaginalis -infected symptomatic and asymptomatic women

The clinical spectrum of Trichomonas vaginalis infection varies from asymptomatic to mild, moderate or severe vaginitis. Nitric oxide and other reactive nitrogen radicals produced by immune effector cells are important cytotoxic and cytostatic mediators against several microorganisms including parasites. In the present study, inducible nitric oxide synthase (iNOS) and reactive nitrogen intermediates (RNI) were determined in leucocyte cultures (stimulated with T. vaginalis in vitro) and vaginal washes (VWs) of 22 symptomatic and 20 asymptomatic T. vaginalis-infected and 20 healthy women by immunoblotting and Griess method respectively. The iNOS protein was detected in leucocytes and VWs of all the symptomatic and asymptomatic women, but was not detected in any of the samples from healthy women. Mean iNOS protein band intensity was significantly higher in leucocytes as compared to VWs (P<0.001) of both symptomatic and asymptomatic women and was also higher in leucocytes of asymptomatic as compared to symptomatic women (P<0.05). Mean RNI concentration was also significantly higher in leucocytes (P<0.01) and VWs (P<0.05) of asymptomatic as compared to symptomatic women, and was also higher in samples of infected as compared to healthy women (P<0.001). These results suggest that reactive nitrogen radicals may have a role in limiting T. vaginalis infection in asymptomatic women.

Results of longterm hospital based cytological screening in asymptomatic women

Routine cytological screening has been carried out in 27,062 asymptomatic women attending Gynaec and Family Planning O.P.D. of Queen Mary's Hospital, Lucknow, India (April 1971-December 2004). Incidence of squamous intraepithelial lesion (SIL) was found to be 5.9% in the series, while cervical malignancy was seen in 0.6% of cases. The study highlighted the immense utility of cytological screening in minimizing the incidence of carcinoma cervix in the segment of the urban population screened, as the incidence dropped down to 0.5% in the second half from 1.1% noticed in the first half of the screening period. The study also emphasized the utility of clinically downstaging the cervical cancer as 7,316 women showing clinical lesions of cervix were found to harbor SIL in 15.3% and carcinoma cervix in 1.3% of cases as against the incidence of 2.5% for SIL and 0.6% for frank cancer in women with normal cervix. The investigation into different risk factors involved in cervical carcinogenesis revealed that the incidence of SIL and cancer cervix showed a rise with increasing age and parity and prolonged sexual period. The incidences of both cervical cytopathologies were also higher in women of low socio-economic status while religion was found to have no bearing on the occurrence of the disease. Among the four sexually transmitted diseases (STDs) diagnosed in the cervical smears, Trichomonas vaginalis was found to be more prevalent (2.6%), while human papillomavirus (HPV) and Herpes simplex was seen in 0.4 and 0.2% of cases, respectively Herpes simplex was found to have strong affinity with both SIL and carcinoma cervix, while only SIL incidence was high with HPV infection. The study emphasizes need of proper education to women of low socio-economic class for creating awareness regarding hazards and risk factors of cervical cancer as well as management and cure of the disease.

Trichomonas vaginalis: intrastrain polymorphisms within the ribosomal intergenic spacer do not correlate with clinical presentation

Trichomoniasis presents a broad spectrum of clinical patterns ranging from asymptomatic to severe vaginitis and cervicitis. Despite its importance, very little is known about the genetic relatedness of its causative agent, Trichomonas vaginalis, and the clinical phenotypes. To address this question, analysis of restriction length polymorphism (RFLP) within the intergenic spacer of the ribosomal DNA (IGS) from 60 clinically defined isolates of T. vaginalis was performed. This is the first description of the IGS polymorphism of T. vaginalis. As expected, a considerable number of patients were asymptomatic (28%) while only 12% presented both leukorrhea and macular colpitis, the most evident symptoms of trichomoniasis. The IGS-RFLP with the use of eight restriction enzymes showed absence of correlation between the genetic relatedness of the isolates and symptomatology. Further studies are necessary to evaluate the importance of the IGS polymorphism to the parasite virulence and clinical phenotype.

Vaginal swabs versus lavage for detection of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women

OBJECTIVES

Cervicovaginal lavage (CVL) is often used for research and may be easier and more accurate than vaginal swabs as a specimen collection method.

GOAL

The goal of this study was to compare (CVL) with vaginal swabs for the detection of bacterial vaginosis (BV) and Trichomonas vaginalis (TV).

STUDY

CVL and vaginal swabs were collected from 216 HIV-infected women. Clinical assessments were made using wet mount for TV and Amsel's criteria for BV through CVL and swab collection methods. Laboratory gold standards used were Nugent's criteria for BV and InPouch (Biomed Diagnostics, San Jose, CA) culture for TV collected by swab.

RESULTS

The prevalence by gold standards for BV was 49.3% and for TV was 25.2%. Sensitivities for direct microscopy versus culture for TV were 72.2 for CVL and 52.8 for vaginal swab (P <0.05). Sensitivities for Amsel's versus Nugent's criteria for BV were 36.2 for CVL and 34.0 for vaginal swab (P <0.80). Kappa scores of agreement between CVL and vaginal swabs for BV and TV were excellent for both.

CONCLUSION

CVL was comparable to vaginal swabs as a specimen collection method for these 2 lower genital tract infections and may be superior for the diagnosis of TV.

Antibiotics for Bacterial Vaginosis or Trichomonas vaginalis in Pregnancy: A Systematic Review

OBJECTIVE

To determine whether antibiotic treatment for bacterial vaginosis or Trichomonas vaginalis during pregnancy decreases the risk of preterm birth and associated adverse outcomes.

DATA SOURCES

Pre-MEDLINE and MEDLINE (1966-2003), EMBASE (1980-2003), and the Cochrane Library were searched using the keywords "bacterial vaginosis", "Trichomonas", "Trichomonas vaginalis", "Trichomonas vaginitis", "Trichomonas infections", "pregnancy", "pregnant", "antibiotics", and "antibiotic prophylaxis".

METHODS OF STUDY SELECTION

The search produced 1,888 titles, of which 1,256 abstracts were reviewed further. Of these, 1,217 were ineligible. Inclusion criteria were the following: randomized controlled trials in which antibiotics were compared with no antibiotic or placebo, for women in the second or third trimester of pregnancy with symptomatic or asymptomatic bacterial vaginosis or Trichomonas vaginalis, intact membranes, and not in labor. Exclusion criteria were as follows: published in a language other than English, dropout rate of more than 20% of women in either group, and lack of usable outcomes. Of the 39 papers reviewed in detail, 14 studies were included in the meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

One of the authors reviewed titles obtained from the searches, and 2 reviewers independently reviewed the abstracts, excluded those that were ineligible, identified eligible papers, and abstracted the data. For women with bacterial vaginosis, antibiotics reduced the risk of persistent infection but did not reduce the risk of preterm birth or the incidence of associated adverse outcomes for the general population or for any subgroup analyzed. For women with Trichomonas vaginalis, metronidazole reduced the risk of persistent infection but increased the incidence of preterm birth.

CONCLUSION

Contrary to the conclusions of 3 recent systematic reviews, we found no evidence to support the use of antibiotic treatment for bacterial vaginosis or Trichomonas vaginalis in pregnancy to reduce the risk of preterm birth or its associated morbidities in low- or high-risk women.

Evaluation of cervical smears at King Hussein Medical Centre, Jordan, over three and a half years

Cervical smears taken from women referred for a check-up or with vaginal itching/discharge over a period of 3.5 years were reviewed at the King Hussein Medical Centre, Jordan. All smears were fixed with 96% alcohol, stained with Papanicolaou stain and screened microscopically. Of the smears from 1176 women aged 18-70 years, 4.5% were classified as inadequate, 7.7% were normal and 79.9% showed non-specific inflammation. Abnormal vaginal flora was found in 4.8% of cases, Candida albicans in 1.2%, Trichomonas vaginalis in 0.9% and actinomycosis in 1 case. Dysphasic changes were rare: 9 cases (0.8%) were classified as atypical squamous cells of undetermined significance (ASCUS) and 2 cases (0.2%) were low-grade squamous intraepithelial lesion (LSIL). No cases of human papillomavirus infection (HPV) or cervical carcinoma were found.

Cytologic features of squamous cell carcinoma in ThinPrep slides: evaluation of cases that performed poorly versus those that performed well in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology

CONTEXT

Although the cytologic features of squamous cell carcinoma in ThinPrep specimens are well known, whether these features are different in cases that are easily identified than in cases that are more difficult to identify is not known.

OBJECTIVE

To determine the cytologic features of squamous cell carcinoma in ThinPrep specimens that are easy to identify versus those that are difficult.

DESIGN

The cytologic features of 6 cases of squamous cell carcinoma that performed poorly in the College of American Pathologists Interlaboratory Comparison Program were compared with 14 cases that performed extremely well.

RESULTS

After evaluation of multiple criteria, 7 different cytologic features were analyzed based on review by a consensus panel blinded to the performance of the cases. The feature that was most strongly associated with cases that performed poorly was the presence of Trichomonas vaginalis (5/6 [83%] vs 0/14; P <.001). The presence of marked nuclear pleomorphism was more common in cases that performed well (4/14 [28%] vs 0/6; P =.27), but was not significant. The number of tumor cells, the number of normal cells, and the presence of keratinization, pleomorphism, nucleoli, and diathesis were not significant. The most common misdiagnosis after Trichomonas vaginalis was reparative change.

CONCLUSIONS

The presence of Trichomonas is characteristic of cases of squamous cell carcinoma in ThinPrep slides that are often misdiagnosed in this program. While Trichomonas is identified by participants in some of these cases, a significant percentage of participants interpreted the findings as reparative, without identifying the organism. These results emphasize the importance of distracting factors, whether identified or not, in evaluating gynecologic cytology.

Is there a seasonal difference in the detection of Trichomonas vaginalis by cervical cytology?

This objective of our study was to determine the prevalence of a Trichomonas vaginalis diagnosis in routine Papanicolaou smears and whether it is seasonal. We reviewed the diagnosis rendered for 93,681 Papanicolaou smears evaluated at a medical school hospital laboratory between 1992 and 1997. The occurrence of a diagnosis of T. vaginalis was analyzed by year, by quarter, and by month using a generalized linear regression model. The prevalence of a T. vaginalis diagnosis during the 6-year study period was 3.1%. The between-month and between-quarter comparisons of prevalence were not statistically different. In the population reported here, the prevalence of a Papanicolaou smear diagnosis of T. vaginalis was low and no seasonal difference in making this diagnosis was identified.

Specific IgA response, T-cell subtype and cytokine profile in experimental intravaginal trichomoniasis

Trichomoniasis caused by Trichomonas vaginalis may lead to either a complete absence of symptoms or to severe inflammatory manifestations in infected women. Studies of the role of immune responses in the pathogenesis and varied symptomatology of this disease are lacking. Mice may prove useful as an experimental model for intravaginal trichomoniasis in developing an understanding of the role of local immune responses in the pathogenesis and varied symptomatology of this disease. The present study reports the levels of anti-Trichomonas IgA antibodies in serum and vaginal washes, and T-cell subtype and cytokine profile in vaginal cervical tissues of mice infected intravaginally with T. vaginalis isolates from 15 symptomatic and 15 asymptomatic women. It also correlates the responses with symptomatology of the patients. Successful intravaginal infection was established by inoculating T. vaginalis in BALB/c mice preinoculated with Lactobacillus acidophilus and pretreated with oestradiol. A significant increase in specific IgA antibody levels was detected with enzyme-linked immunosorbent assay in vaginal secretions and serum samples collected on the 7th post-infection day from animals infected with isolates from asymptomatic women when compared with mice infected with isolates from symptomatic women. T-cell subset analysis showed significant differences, with increased CD4+ T-cell count in animals infected with isolates from asymptomatic women compared with animals infected using isolates from symptomatic women. No difference in CD8+ T cells was observed between the two groups. Cytokine profile revealed significantly higher (P < 0.001) production of gamma-IFN and IL-2 in mice infected with asymptomatic isolates compared with animals infected with symptomatic isolates, using T. vaginalis crude antigen extract and nonspecific mitogen (ConA) as stimulants for vaginal cervical lymphocytes. However, no difference in IL-4 levels was observed in the two groups of animals. In contrast, significant increase in tumour necrosis factor (TNF-alpha) levels was observed in animals infected with asymptomatic isolates compared with those infected with isolates from symptomatic women and controls, thereby indicating that TNF-alpha may play an important role in the inflammatory response to trichomoniasis. The study further suggests that specific IgA antibodies might help to protect asymptomatic individuals from severe infection and T-lymphocytes may play an important function in the eradication of the parasite. The cytokine profile indicated the involvement of Th-1 like responses in mice infected with asymptomatic isolates, compared with those infected with symptomatic isolates.

Effect of iron on the virulence of Trichomonas vaginalis

The role of iron was evaluated with respect to the virulence of Trichomonas vaginalis in mice. Iron-supplemented and iron-depleted Diamond's trypticase-yeast extract-maltose (TYM) media were prepared by adding 360 microM of ferrous sulfate and 100 microM of 2,2'-dipyridyl. Trophozoites cultivated from normal TYM and iron-supplemented TYM media produced subcutaneous abscesses; however, trichomonads grown in an iron-deficient TYM medium failed to produce any pathology. In addition to the increased virulence of trophozoites in mice, iron affects the level of adherence and the cytotoxicity of trichomonads to HeLa cells, which are significantly reduced in trophozoites grown in iron-deficient medium. In conclusion, it is suggested that under iron-depleted conditions such as that induced by 2,2'-dipyridyl the virulence of T. vaginalis is reduced.

Clinical impact of identifying Trichomonas vaginalis on cervicovaginal (Papanicolaou) smears

The purpose of this study was to understand how clinicians manage asymptomatic women after Trichomonas has been reported on Papanicolaou (Pap) smears. Clinical information was obtained from questionnaires sent to healthcare providers whenever Trichomonas was identified during the study period. Trichomonas was identified in 173 (1.4%) of 12,547 Pap smears examined. Completed questionnaires were returned on 95 (55%) patients, and 92 patients were included in this study. Sixty-three (68%) patients were asymptomatic, 16 (18%) had symptoms characteristic of infection, and 13 (14%) had nonspecific symptoms. Twenty-six (28%) patients received treatment during the original clinic visits. After the Pap smear reported Trichomonas, 49 (81%) of the 66 patients were contacted and treated, 7 (12%) were contacted and scheduled for further evaluation, and no action was taken on the remaining 10 (17%) patients. There was a significant association between presenting with symptoms and receiving treatment at the time of the original visit (P < 0.001), but not with receiving subsequent treatment. Clinical suspicion of infection was also associated with receiving treatment at the time of the original visit only (P < 0.001). Clinical suspicion of infection correlated with symptoms and results of wet mount smears (P < 0.001). In conclusion, the Pap smear report of Trichomonas identification directly impacted the management of 61% of patients and served as confirmation for clinical management in another 28% who had received treatment at the time of original visit. Despite the fact that most patients were asymptomatic, the majority received treatment and/or evaluation after the Pap smear report was received.

The interaction of trichomonas vaginalis with epithelial cells, polymorphonuclear leucocytes and erythrocytes on vaginal smears: light microscopic observation

In this study, vaginal smears taken from 400 patients were examined cytologically using the Papanicolaou technique. Twenty of the 400 patients were detected as harbouring Trichomonas vaginalis. The interactions of T. vaginalis with epithelial cells, polymorphonuclear leucocytes (PMNLs) and erythrocytes were determined at light microscopic level. It was observed that T. vaginalis were juxtaposed to the epithelial cells and changed shape according to the contours of the epithelial cell revealing the cytopathic effect of trichomonads on epithelial cells. Trichomonads attached to PMNLs produced pseudopodia to phagocytose the cells. Occasionally an amoeboid shaped T. vaginalis organism was seen trailed by a row of PMNLs. This light microscopic study supports the production by trichomonads of a chemotactic factor for PMNLs. Phagocytosed erythrocytes were also seen in the cytoplasm of T. vaginalis, suggesting the need for the patient to be tested for anaemia.

Trichomonas vaginalis and bacterial vaginosis. Coexistence in vaginal wet mount preparations from pregnant women

OBJECTIVE

To identify how frequently trichomoniasis and characteristics of bacterial vaginosis (BV) occur concomitantly in wet mount preparations from pregnant women.

STUDY DESIGN

Diagnosis of trichomoniasis was predicted on visualization of the organism. Diagnosis of BV required a positive volatile (whiff) test, presence of "clue cells" and one of two minor criteria: (1) absence of lactobacilli, or (2) a pH > 4.5. Pregnant women from January 1995 to July 1997 at our clinic had wet mount/KOH preparations performed as standard prenatal care. Corresponding medical charts were analyzed for symptoms, race, BV, sexually transmitted diseases, urinary tract infections and other infections.

RESULTS

Of 191 pregnant women identified, 69 had trichomoniasis. Seventy-nine percent of the 69 were African American. Fifteen percent of pregnant women (17) had concomitant trichomoniasis and BV. Irrespective of race, 35-38% of pregnant women with trichomoniasis had another sexually transmitted disease or a urinary tract infection diagnosed in that pregnancy.

CONCLUSION

BV, or bacteria excess syndrome, is a frequent coinfection in pregnant women harboring Trichomonas vaginalis.

Trichomonas vaginalis interactions with fibronectin and laminin

The sexually transmitted protozoan Trichomonas vaginalis cytoadheres to vaginal epithelial cells and causes contact-dependent cytotoxicity which, when combined with the normal exfoliation process, leads to erosion of the epithelium, which may allow trichomonads into extracellular matrix and basement membrane sites. Therefore, the association of T. vaginalis with immobilized fibronectin (FN) and laminin (LM) on cover-slips was examined. Binding of live parasites to coated cover-slips was time- and parasite-density-dependent. Coincubation with an inhibitor of trichomonad cysteine proteinases resulted in an increased attachment of parasites to FN but had no effect on binding to LM, denoting that protease activity influenced optimal FN associations. Further, 20 h mid-exponential phase trichomonads placed in fresh culture medium for 3 h gave higher levels of binding to FN, suggesting that changes during growth in vitro to T. vaginalis organisms affect maximal levels of binding to FN. Extended incubation with substrates diminished the capacity of parasites to bind FN and LM. Treatment of live organisms with periodate reduced binding to LM but not FN, suggesting a role for carbohydrates. In addition, trypsinization of live parasites decreased numbers bound to both substrates. Placement of trypsinized parasites in medium for 2 h fully regenerated binding to FN but not LM. Incubation of trypsinized parasites with cycloheximide abrogated regeneration of attachment to FN, affirming a role for synthesized surface proteins in FN binding. Importantly, the T. vaginalis adhesin proteins that mediate cytoadherence, and iron, a factor that regulates adhesin synthesis, were not involved in FN and LM recognition. These results suggest a role for surface proteins and carbohydrates in trichomonal associations with FN and LM, respectively.

Performance of the AutoPap primary screening system at Jefferson University Hospital

OBJECTIVE

To evaluate the performance of the AutoPap System for primary screening of cervical/vaginal cytologic smears at the 25% no review rate at Jefferson University Hospital.

STUDY DESIGN

A total of 5,865 consecutive conventional and suitable cervical/vaginal smears, including high-risk cases, were processed by the AutoPap System. Slides designated "no further review" (NFR) were manually screened by a cytopathologist (rapid screening) and a cytotechnologist (detailed screening) to detect epithelial abnormalities and assess the slide adequacy. The presence of Candida or Trichomonas was noted. Three cytopathologists determined the final diagnosis of all epithelial abnormalities by majority agreement.

RESULTS

Of 5,865 slides, 5,120 (87%) qualified for scanning. The system classified 1,280 slides as NFR (25%) and 3,840 (75%) as review. Manual screening of 1,280 slides classified as NFR revealed 1,252 cases within normal limits, 10 atypical squamous cells of undetermined significance (4, favor low grade squamous intraepithelial lesion, 6 favor reactive) and 18 benign cellular changes. Adequacy assessment discrepancies were detected on 98 (19%) of 515 cases of satisfactory but limited by lack of endocervical component (SBLBLEC) and 15 (14%) of 105 cases on satisfactory but limited by inflammation/obscuration. Twenty-five percent of cases classified as SBLBLEC were vaginal smears. Trichomonas vaginalis was noted in 12 slides and Candida in 29.

CONCLUSION

These preliminary results show that in our patient population, the AutoPap primary screener selected as NFR mostly slides within normal limits. The adequacy assessment discrepancies were comparable to those found in routine laboratory practice.

Cytodiagnosis of discharge per vaginum

Simple, rapid, inexpensive methods such as pH determination, wet mount, KOH mount, amine test, Gram staining of vaginal discharge were undertaken prior to Pap stained smears of 158 patients of leucorrhoea. We were able to detect non-specific vaginitis (44.30%), Trichomoniasis (16.45%), Candida vaginitis (9.49%), gonococcal vaginitis (0.63%) and senile vaginitis (12 cases). No specific pathology was shown in 26 cases. 1.69% of the cases were of cervical erosion and 3.79% cases suggestive of squamous malignancy.

Evaluation and management of vaginitis

OBJECTIVE

To evaluate recent advances in our understanding of the clinical relevance, diagnosis, and treatment of vaginal infections, and to determine an efficient and effective method of evaluating this clinical problem in the outpatient setting.

DATA SOURCES

Relevant papers on vaginitis limited to the English language obtained through a MEDLINE search for the years 1985 to 1997 were reviewed.

DATA SYNTHESIS

Techniques that enable the identification of the various strains of candida have helped lead to a better understanding of the mechanisms of recurrent candida infection. From this information a rationale for the treatment of recurrent disease can be developed. Bacterial vaginosis has been associated with complications, including upper genital tract infection, preterm delivery, and wound infection. Women undergoing pelvic surgery, procedures in pregnancy, or pregnant women at risk of preterm delivery should be evaluated for bacterial vaginosis to decrease the rate of complications associated with this condition. New, more standardized criteria for the diagnosis of bacterial vaginosis may improve diagnostic consistency among clinicians and comparability of study results. Use of topical therapies in the treatment of bacterial vaginosis are effective and associated with fewer side effects than systemic medication. Trichomonas vaginalis, although decreasing in incidence, has been associated with upper genital tract infection. Therapy of T. vaginalis infection has been complicated by an increasing incidence of resistance to metronidazole.

CONCLUSIONS

Vaginitis is a common medical problem in women that is associated with significant morbidity and previously unrecognized complications. Research in recent years has improved diagnostic tools as well as treatment modalities for all forms of vaginitis.

Clinical presentation of gynecologic infections among Indian women

OBJECTIVE

To study the clinical presentation of different gynecologic infections among Indian women.

METHODS

This was a cross-sectional study of 257 women that included clinical, cytologic, colposcopic, and microbiologic screening for various gynecologic infections.

RESULTS

Human papillomavirus (HPV) was the leading infection, affecting 127 (49.4%) women; however, overt warts were only seen in seven (2.7%) patients. Women infected with HPV had a 60.3-fold higher risk of developing a bleeding ectopia compared to those with other infections; women with an unhealthy cervix and cervical ectopias also had an increased risk of HPV infection (7.6- and 2.8-fold, respectively). Bacterial vaginosis, detected in 33.5% of the women studied, had an increased risk of bleeding ectopia (9.3-fold), cervical ectopia (3.1-fold), cervicitis (2.9-fold), vaginitis (6.9-fold), and cervical hypertrophy (2.1-fold). Chlamydial infection, detected in 23.3% of the patient population, was associated with an eightfold increase in the risk of an unhealthy cervix and a fourfold increase in risk of a hypertrophied cervix. Immunoglobulin-A antibodies to the herpes simplex virus were detected in 53 (20.6%) women. More than half (55.2%) of the women had two or more infections, and the mean delay of seeking medical treatment was 7-13 months.

CONCLUSION

The specific finding of bleeding cervices was associated with HPV and bacterial vaginosis, hypertrophied cervices with chlamydia and bacterial vaginosis, and unhealthy cervices with chlamydia and HPV infections.

Epidemiologic analysis of Trichomonas vaginalis infection in inflammatory smears

Infections of the lower reproductive tract are common in Indian women of reproductive age. Hospital-based cytologic screening was undertaken on 63,265 women. The smears were examined for the presence of specific infections, such as Candida, herpes simplex virus, human papillomavirus, Trichomonas vaginalis (TV) and Chlamydia. This paper highlights the prevalence of TV infection in inflammatory cervical smears. Among the various infections detected, the rate of TV infection was the highest (5.1%). On further analysis the rate of TV infection showed an increasing trend up to the age of 49 years; an inverse association was observed with the educational status of the women. The prevalence was high in women with clinical signs (vaginitis, 6.9%) and low in those with a prolapsed uterus (1.2%) as compared to a normal cervix. These observations reveal the need for providing proper counseling and education on sexual behavior and genital hygiene besides treatment to control and prevent these infections.

Trichomonas vaginalis (TV) and human papillomavirus (HPV) infection and the incidence of cervical intraepithelial neoplasia (CIN) grade III

The temporal relationship between cervical infection with Trichomonas vaginalis (TV) or human papillomavirus (HPV) and the incidence rate of cervical intraepithelial neoplasia grade three (CIN III) was examined in a cohort of 43,016 Norwegian women. From 1980 to 1989, a cervico-vaginal infection from TV and HPV was diagnosed cytologically in 988 and 678 women, respectively. During the 181,240 person-years of observation, 440 cases of CIN III/cervical cancer developed. The age-adjusted incidence rates (IR) of CIN III were 225 per 100,000 person-years among women with no cytologic evidence of infection, 459 among women with TV infection, and 729 among women with HPV infection. A multiple regression model yielded a relative rate (RR) of CIN III of 2.1 (95 percent confidence interval [CI] = 1.3-3.4) among women with TV infection and 3.5 (CI = 1.9-6.6) among women with HPV infection, compared with women with neither infection. As CIN can be misclassified as HPV infection, the entry Pap-smears of 10 women with HPV infection who later developed CIN III were re-examined. Excluding the four discordant cases with the corresponding person-years decreased the RR of CIN III to 2.1 (CI = 0.9-4.8). Our report demonstrates the limitations of studies that rely only on cytologic detection of HPV infection. Nevertheless, the results support the hypothesis that HPV is a causal factor for CIN III lesions, and also display an association between TV infection and cervical neoplasia.

Trichomoniasis: trends in diagnosis and management

The mainstay of the diagnosis of trichomoniasis has been the saline vaginal wet preparation. With a less than desirable sensitivity, the wet preparation may be replaced in the near future by newer methods employing monoclonal antibodies, such as the enzyme immunoassay, which has the potential to become an in-office procedure. The direct fluorescent antibody test also represents an advance in laboratory diagnosis. However, until the sensitivity, specificity, and cost of these newer techniques are defined outside the research arena, the wet preparation will remain the first-line diagnostic tool. Current treatment of trichomoniasis in the United States is with metronidazole, which in repeated or increased dosage can often overcome the organism's resistance to the drug. Other treatments offer little or no chance for cure but may provide some relief of symptoms. Tinidazole (not available in the United States) may be effective in curing refractory cases of metronidazole resistance. Metronidazole treatment during pregnancy should be resorted to only when absolutely essential.

Histopathology of endocervical infection caused by Chlamydia trachomatis, herpes simplex virus, Trichomonas vaginalis, and Neisseria gonorrhoeae

We determined the histologic correlates of clinically identified mucopurulent cervicitis, culture-proven cervical infection with Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus (HSV), and vaginal infection with Trichomonas vaginalis by examining cervical biopsies from 83 women. Clinical mucopurulent cervicitis and culture-documented infection with one or more of these pathogens correlated histologically with intraepithelial neutrophils, reactive endocervical cells, edema, luminal neutrophils, and with several deeper tissue changes such as extensive and dense subepithelial inflammation, granulation tissue, and necrotic ulceration. Focal loss of surface columnar cells and spongiosis were also correlated with culture-confirmed infection. Well-formed germinal centers were seen in biopsies from 14 of 21 patients (67%) with C trachomatis infection alone, but in none of 17 patients with infections other than C trachomatis (P less than 0.001). A predominantly plasmacytic infiltrate was also significantly associated with chlamydial infection. Necrotic ulcers overlying a predominantly lymphocytic infiltrate were seen in six of nine patients (67%) with HSV infection alone but in only two of 40 patients (5%) with other infections (P less than 0.001). Marked inflammatory changes were not seen in the patients infected with N gonorrhoeae. The organism T vaginalis was not associated with any endocervical pathology. If these results are confirmed by prospective studies, they suggest that pathologists should alert clinicians to the possibility of recent or current infection with C trachomatis or HSV when cervical biopsies show the above changes. The loss of surface columnar epithelium with HSV, chlamydial, and gonococcal infection offers a possible explanation for the reported association of these infections with increased risk of acquiring human immunodeficiency virus infection.

Experimental genital trichomoniasis in the squirrel monkey (Saimiri sciureus)

The squirrel monkey (Saimiri sciureus) has been proposed as a model for urogenital trichomoniasis in man, but has not been accepted as such because of the purported presence of naturally occurring vaginal trichomonads in this animal. The study published here shows that these are easily eradicated organisms of intestinal origin, which eliminates the potential confusion created by them. In addition, our experiments have shown that the hormonal status of primates seems to be a determinant in successfully establishing experimental trichomoniasis. This experimental infection recapitulates the clinical observations sufficiently to warrant the use of this model for studies of vaginal trichomoniasis.

Experimental transmission of Trichomonas vaginalis in laboratory animals and the chemistry of vaginal exudates

Experimental transmission of Trichomonas vaginalis into laboratory was carried out. The protein and glucose levels of infected vaginal exudates were also investigated. Subcutaneous lesions were produced in the mice with influx of neutrophils and macrophages and sloughing of epidermal parts. Rats, seem to be refractory to this infection. Compared with normal persons, the protein and glucose levels were higher and richer in exudates of patients with T. vaginalis infection.

Vaginal trichomoniasis at a sexually transmitted disease clinic at Khartoum

At a sexually transmitted disease clinic at Khartoum 613 Sudanese women presenting with vaginal discharge were investigated. Specimens were examined by microscopy and culture. Trichomonas vaginalis infestation was found in 123 patients (20.1%), predominantly in the age groups 16-19 years (27.1%) and 46-65 years (27%). Frequency of trichomonal vaginitis was highest (35.9%) among divorced women. Of the pregnant women investigated, 16.3% were found to harbour the parasite. There was no significant difference in the parity of parasitized and non-parasitized patients.

Association of mast cells with vaginal trichomoniasis in endocervical smears

In endocervical smears obtained from 40 women with Trichomonas vaginalis infection, 25 women with infections other than T. vaginalis and 35 cytologically normal women, inflammatory cells consistent with mast cells (tissue basophils) were examined. Mast cells were present predominantly in the smears of patients infected with T. vaginalis but were infrequent in those of patients with other infections and in those of the normal, control group. The numbers of mast cells in endocervical smears and the white blood cell counts in vaginal discharges showed a positive correlation with the degree of T. vaginalis infection. Our data seem to indicate that the presence of mast cells in the uterine cervix may be an immunologic response, possibly of an allergic nature, to T. vaginalis.

The clinical diagnosis of trichomoniasis

Two hundred twenty-six consecutive women attending an inner-city clinic for sexually transmitted diseases were evaluated. Problem-directed histories and physical examinations were conducted and vaginal specimens for wet preparation and Trichomonas vaginalis culture were obtained from each patient. One hundred patients were found to be infected. Patients with multiple sex partners were found to be at increased risk of trichomoniasis (P less than .05). Those with abnormal discharge noted on examination had a higher frequency of positive cultures for T vaginalis (P less than .001). Only 50% of patients with trichomoniasis had an abnormal discharge. Patients with greater than 10 white blood cells per high power field on wet preparation, regardless of whether trichomonads were visualized, had a higher incidence of trichomoniasis (P less than .01). Factors that were not associated with Trichomonas infection included patient age, frequency of coitus, date of most recent coitus, day of menstrual cycle on which patient was examined, recent antibiotic use, use of contraceptives or specific contraceptive methods, symptoms of discharge or pruritus, or the finding of Leptothrix on wet preparation. These data support the contention that the classic description of trichomoniasis cannot be uniformly relied upon for diagnosis, but that patients with multiple sex partners, abnormal vaginal discharge and/or greater than 10 white blood cells per high power field on wet preparation are at increased risk of infection by T vaginalis.