PART TWO
Diagnostic Cytology
Fig. 7.15 “Clue cells"
in LBGS (Papanicolaou x LP).
Fig. 7.16 Tampon fibers.
Occasionally, these may have a core center that
may contain red blood cells. Vaginopancervical smear (Papanicolaou x LP).
Lactobacillus Vaginitis (Cytolytic Vaginosis)
Lactobacilli are a heterogeneous group of organisms normally
present in the vaginal flora. They occur in abundance in the
late luteal phase and in pregnancy, prefer an acid environment,
and are common among women using hormonal preparations
(contraceptives and replacements) and in the premenarchal
and menopausal age groups. They are Gram-positive, immo-
bile, non-spore-forming anaerobes or facultative anaerobes.
Certain species may be aerobic in their growth characteristics.
In the presence of lactobacilli, glycogen-rich intermediate cells
are often lysed. Smears in such cases show cellular crowding,
cytolysis with cytoplasmic debris, and numerous bare nuclei
occurring in a predominantly bacillary background. False clue
cells can be reported in these cases as the lactobacilli adhere to
the edges of squamous cells. Lactobacilli may be observed in up
to 50% of healthy women depending on the day of the men-
strual cycle. In the symptomatic population, the observed figure
may be lower, about 20%. It is debatable whether pure lactoba-
cilli (an unlikely occurrence) produce vaginitis, although vagi-
nal discharge and leucorrhoea may occur as a result of excessive
cytolysis.
Fig. 7.17 Gonococcal organisms.
These reveal diplococci within the
polymorphonuclear leukocytes, and on the surface. Vaginopancervical smear
(Papanicolaou x OI).
Gonococcus Vaginitis
These Gram-negative diplococci cause abundant, purulent vagi-
nal exudates. The infection affects the urethra and the perivaginal
glands. On the surface of squamous cells, these organisms occur
as bean-shaped diplococci. The gonococci are better observed in
the air-dried areas of the smears, such as the edges of the smear.
This is an uncommon occurrence in properly prepared LBGS.
Within the air-dried distended polymorphonuclear leukocytes,
diplococci may be present in large numbers (Fig. 7.17). Gono-
coccus vaginitis is a venereal infection with important social and
medical implications. Although it is detectable cytologically, we
do not advise rendition of such a diagnosis on cytologic exami-
nation of Papanicolaou stained smears alone; they may be indis-
tinguishable from other cocci organisms, phagocytosed debris,
or
Chlamydia
organisms.
Curved Anaerobic Bacterial Vaginitis
These motile, anaerobic, rod-shaped organisms resemble
Wolinella
and have been recognized as a cause of nonspecific vaginitis by
Hjelm and colleagues.2,26,27 In the Papanicolaou stained smears,
these bacteria cannot be easily diagnosed but are better detected
in wet mount preparations. Clinically, the presentation is of non-
specific vaginitis.
Vaginal Lactobacillosis
A recently recognized clinical picture has been reported among
women who have used antifungal local medications for genital
Candida
infection for a prolonged period of time, generally more
than 20 months. These result in the proliferation of giant lacto-
bacilli accompanying often the yeast forms of
Candida
organisms.
A correct morphologic recognition of this condition is important
for specific treatment with appropriate antibiotics28,29 (Fig. 7.18).
Foreign-Body Vaginitis
A forgotten tampon is the most common cause of this type of
vaginitis, in which there is a secondary overgrowth of anaerobic
organisms. The tampons may irritate and ulcerate the vaginal
wall and ectocervix. Occasionally, fragments of tampons can be
observed in vaginal smears. Their presence is not diagnostic of
vaginitis. Heavy acute inflammation, mucus, and foreign-body
giant cells may be observed.
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