7
Microbiology, inflammation, and Viral infections
Fig. 7.25 Michaelis-Gutmann bodies.
Intracytoplasmic laminated
structures from a case of malacoplakia of the cervix. Vaginopancervical smear
(Papanicolaou x HP).
Fig. 7.26 Langerhans cell histiocytosis.
Note numerous histiocytic cells
with intranuclear grooves (arrowhead) and an occasional eosinophil (arrow).
Vaginopancervical smear (Papanicolaou x HP).
anaerobic or facultative anaerobes. They are Gram-positive and
occur in filamentous and diphtheroid forms. With the recent
increase in IUD usage, genital
Actinomyces
infection appears to
also be increasing in prevalence. It is, however, true that the new
device designs and the judicious usage make the clinical disease
less likely.37
Actinomyces
occur commonly within the tonsillar crypts, tar-
tar of teeth, and the alimentary tracts.
Actinomyces
do not occur
as commensals in the vaginal flora. In the female genital tract,
ascending infection is the most common mode of occurrence of
clinical disease; however, rarely, hematogenous and lymphatic
spread, or dissemination of infection from the alimentary tract or
other distant sources, may occur. Ascending infection occurs in
the presence of intrauterine or intravaginal contraceptives, IUDs
of various types being the most common. Vaginal pessaries, surgi-
cal clamps, and foreign bodies, including forgotten tampons, all
have been associated with vaginal
Actinomyces
. Among untreated
women, clinical disease may be manifest for as much as 12
months after the removal of the Actinomyces-associated IUD.
Fig. 7.27 Langerhans cell histiocytosis.
Note atypical histiocytic cells and
numerous eosinophils. This smear was obtained 14 months after that in Fig. 7.26.
Vaginopancervical smear (Papanicolaou x HP).
Gupta has reviewed the subject and the relationship of
Actin-
omyces
with clinical female genital tract disease.38 It is appropri-
ate to say that nearly 10% of women using an IUD may develop
vaginal
Actinomyces
infection at some stage. If such users have
symptoms of lower genital tract infection such as pelvic pain,
vaginal discharge, bleeding, fever, or lower abdominal tender-
ness, approximately one-quarter of these women may have geni-
tal
Actinomyces
infection. Of the women using an IUD and being
admitted to the hospital for clinically suspected pelvic inflam-
matory disease, about 40% may harbor the organism in the
lower genital tract.39,40 Dissemination of the infection to distant
sites has been documented by de la Monte and co-workers,41
and by Hager and Majmudar.42
Cytomorphology of
Actinomyces
In close proximity to the calcified and mineralized fragments of
a disintegrating IUD, the
Actinomyces
organism can be detected
in Papanicolaou stained vaginal smears. Typically, the organisms
appear as spidery, amorphous clumps that are darker in the center
(Fig. 7.28A). Morphologic features of the
Actinomyces
colonies are
more distinct in LBGS-based slides (Fig. 7.28B). These aggregates
of
Actinomyces
in the cervicovaginal smears have been referred
to as "Gupta bodies" by Hager and Majmudar.42 Upon careful
examination, numerous filamentous organisms with acute angle
branching patterns are recognizable in these clumps (Fig. 7.29).
They can be uniformly thick and beaded. The filaments generally
extend to the outer limits of the dark clumps. Only a few delicate,
branching filamentous forms may occur scattered randomly in
the smear. In Papanicolaou stained smears, calcified filamentous
forms that may not be stainable by antigen antibody techniques,
club forms, or the Splendore Hoeppli phenomenon may be iden-
tified. Typical sulfur granules may be observed in smears obtained
from symptomatic patients (Fig. 7.30). These per se are not diag-
nostic of
Actinomyces
, and proper morphologic identification of
the filamentous forms is necessary in all cases. Gupta and co-
workers have detailed various other morphologic forms.38,43
Actinomyces
organisms can be stained with modified Gram, peri-
odic acid-Schiff (PAS), and silver stains. A definitive species diagnosis
requires specific antigen antibody reaction using an immunoenzy-
matic or immunofluorescence or bacterial culture procedures.44
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