7
Microbiology, inflammation, and Viral infections
Fig. 7.30 Sulfur granule.
In the center are radiating filamentous structures
of
A c tin o m y c e s
organisms. Vaginopancervical smear (Papanicolaou x MP).
Table 7.4
Differential diagnosis of Actinomyces in vaginal smears
Other organisms
C andida
,
Aspergillus
,
Nocardia, Penicillium ,
Trichophyton
,
Leptotrichia,
lactobacilli
Miscellaneous structures
Filamentous structures: Fibrin, mucus,
sulfa crystals, cotton and synthetic fibers
Nonfilamentous structures: Contraceptive
cream, bacterial clumps, hematoxylin
pigment, spermatozoa, hematoidin,
foreign material (spores, pollen, douche
ingredients)
and be confused with dysplastic and neoplastic cellular changes
of the squamous, metaplastic, endocervical, and endometrial
epithelia. These changes appear more pronounced in LBGS and
interpretation can be problematic especially in the paucity of
an inflammatory background. There is no definite evidence for
the association of squamous dysplastic changes and IUD usage.
Squamous cell changes are essentially reactive and reparative in
nature. These occur in about 40% of women using IUDs. DNA
analysis of IUD-associated cellular changes does not reveal any
aneuploidy.
The morphological picture is further complicated by inter-
play among the reactive-proplastic and degenerative-retroplastic
changes occurring over a prolonged period and affected by
polymicrobial and physiologic factors.
Endocervical columnar cells may become hyperplastic with
large papillary tissue fragment formations.
Bibbo and co-
workers46 and Gupta and colleagues47 have systematically
reviewed these changes. Columnar cell hyperplastic changes
should be distinguished from adenocarcinoma (Fig. 7.33). They
may mimic papillary tumors of ovarian or endometrial origin.
Single cells can be extremely bizarre and resemble neoplasia.
Cells may show large cytoplasmic vacuoles referred to as "bub-
ble gum" cells. The presence of heavy inflammation and degen-
erative changes helps diagnostically. The salient features of these
cellular changes are summarized in Table 7.5. The presence of
psammoma or calcified bodies among IUD users is not an indi-
cation of neoplasm.
Another cell type, best described as indeterminate cell changes
or "IUD cells," probably arises from the endometrial surface.
Fig. 7.31
A u re o b a s id iu m p u llu la n s .
These black yeast organisms can
vary in color from light yellow, gold-brown, to black. Vaginopancervical
smear (Papanicolaou x HP). Reproduced with permission from Gupta PK:
Intrauterine contraceptive device: Vaginal cytology, Pathologic changes, and
their clinical implications.
A cta C ytol
1982;26:571-613.
Such conclusions are supported by the work of Gupta and co-
workers.47 These cells with a high nucleus-to-cytoplasmic ratio
should be distinguished from the third type of cell described
by Graham48 and from in situ carcinoma (HSIL, CIN III) cells.
Nuclear degeneration, the presence of nucleoli, and a hiatus
between normal and abnormal cells help differentiate these
cells from true neoplastic cells (Fig. 7.34). Table 7.6 summarizes
the salient features of these cells. Occasionally, the endometrial-
type reactive cells and the IUD cells may occur together.
Binucleated and multinucleated giant forms and psammoma
body formation are other findings that may be observed in
the presence of the IUD and
Actinomyces
. These develop from
endometrial surface changes. Extensive squamous metaplasia of
the endometrial surface may occur in some cases as the result of
prolonged endometritis accompanying the IUD.
Key features of IUD-associated cellular changes
• Bubble gum cells;
• IUD cells;
• Metaplastic cells;
• Mesenchymal proliferation;
• Multinucleation; and
• Psammoma body formation.
Leptotrichia buccalis
These microbes, also known as just
Leptotrichia
or
Leptothrix,
are
Gram-negative, non-spore-forming anaerobic organisms. They
occur in the oral and vaginal cavities as very thin, segmented,
large, filamentous structures. Occasionally, branching may be
observed (Fig. 7.35). Morphologically they may be indistin-
guishable from certain forms of Doederlein's bacillus. Most
frequently (75-80% ), cases of
Leptotrichia
have concomitant
T. vaginalis
infection. Numerous other infective organisms,
including
Candida
and
G. vaginalis,
may occur in the presence of
L. buccalis
infection.
Bibbo and Wied13 made an investigative study on the preva-
lence of
Leptotrichia
in cervicovaginal smears. They observed
Leptotrichia
organisms in 75% cases with trichomonads, 1.5%
with Doederlein's bacillus, and about 1% among patients with
103
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