PART TWO
Diagnostic Cytology
Fig. 7.46
(A)
Cytomegalovirus cervix.
Note the chromatin threats. (B) Intracytoplasmic inclusions, LBGS (Papanicolaou x OI).
herpes viruses, however, clinically overt manifestations of viral
replication are seen only rarely. The infection spreads by inti-
mate contact through body secretions, including saliva, tears,
urine, endocervical mucus, semen, and transplanted organs.
Nearly 50-60% of adult women have circulating antibod-
ies to CMV. Serologic evidence of infection is more common in
low socioeconomic groups. Cervical shedding of CMV occurs
in nearly 10% of the female population.21 These figures vary in
different populations; e.g. the recovery rate for CMV in cervical
specimens has been reported to be 28% in Japan. In a number
of studies summarized by Kumar and co-workers,68 the inci-
dence of primary genital CMV infection has been reported as
between 0.2 and 2.2%. Most cases of primary genital CMV infec-
tion are clinically asymptomatic. Stagno and colleagues reported
symptomatic episodes in only 1 of 21 cases,68a and Griffiths and
associates69 in only 1 of 14 pregnant women with primary CMV
infection. Almost always these symptoms are infectious mono-
nucleosis-like and include lethargy, malaise, and fever.
Characteristically, epithelial tissues, including salivary gland,
alimentary tract, bronchial and alveolar lining cells, hepatocytes,
renal tubule cells, hematopoietic cells, and endocervical and
endothelial cells, are targeted by CMV infection. Cytologically,
the infected cells, endocervical columnar, perhaps, occur more
commonly in the cervical smears than is recognized. According
to Naib,70 the CMV-bearing cells occur within the endocervical
glands, and not many cells may be observed in the epithelium
of the endocervical canal. Proper cellular specimens, as can be
obtainable with a Cytobrush or similar technique, may be more
rewarding. In addition, because almost all women are asymp-
tomatic, very little effort may be made to screen these smears
critically for CMV-associated changes. In a certain number of
patients, concomitant CMV and HSV infections may occur. It is
not infrequent to overlook the not-so-obvious CMV-infected cells
in such cases. At times, the morphologic identification of CMV
and its differentiation from HSV may be extremely difficult.
The CMV-infected cells may be multinucleated and some-
what enlarged. The nuclear degenerative changes may be simi-
lar to those in HSV. We have observed that the internuclear
molding tends to be less obvious in CMV-infected cells than in
those infected with HSV. Infected endocervical cells are aniso-
cytotic. They contain round intranuclear inclusions, generally
acidophilic, which are disproportionately large when compared
with the total size of the nuclei. These inclusions have a clear
zone of halo around them, and frequently threads of chromatin
material may stretch between the inclusion and the inner leaf of
the nuclear membrane, which may be considerably thickened
with the chromatin material in apposition against it, giving a
wheel spoke appearance. The infected cells may have an intra-
cytoplasmic, irregular inclusion (Figs 7.46 and 7.47).
Infected endocervical cells may be buried among inflamma-
tory or other epithelial cells and may be hard to screen for in
a routine fashion. In selected cases, CMV-specific monoclonal
antibodies and in situ techniques can be used to establish the
presence of CMV-infected cells.
Herpes zoster
Varicella-zoster is related to varicella (chickenpox) that is so
common in childhood and infancy. Herpes zoster (shingles)
infection may involve the vulva and vagina. Lesions often appear
in patients who were exposed to the varicella virus in childhood.
They occur in older individuals along the distribution of sensory
nerves as extremely painful vesiculae or blisters, and tend to be
unilateral.
110
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