Infections in the female genital tract

andcytological features of each of the infection

cases.

By Mohamad Azmir Bin Azizan

Faculty of Medicine UiTM

Infections of the female genital tract is causes by etiological agent such as

BacteriaFungusParasiteViruses

BACTERIAChlamydia trachomatisGardnerella vaginalis Acinomyces israelii

Virus infectionHerpes simplx virus(HSV)Human papilloma virus(HPV)cytomegalovirusCMV)

Fungal InfectionCandida albicans

Parasite infectionTrichomonas vaginalis

Infections of the female genital tract

BACTERIA Chlamydia trachomatis

Chlamydia trachomatis is specialized Gram Negative small bacteria –an obligate extracellular pathogenChlamydia resembles viruses in being unable to reproduce outside of living cells.Normal habitat of Chlamydia trachomatis can be found n the human genitourinary tract.

Its occur in two forms:-infective extracellular elementary body-the intermediated reticulate bodies /particle

Pathogenesis-urethritis-vaginitis-cervicitis

Microscopy and cytological features

Show infected the metaplastic squamous cells and endocervical cells frequently affected.Parabasal cells sometimes involved

The important features significant is intra cytolplasmic inclusion that also show faint eosinophilic coccoid bodies

The inclition bodies also can be detect microspically by immunofluorescence or Giemsa stained prepared.

Other features is showreactive changes of squamous and columnar cells and multinucleation

Gardnerella vaginalis

Gardnerella vaginalis previously known as Haemophilus vaginalis that causes vaginitis ,probably by acting with anaerobs such as Bacteroids the infection usually sexual trassmitted disease. Gardnerella vaginalis infection usually associated with vaginosisG.V is found in healthy women also causesneonatal sepsis and bladder bacteuria.

Signs and symptoms

excessive malodorous vaginal discharge vaginal pH greater than 4.5a fishy ,amine –like odour

Microscopy and cytological features

Microscopy show Gram positive ,non motile and non capsulated coccobaccilus or rod

Large number of coccobacilli can often be seen attached to epithelial cells known as clue cells.

The presence of clue cells (vaginal epithelial cells coated with masses of (coccobacilli)

significant of increase in number of obligate anaerobes such as Bacteroids in Vaginal flora.

Other organism of normal flora of vaginal and Lactobacilli are absent or scanty.

Acinomyces israelii

Acinomyces species form part of the normal microbialflora of the mouth and female genital tractAcinomyces israelii is Gram Positive bacilli non motile,non sporingand the morphologically resemble the thin branches.Facultative anaerobes that causes pelvic actinomycosisUsually infection occurs at human with IUCD ,Foreign body ,vaginal pessaries ,surgical clumps and forgotten tampons associated with actinomycosis usually.Acinomyces israelii causes actinomycosis a chronic granulamataus.

Microscopy and cytological features

amorphous deep purple clumps and dark in centre are seenAlso show a thin and thick filaments

Fungal Infection

Candida albicans

Candida albicans is the commonest cause of candidiasis(moniliasis) The yeast is a common commensal of gastrointestinal tract .

Candida albicans is a normal in habitat of female genital tractLoad of candida in FGT may causes irritants vaginitis

Candidiasis is also associated with prolonged broad spectrum antibiotic theraphy.

Depression normal acidity of FGT condition candidato invade epithelium favored by the administrationof broad spectrum antibiotics

Women who use oral contraceptive will develop this infection.Diagnosis confirm by microscopy and culture of discharges.

Candida yeast cells can be detected in unstained with germ tube and stained with Gram stain

Cytological features

Candida albicans can be icentified by the formation of pseudohyphae and spores.

candida have two form Yeast-small pink sporesPseudohyphae –elongated and become long

Candida stains eosinophilicClear zone outside the hyphae and the sporesSmear show prodominent intermediated

Glycogen granules easily seenEpithelial cells clumps in group and fungus usually seen at the end of clumps

Nuclei enlarged and may darker

Parasite infection

Trichomonas vaginalis

Trichomonas vaginalis is protozoan parasite that inhibit the vaginal inwomen and the urethra in men and also in prostate sometimes.T.V Transmitted with sexual intercourse from men to women and also women to men.In women,vaginal show foul smelling green yellow discharge Vaginal pH also show alkaline40-50% infected woman is asymptomatic Cytological features of the TV parasite

Round oval and pear shapeVariable stained –greenish-blue ,blue greyNucleus usually single and eccentrically occasionally –binuclear ,side by side lyingOccur single and irregular Crowd epithelial cells(intermediated cells)Motile identified by wet preparation of vaginal dischargeStaining with PAP

Cellular changes

Abundant polymorph and cannonball cells.Squamous cells shift to the right in maturation indexAnucleated squamous cells and squamous cells smaller than usual (parakeratosis)A background mucus may form a net like structure on the slidePerinuclear halos-clear zone around nuclei Associated bacteria –coccoid bacteria and leptophrix

Nucler changes

Enlargement of nucleus and increase ratio of N/C Chromatin structure –slightly granular and many small dark chromacentres Nucleolus may be seenBinucletion and multiniclition may occur especially with endocervical cellsNuclear degeneration nuclei loss (karyolysis)

Virus infection

Herpes simplx viruse(HSV)

Herpes simplx viruse(HSV) belong to the family Herpesvirus.

The viruses is Double Stranded DNA that have two types HSV –1 and HSV -2

Infection caused by HSV –1 included gingivostomatitis (ulceration of the gums and lining of the mouth) in young children.

An important infection caused by HSV-2 is genital herpes.

The virus is sexually transmitted and can causes painful ulceration of he genital tract and uro genital organs .HSV -2 has been associated with cancer of the cervix .

Cytological features The cytologic appearance of HSV infection is easily recognized,HSV show cytologic canges where the cells are characteristic by large multiple nuclei that are molded together (arrowed) and show marginatin of chromatin and generally empty nuclei.large intranuclear inclusion are also commonly seenit is important to different such as cell from binucleated cell that are common found in associated with HPV infection .cytologically appearance of degeneration and necrotic cells in which ghost of the nuclei can just be recognized .

this necrotic cellular appearance have to be different from those that associated with carcinoma. microscopically can show enlargement squamous and metaplastic type cells and also multinucleation .Internuclear moulding present on the cells and the blurring and show smudge cells that lost of chromatin structure .

the chromatin also show the degeneration of chromatin form distinct nuclear border. in the primary infection ,nuclei show typical ground glass, overlapping and molding nuclei and in the re-current infection a large eosinophilic intranuclear inclusions.

Characteristic of Human Papilloma Virus (HPV)

Human Papilloma Virus (HPV) is a very common virus (germ) that causes abnormal cells or growth of tissue on the skin of the body.

HPV can cause abnormal tissue changes on the feet, hands, vocal cords, mouth and genital (sex) organs. Over 60 types of HPV have been identified so far.

Each type infects certain parts of the body. In gynecology, we are concerned about the types of HPV that infect the femaleorgans Human papilloma virus(HPV) is double stranded DNA virus .

HPV have 60 types the important type is Type 6,11,31,42,45 and this type of HPV only produce a low risk lesions.

Type 16,18,31,35,39 cause high risk lesions of ano genital ,laryngeal esophageal and lung in the service may causes high grade lesions progress to malignancy .

Cytological features

Cytological features of Human Papilloma Virus (HPV) can see microscopically from the cellular changes.thimportant cellular changes that perform the characteristic of Human Papilloma Virus (HPV) is Koilocytosis, Parakeratosis ,Binucletion and multinucletion ,Dyskeratosis ,and Hyperkeratosis

Koilocytosis

Many cell show perinuclear clearing of the cytoplasm with a hard margins to the vacuole(arrowed) .

The borderline of nuclear also changes.that increase cytoplasmic ratio, smooth muscle outline and fine evenly dispersed chromatin.

The Squamous cells also show peripheral well defined dense cytoplasmic and surrounding clear perinuclerahalos .

It is commonly in the type of superficial and intermediated cells .Cytoplasmic staining amphophilic

ParakeratosisParakeratosis mean of when the cell become smaller than normal cells.or Minture squamous cell singly or in groups.the type of cells to differ is smaller than parabasal cells.The nucleus show pyknotic nucleus and cytoplasm may be keratinizedBinucletion and multinucletionBinucletion and multinucletion always seen in mature squamous ,metaplastic cells and in parakeratotic cells. The chromatin structure due to nuclear smudge and pyknotic. The Nuclear also enlargement and dysplastic changes DyskeratosisEnlargement of nucleus with chromatin clearing and incomplete nuclear envelope and a result of degeneration superimposed changes.Cytoplasm also become darkerHyperkeratosisHyperkeratosis show anucleated squamous due to karyolysis.karyolysis is cytoplasm when nucleus are disappear.(not have nucleus).Also show yellow and orange cytoplasm.

CytomegalovirusCMV) belongs to the family Herpesvirus Disease caused by CMV can occurs conginental neonatal and childhood

thatcan causes infection in epithelial tissue of salivary gland ,bronchus alveolar,renal tubes and endoservic .

During pregnancy lead to conginental disease ,mental diagnosed ,deafness and multiple other birth defectsRarely diagnosed with cervical-vaginal smear.

Cytological featuresCytomegalovirusCMV) microscopically characteristic by eosinophilic intranuclear inclusion with single nuclei.CMV differ from HPV because multinucletion not occur.

To confirm CMV case must diagnosed by immunocytochemical method

CytomegalovirusCMV

Normal flora of female genital tract is lactobacillus spp. Account for 95% of vaginal microorganism, lactobacillus acidophilus. Maintain vaginal pH 3.8-4.2 from the production of lactic acid.

Lactobacillus also suppress the growth of gram negative and gram positive facultative and obligate anaerobes via the production of hydrogen peroxide.

The organism make up Normal flora of female genital tract is corynebacterium, streptoccus,peptostreptococci and bacteroids. Infections in the female genital tract are extermly common in clinical and cytophatology practice and include complication of pregnancy,inflammation,tumor and hormonally.other high risk factor is IUCd user,oral contraceptive,and via sexually.

The main symptom of infections in the female genital tract is diching,pruritus,dysuria and dysparaeunia.

CONCLUSION

From the TBS (the Bethesda system) Infections of the female genital tract is categories of benign cellular changes.

The main focus of cervical/vaginal cytology traditionally been the detection of cervical cancer precursor.

However, various benign processes can also be recognized morphologically, and diagnosis of these entities can make an important contribution to patient care.

The Infections of the female genital is causes by etiological agent such as Bacteria ,Fungus,viruses and parasite.