Original article / research
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Determination of Prevalence and Clinical Significance of Detection of Micro-organisms in Pap Smear with Seasonal Variation |
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Sonti Sulochana, Esakki Muthuvel, Volga Harikrishnan, Chitra srinivasan 1. Associate Professor, Department of Pathology, Saveetha University, Chennai, Tamil Nadu, India. 2. Associate Professor, Department of Pathology, Saveetha University, Chennai, Tamil Nadu, India. 3. Assistance Professor, Department of Pathology, Saveetha University, Chennai, Tamil Nadu, India. 4. Professor and Head, Department of Pathology, Saveetha University, Chennai, Tamil Nadu, India. |
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Correspondence
Address : Dr. Sonti Sulochana, Bougainvilla Villa 90, Srinivasapuram Gajalakshmi Street, Iyyappanthangal, Chennai-600056, Tamil Nadu, India. E-mail: sulochanamaster@gmail.com |
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ABSTRACT | |||||||||||||||||||||||||||||||||||||||||||||||||||||
: The most common problem in reproductive age group women is vaginitis. In the vaginal flora an extensive and diverse spectrum of pathogenic agents may be observed. The important infectious agents in vaginal flora are Bacterial Vaginosis (BV), Candida (Can) and Trichomonas vaginalis (TV). The pap smear is a screening test to diagnose cervical cancer and has also been used as a diagnostic test in cervical infection caused by different pathogenic organisms. Aim: To determine the prevalence and clinical significance of micro-organisms in pap smears. Materials and Methods: A two year retrospective Pap smear study was done from January 2014 to December 2015, in a tertiary care unit, Saveetha Medical College and Hospital, Thandalam, Chennai, India. This study was undertaken to determine the prevalence, clinical significance and seasonal variation in cervicovaginal infections. The Chi-square test was used for statistical analysis. A p-value of <0.05 was considered significant for statistical evaluation. Results: The total number of pap smears examined was 6424, out of which the total pap positive smears for infectious organisms were 896(13.94%). The prevalence of organisms among total infectious organisms is 51.4% (BV), 30% (Can), 12.4% (TV) and mixed infections 3.5% and 2.7% (BV+TV and BV+Can). Comparison of seasonal variation in prevalence of vaginal infectious agents was also analyzed. Conclusion: It is concluded that cervical cytology is important for diagnosis of cervical infections. The most important cause of cervico-vaginitis are bacterial vaginosis, next important cause is candidiasis. It is important to mobilize all reproductive age women to undergo pap smear examination and to prevent complications caused by infectious agents. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Keywords : Clue cells, Cytobrush, Prurituis, Vaginal discharge, Yeast forms | |||||||||||||||||||||||||||||||||||||||||||||||||||||
INTRODUCTION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Cervico-vaginal infections are common in the reproductive age group of females. The pap smear is a screening test to know the premalignant and malignant lesions and also useful for diagnosis of cervico-vaginal infections and also mixed infections. It is a simple, quick, and painless procedure.Pap smear was first introduced by George Papanicolaou in 1943. It is a screening test to detect the presence of abnormal cells in the cervix that could become cancerous if not diagnosed early (1),(2). About two thirds of patient present with vaginal discharge, abdominal pain, postcoital bleeding, dyspariunia and other symptoms. Bacterial vaginosis, candidiasis and trichomoniasis are responsible for 90% of the cases of diseases of infectious origin, and less than 1% of these cases show mixed infection. Actinomycosis is common in women who used IUD (3). | |||||||||||||||||||||||||||||||||||||||||||||||||||||
MATERIAL AND METHODS | |||||||||||||||||||||||||||||||||||||||||||||||||||||
A retrospective analysis of cervical pap smear study was done over a period of two years from January 2014 to December 2015 in a Tertiary Care Unit, Department of Pathology, Saveetha Medical college and Hospital, Thandalam, Chennai, India. Patients were included in the study if a pap smear was performed for routine screening and medical necessity. The study was approved by scientific review board and ethical clearance was obtained from the Ethical Committee of Saveetha University. Prior to data collection, the objectives of the study were explained in community meetings. A sample of 6424 pap smears were analyzed. The pap smear material was obtained by using cytobrush and placed immediately into a vial of pap spin collection fluid (EZI prep). Liquid Based Cytology (LBC) preparations were made with the cytospin 4 cytocentrifuge (Nanocyt). The smears were stained with Papanicolaous method and analyzed by pathologist based on Bethesda system 2001 (4). Statistical Analysis A SPSS window, version 16 software was used for statistical calculations. The Chi-square test was used for statistical analysis. A p-value of <0.05 was considered significant for statistical evaluation. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
RESULTS | |||||||||||||||||||||||||||||||||||||||||||||||||||||
The total number of pap smears examined was 6424, the samples were obtained from the women who attended the Gynaecology OPD in the age group of 15 to > 50 years and the mean age group commonly affected is 20 to 40 years (Table/Fig 1). Out of 6424 cases, the pap positive smears for infectious organisms were 869 (13.94%). The prevalence of organisms among total infectious organisms is 51.4 % (BV), 30% (Can), 12.4% (TV), and mixed infections 3.5% and 2.7% (BV + TV and BV + Can) (Table/Fig 2). The prevalence of Bacterial Vaginosis (7.12%), Candida species (4.61%), Trichomona vaginalis (1.73%) and mixed infections [BV+Can (0.37%), BV+TV (0.48%)] respectively from total cases. Comparison of seasonal variation in prevalence of cervicovaginal infectious agents was also analyzed (Table/Fig 3). It is important to mobilize all reproductive age women to undergo pap smear examination and to prevent complications caused by infectious agents. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Cervicovaginal infection is commonest problem in most of the women who are in reproductive age group (2). The Papanicolaou test has become an important screening test for cervical cancers and also useful for diagnosis of cervicovaginal infections (5). Several studies have identified BV as the leading vaginal infection [6-8]. Simoes Barbosa A et al., studying 142158 women in Brasilia, reported BV prevalence as 17.2% (9). In Turkey, Krabulut A et al., reported frequency of BV to be 8.3% (10). In this study, BV was found as the main infectious agent in 51.4 % among total infectious agents, which is very high and 7.12% among total cases of the patients, which is similar to Krabulut’s result. The diagnosis of BV was made by the presence of clue cells i.e., mature squamous cells are covered by cocobacilli, typically extending beyond the cell margin and relative absence of lactobacilli on mixed flora (Table/Fig 4). Half of the patients with BV are asymptomatic; the Pap smear study may be only means of diagnosis (11). For the diagnosing BV most of the studies proved that the finding of clue cells in the Pap smear examination had 100% sensitivity and a 96% specificity (12). The frequency of clue cells are decreased due to the less variable pH in older women and in younger women BV is more frequent with related pH alterations (13). In the present study, younger and middle aged women had significantly higher prevalence of BV. The diagnosis of BV is important as it causes endometritis, urinary tract infections, preterm delivery, chorioamnionitis and pelvic inflammatory disease (14). BV also increases the risk of HIV acquisition (15). Other mixed infections are also observed are BV with TV and BV with Candidiasis. The most common fungal disease in women is vaginal cadidiasis and affects 75% of women at some stage in their lifetime. The patients present with curdy white discharge and pruritis. Candida species was diagnosed when yeast forms or pseudohyphae are present (Table/Fig 5) and mixed infections candida with BV are seen. Adad et al., reported an increase of Candida infection over the last decade (8.1% in 1978 to 22.5% in 1998) (7). Present study showed 30% of higher prevalence rate among total infectious agents and 4.61% of Candida infection from total cases similar to Adad et al., and Bukhari et al., 6.5% [7,2]. In this study, younger and middle aged women had significantly higher prevalence of cadidiasis. The most common sexually transmitted disease in sexually active women in all age groups is Trichomonas vaginalis (TV) (16). Approximately 57-10 million people are affected by TV globally, majority living in developing countries [17,18]. In Nigeria an overall prevalence of TV is 2.6% (19) and in Asian studies were as follows- 2.9% women in China, 18.2%, 25% and 28.1% women from Palestine, Turkey and Saudi Arabia are affected. Occurrence of TV was 12.4% in the present study, which had higher prevalence rate among total infectious agents and constituted 1.73% of total cases. Current study showed middle aged women had significantly higher prevalence of TV. TV was diagnosed as a unicellular organism of ovoid or pear shaped with single nucleus present (Table/Fig 6). The pelvic inflammatory disease, infertility, genitourinary tract infection premature labor, ectopic pregnancy, and there was an increased chance in the risk of both the transmission and acquisition of Human Immunodeficiency Virus (HIV) in TV patients (15). Vikki M et al., studies showed that epidemiological association between TV infection and subsequent cervical neoplasia and carcinoma (20). The cause for the development of cancer was chronic inflammation either specific or nonspecific has been associated with malignancy (21). In the previous literature mixed infections (BV+ Can, BV+TV) were not determined but were slowly started to find the mixed infections in pap smear. This study showed mixed infections of 3.5% and 2.7 % (BV+TV and BV+ Can) of prevalence rate among total infectious agents and BV+ can infection was 0.37% and TV with BV was 0.48% of total cases. Regarding seasonal variation in the detection of microorganisms in the cervical canal was published by a few research studies and the results varied from study to study. No seasonal variation was reported by some authors. The occurrence of candidiasis was variable in different seasons and an increased incidence rate was seen in rainy season as reported by Sodhani (22). Present study also correlated with Sodhani P et al. A study by Rietveld et al., and Sodhani et al., reported that trichomoniasis exhibited a higher incidence in winter and lower incidence in summer (23).The rainy season (July-October) gave intermediate values. In this case, the early and exogenous rhythmicity of the monsoon might interact with the endogenous rhythm of the immune system. Shrader S et al., reported no seasonal variation in the detection of TV (24). Trichomonas can thrive in moist environment, like in bathing water, on toilet seats, on wet clothing and can survive up to 45 minutes (25). The countries with a more moderate climate and with more gradual changes of the various seasons over the year, no data are yet available on seasonal patterns detected through cervical screening. The study was undertaken to document a seasonal variation in genital infections as detected in cervical smears. A seasonal variation of BV, Candida, TV and mixed infections (BV+Can, BV+TV) were reported with higher detection rate in rainy season followed by summers. Limitation Microbiological study was not included, as it was not of much use in this study. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
The study concludes that cervical cytology is important for diagnosis of cervical infections. The most important cause of cervicovaginitis are BV, next important cause is candidiasis. Higher incidence of BV and Candida infection are seen in younger to middle aged women and TV was in middle aged group. Seasonal variation was observed for all infectious organisms and mixed infections showed higher incidence rate in rainy season. It is important to mobilize all reproductive age women to undergo pap smear examination and to prevent complications caused by infectious agents and also gynecological disease prevention, community and school based STD prevention programs are needed. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLES AND FIGURES | |||||||||||||||||||||||||||||||||||||||||||||||||||||