Cervical cytology as a diagnostic tool for female genital schistosomiasis: Correlation to cervical atypia and Schistosoma polymerase chain reaction

Pavitra Pillay, Lisette van Lieshout, Myra Taylor, Motshedisi Sebitloane, Siphosenkosi Gift Zulu, Elisabeth Kleppa, Borghild Roald, Eyrun Floerecke Kjetland, Pavitra Pillay, Lisette van Lieshout, Myra Taylor, Motshedisi Sebitloane, Siphosenkosi Gift Zulu, Elisabeth Kleppa, Borghild Roald, Eyrun Floerecke Kjetland

Abstract

Background: Female genital schistosomiasis (FGS) is a tissue reaction to lodged ova of Schistosoma haematobium in the genital mucosa. Lesions can make the mucosa friable and prone to bleeding and discharge. Women with FGS may have an increased risk of HIV acquisition, and FGS may act as a cofactor in the development of cervical cancer.

Objectives: To explore cytology as a method for diagnosing FGS and to discuss the diagnostic challenges in low-resource rural areas. The correlation between FGS and squamous cell atypia (SCA) is also explored and discussed. Cytology results are compared to Schistosoma polymerase chain reaction (PCR) in vaginal lavage and urine and in urine microscopy.

Materials and methods: In a clinical study, 394 women aged between 16 and 23 years from rural high schools in KwaZulu-Natal, South Africa, underwent structured interviews and the following laboratory tests: Cytology Papanicolaou (Pap) smears for S. haematobium ova and cervical SCA, real-time PCR for Schistosoma-specific DNA in vaginal lavage and urine samples, and urine microscopy for the presence of S. haematobium ova.

Results: In Pap smears, S. haematobium ova were detected in 8/394 (2.0%). SCA was found in 107/394 (27.1%), seven of these had high-grade squamous intraepithelial lesion (HSIL). Schistosoma specific DNA was detected in 38/394 (9.6%) of vaginal lavages and in 91/394 (23.0%) of urines. Ova were found microscopically in 78/394 (19.7%) of urines.

Conclusion: Schistosoma PCR on lavage was a better way to diagnose FGS compared to cytology. There was a significant association between S. haematobium ova in Pap smears and the other diagnostic methods. In low-resource Schistosoma-endemic areas, it is important that cytology screeners are aware of diagnostic challenges in the identification of schistosomiasis in addition to the cytological diagnosis of SCA. Importantly, in this study, three of eight urines were negative but showed Schistosoma ova in their Pap smear, and one of them was also negative for Schistosoma DNA in urine. In this study, SCA was not significantly associated with schistosomiasis. HSIL detected in this young population might need future consideration.

Keywords: Cervical atypia; cytology; female genital schistosomiasis; gynecology; laboratory diagnostics; real-time polymerase chain reaction.

Figures

Figure 1
Figure 1
(a) Cervical smear, (Papanicolaou stain, ×40). Schistosoma haematobium ovum with an embryo miracidium. Note the diagnostic terminal spine(arrow). (b) Cervical smear, (Papanicolaou stain, ×40). Cytological changes consistent with high grade squamous intraepithelial lesion including human papillomavirus infection. Long arrow: Human papillomavirus cytopathic changes including nuclear and cellular enlargement, and koilocytosis. Double arrow: Cells with increased nuclear to cytoplasmic ratios, nuclear membrane irregularities and marked hyperchromasia consistent with high-grade squamous intraepithelial lesion. The background contains neutrophil granulocytes denoting inflammation
Figure 2
Figure 2
Flowchart of the study participation
Figure 3
Figure 3
(a) Cervical smear, magnification (Papanicolaou stain, ×40). Poorly preserved smears with cellular detail obscured by blood and inflammatory cells. Small arrow: Non-diagnostic, poorly preserved epithelial cells. Double arrow: Two Schistosoma haematobium ova, identifiable by their refractile shells and characteristic terminal spines. (b) Cervical smear, magnification (Papanicolaou stain, ×40). Schistosoma ovum surrounded by many neutrophil granulocytes. Terminal spine detected on fine focus, however, not seen clearly in this image
Figure 4
Figure 4
(a) Cervical smear, magnification (Papanicolaou stain, ×40). Arrows: emergent miracidium with a finely ciliated outline. (b) Cervical smear, magnification (Papanicolaou stain, ×40). Numerous calcified, dead ova (four calcified ova - short arrows and two non-calcified ova - long arrows) of Schistosoma haematobium
Figure 5
Figure 5
Percentage of squamous cell atypia positive in relation to age of the 394 examined young women. The number of examined women per year of age is indicated
Figure 6
Figure 6
(a) Cervical smear, magnification (Papanicolaou stain, ×40). A contaminant easily misdiagnosed for Schistosoma haematobium ova. Note the lack of a diagnostic terminal spine. (b) Cervical smear, magnification (Papanicolaou stain, ×40). Arrow: Schistosoma ovum with a terminal spine found among contaminants

References

    1. World Health Organization. WHO Global Health Observatory (GHO) Data. Schistosomiasis Situation and Trends Published. 2015. [Last accessed on 2015 Aug 09]. Available from:
    1. Appleton CC, Kvalsvig JD. A school-based helminth control programme successfully implemented in KwaZulu-Natal. [Last accessed on 2015 Aug 01];South Afr J Epidemiol Infect. 2006 21:55–67. Available from: .
    1. Saathoff E, Olsen A, Magnussen P, Kvalsvig JD, Becker W, Appleton CC. Patterns of Schistosoma haematobium infection, impact of praziquantel treatment and re-infection after treatment in a cohort of schoolchildren from rural KwaZulu-Natal/South Africa. BMC Infect Dis. 2004;4:40.
    1. Pillay P, Taylor M, Zulu SG, Gundersen SG, Verweij JJ, Hoekstra P, et al. Real-time polymerase chain reaction for detection of Schistosoma DNA in small-volume urine samples reflects focal distribution of urogenital schistosomiasis in primary school girls in KwaZulu Natal, South Africa. Am J Trop Med Hyg. 2014;90:546–52.
    1. Edington GM, Nwabuebo I, Junaid TA. The pathology of schistosomiasis in Ibadan, Nigeria with special reference to the appendix, brain, pancreas and genital organs. Trans R Soc Trop Med Hyg. 1975;69:153–6.
    1. Jourdan PM, Roald B, Poggensee G, Gundersen SG, Kjetland EF. Increased vascularity in cervicovaginal mucosa with Schistosoma haematobium infection. PLoS Negl Trop Dis. 2011;5:e1170.
    1. Moubayed P, Lepère JF, Mwakyoma H, Neuvians D. Carcinoma of the uterine cervix and schistosomiasis. Int J Gynaecol Obstet. 1994;45:133–9.
    1. Kjetland EF, Ndhlovu PD, Mduluza T, Deschoolmeester V, Midzi N, Gomo E, et al. The effects of genital schistosoma haematobium on human papillomavirus and the development of cervical neoplasia after five years in a Zimbabwean population. Eur J Gynaecol Oncol. 2010;31:169–73.
    1. Kjetland EF, Leutscher PD, Ndhlovu PD. A review of female genital schistosomiasis. Trends Parasitol. 2012;28:58–65.
    1. Norseth HM, Ndhlovu PD, Kleppa E, Randrianasolo BS, Jourdan PM, Roald B, et al. The colposcopic atlas of schistosomiasis in the lower female genital tract based on studies in Malawi, Zimbabwe, Madagascar and South Africa. PLoS Negl Trop Dis. 2014;8:e3229.
    1. Kjetland EF, Ndhlovu PD, Mduluza T, Gomo E, Gwanzura L, Mason PR, et al. Simple clinical manifestations of genital Schistosoma haematobium infection in rural Zimbabwean women. Am J Trop Med Hyg. 2005;72:311–9.
    1. Papanicolaou GN. A new procedure for staining vaginal smears. Science. 1942;95:438–9.
    1. Berry A. Multispecies schistosomal infections of the female genital tract detected in cytology smears. Acta Cytol. 1976;20:361–5.
    1. Solomon D, Nayar R. New York: Springer Science & Business Media; 2004. The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria, and Explanatory Notes.
    1. Obeng BB, Aryeetey YA, de Dood CJ, Amoah AS, Larbi IA, Deelder AM, et al. Application of a circulating-cathodic-antigen (CCA) strip test and real-time PCR, in comparison with microscopy, for the detection of Schistosoma haematobium in urine samples from Ghana. Ann Trop Med Parasitol. 2008;102:625–33.
    1. Utzinger J, Becker SL, van Lieshout L, van Dam GJ, Knopp S. New diagnostic tools in schistosomiasis. Clin Microbiol Infect. 2015;21:529–542.
    1. Kjetland EF, Hove RJ, Gomo E, Midzi N, Gwanzura L, Mason P, et al. Schistosomiasis PCR in vaginal lavage as an indicator of genital Schistosoma haematobium infection in rural Zimbabwean women. Am J Trop Med Hyg. 2009;81:1050–5.
    1. Samuel MI, Taylor C. A case of female urogenital schistosomiasis presenting as viral warts. Int J STD AIDS. 2015;26:599–601.
    1. Kjetland EF, Mduluza T, Ndhlovu PD, Gomo E, Gwanzura L, Midzi N, et al. Genital schistosomiasis in women: A clinical 12-month in vivo study following treatment with praziquantel. Trans R Soc Trop Med Hyg. 2006;100:740–52.
    1. Jourdan PM, Holmen SD, Gundersen SG, Roald B, Kjetland EF. HIV target cells in Schistosoma haematobium-infected female genital mucosa. Am J Trop Med Hyg. 2011;85:1060–4.
    1. Magak P, Chang-Cojulun A, Kadzo H, Ireri E, Muchiri E, Kitron U, et al. Case-control study of posttreatment regression of urinary tract morbidity among adults in Schistosoma haematobium – Endemic communities in Kwale County, Kenya. Am J Trop Med Hyg. 2015;93:371–6.
    1. Hegertun IE, Sulheim Gundersen KM, Kleppa E, Zulu SG, Gundersen SG, Taylor M, et al. S. haematobium as a common cause of genital morbidity in girls: A cross-sectional study of children in South Africa. PLoS Negl Trop Dis. 2013;7:e2104.
    1. Randrianasolo BS, Jourdan PM, Ravoniarimbinina P, Ramarokoto CE, Rakotomanana F, Ravaoalimalala VE, et al. Gynecological manifestations, histopathological findings, and schistosoma-specific polymerase chain reaction results among women with Schistosoma haematobium infection: A cross-sectional study in Madagascar. J Infect Dis. 2015;212:275–84.
    1. Poggensee G, Sahebali S, Van Marck E, Swai B, Krantz I, Feldmeier H. Diagnosis of genital cervical schistosomiasis: Comparison of cytological, histopathological and parasitological examination. Am J Trop Med Hyg. 2001;65:233–6.
    1. Poggensee G, Feldmeier H. Female genital schistosomiasis: Facts and hypotheses. Acta Trop. 2001;79:193–210.
    1. Hutchinson ML, Zahniser DJ, Sherman ME, Herrero R, Alfaro M, Bratti MC, et al. Utility of liquid-based cytology for cervical carcinoma screening. [Last accessed on 2015 Aug 01];Cancer Cytopathol. 1999 87:48–55. Available from: .
    1. Szarewski A, Sasieni P. Cervical screening in adolescents – At least do no harm. Lancet. 2004;364:1642–4.
    1. Firnhaber C, Van Le H, Pettifor A, Schulze D, Michelow P, Sanne IM, et al. Association between cervical dysplasia and human papillomavirus in HIV seropositive women from Johannesburg South Africa. Cancer Causes Control. 2010;21:433–43.
    1. Pillay P, Knight S, Rmaih WN. Cervical cancer screening in urban clinics in eThekwini municipal area. [Last accessed on 2015 Aug 01];South Afr J Epidemiol Infect. 2009 24:18–20. Available from: .

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