Aspergillus in a cervico-vaginal smear of an adult postmenopausal female: An unusual case

Abstract

There are several case reports documenting opportunistic fungal infection in the female genital tract, withr Aspergillus spp being a rarely reported causative organism. We hereby report a case of Aspergillus infection in a 48 year-old, postmenopausal female with carcinoma of the cervix. She presented with features of pelvic inflammatory disease, and an initial routine cervico-vaginal smear revealed severe inflammation along with fungal bodies. The features were consistent with the presence of Aspergillus spp, while the background epithelial cells were negative for intraepithelial malignancy. She was offered therapy for pelvic inflammatory disease. A repeat Papanicolaou smear after two weeks was negative for intraepithelial organisms, but showed the evidence of a high-grade squamous intraepithelial lesion, with biopsy confirming squamous cell carcinoma.

Introduction

Aspergillus spp is a fungus known to cause both acquired and nosocomial infections in human beings. The most commonly affected sites are the lungs, soft tissue, and skin.[1,2]

We report here an unusual case in which Aspergillus spp. was detected in the cervical smear of a postmenopausal female who presented with features of pelvic inflammatory disease.

Case Report

A 48 year-old postmenopausal female was referred to the Gynecology clinic with complaints of a foul-smelling vaginal discharge and pain in the hypogastric region. There was no associated history of bleeding per vaginum, dyspareunia, weight loss, or other local symptoms.

Gynecological examination revealed an unhealthy cervix without any other incriminating signs. Results of routine clinical and laboratory examinations, including blood glucose levels, were within normal limits. Screening for human immunodeficiency virus (HIV) serology yielded negative results.

Cytological findings

A routine Papanicolaou smear showed the features of severe inflammation, along with fungal structures with fruiting bodies consistent with the presence of Aspergillus spp, while background epithelial cells were negative for intraepithelial malignancy [Figure 1]. The patient was offered therapy for pelvic inflammatory disease only, and instructed to report after two weeks.

Figure 1.

Papanicolaou smear showing features of severe inflammation, along with fungal structures (Pap, ×200) with fruiting bodies consistent with Aspergillus spp (inset: Pap, ×400)

A repeat Papanicolaou smear was negative for intraepithelial organisms, but showed epithelial cell abnormality: A high-grade squamous intraepithelial lesion (HSIL).

Histopathology findings

In light of the HSIL seen in the Papanicolaou smear, the patient was taken up for four-quadrant cervical biopsy, the histopathological examination of which confirmed squamous cell carcinoma.

Based on the histopathology report, the patient was referred to an oncology centre.

Discussion

Infections of the genitourinary tract are a common problem. Sullam et al.[1] reported a prevalence of 52.8% with a spectrum consisting of Candida albicans (28.0%), Trichomonas vaginalis (8.7%), Aspergillus species (7.4%), Streptococci (4.6%), and Chlamydia trachomatis (4.2%).

However, apart from Candida albicans, fungal pathology is rarely seen in cervico-vaginal smears. Most reported cases of female genital tract infections with opportunistic fungi in cervical smears included Blastomyces dermatitidis, Coccidioides immitis, Aspergillus flavus, Cryptococcus neoformans and Mucor, with very few cases of Aspergillus spp.[2]

Aspergillus species are members of the eumycetes and although most species reproduce asexually, some also have a sexual phase (teleomorphs). Conidia are produced in both forms; the conidiogenous cell is phialidic. A. fumigatus, for example, grows as gray-green colonies with a conidial mass and microscopic examination reveals septate hyphae branched at 45-degree angles with conidial heads composed of a vesicle, phialides, and conidial chains. Aspergillus species have antigenic moieties that elicit antibody responses in patients with allergic forms of the disease or with mycetoma.[3]

The respiratory system, as seen with aspergilloma, is the most common site of infection, as seen in opportunistic infections in immunocompromised patients. Disseminated disease almost always results from a primary pulmonary infection, but it can also occur from skin inoculation or when no likely entry source is identifiable. Virtually any site can be involved as a result of hematogenous dissemination, including the central nervous system, heart (abscesses or pericarditis), gastrointestinal tract, kidney, liver (resembling hepatosplenic candidiasis), thyroid, or spleen.[4–6]

In the present case, Aspergillus was incidentally detected in a female who presented with features suggestive of pelvic inflammatory disease and was subsequently diagnosed as a case of cervical carcinoma. The aim of this case report is to highlight an unusual site of infection by Aspergillus spp.