2013, Volume 1, Number 1, Page(s)
Concomitant Aspergillus Species Infection and Squamous Cell Carcinoma Diagnosed on Pap Smear
Prajwala GUPTA, Snigdha GOYAL, Manju KAUSHAL
Department of Pathology, PGIMER, Dr. RML Hospital, NEW DELHI, INDIA
Keywords: Aspergillus, Squamous cell carcinoma, Cervical smear
Concomitant infection with Aspergillus species and cervical
squamous cell carcinoma in the female genital tract is a rare
occurrence and attributed to the opportunistic nature of infection in
the immunocompromised state due to the underlying malignancy.
The contamination of smears with Aspergillus species should be
excluded. The diagnosis of Aspergillus species infection along with
squamous cell carcinoma was established on cervicovaginal pap
smears in a 62-year-old female presented to gynecological clinic with
complaints of stress urinary incontinence. Speculum examination
revealed first-degree cervical descent. Smears showed features of
squamous cell carcinoma along with fungal spores and fruiting body
with hyphae of Aspergillus species. The presence of fruiting bodies
and hyphae of Aspergillus species with coexisting squamous cell
carcinoma is rare in routine pap smears. True infection needs to
be distinguished from contamination by Aspergillus species. Early
diagnosis can be established on routine cervicovaginal Pap smear
Fungal infections of the genitourinary tract are a common
cause of itching and vaginal discharge in females. Among
the various fungal species, Candida is the most common
pathogen seen in cervicovaginal Pap smear whereas infection
with other fungi like Paracoccidiodes and Aspergillus
are rarely seen1,2
. Aspergillus species is a common
fungus causing allergies, severe respiratory infections and
invasive aspergillosis. Immunocompromised patients are at
increased risk of invasive Aspergillus infection.
Aspergillus species in a cervicovaginal smear is rare. It
may represent a contamination or a true infection following
prolonged antibiotic therapy or immunosuppression4. Immunocompromised hosts harboring leukemia or lymphoma and receiving chemotherapy and bone marrow
transplant are vulnerable for infection by Aspergillus species.
We report a rare case of squamous cell carcinoma of cervix
with concomitant infection with Aspergillus species that
was diagnosed on routine cervicovaginal pap smear.
A 62-year-old woman presented to the gynecological
clinic with a complaint of stress urinary incontinence. On
speculum examination, first-degree cervical descent was
noted. The biochemical and hematological investigations
were within normal limits. Routine and microscopic urine
examinations were normal. Two slides of cervicovaginal pap smears were sent for cytopathological examination.
One slide showed features of squamous cell carcinoma with
necrosis and inflammation in the background (Figure 1
The other slide showed mostly superficial and intermediate
squamous cells and few atypical squamous cells with high
N:C ratio and hyperchromatic nucleus along with fungal
spores which were seen scattered in the smear along with
septate hyphae. The hyphae were seen in association
with the fruiting body (Figure 2
). The fruiting body was
composed of conidiophores and club shaped vesicles
covered with a row of phialides. These 2 were capped with
long chains of conidiophores. Background showed minimal
inflammation. The fungal spores and hyphae with fruiting
body were in the same plane as the squamous cells. It was
noted that none of the other cervicovaginal pap smears from
the gynaecological outpatient clinic showed evidence of
fungus thereby excluding the use of contaminated spatulas.
The slides were clean and immediate transportation of slides to the cytopathology laboratory was ensured. Thus
in this case we ruled out Aspergillus contamination before
concluding the cytology report as squamous cell carcinoma
and associated infection by Aspergillus species.
Click Here to Zoom
|Figure 1: Smear shows malignant squamous cells in a necrotic
background (Papanicolaou stain, x400).
Click Here to Zoom
|Figure 2: Smear shows the fruiting body of Aspergillus Species
(Papanicolaou stain, x400).
The patient was lost to follow up for further investigation
and the systemic involvement by the Aspergillus species
and especially those of the lungs could not be excluded and
the histopathological diagnosis was unavailable.
The cervicovaginal pap smear is considered an important
tool in diagnosing neoplastic lesions in the genital tract. It is
also of use in detecting fungal infections especially Candida
which shows spores in association with pseudohyphae and
budding phenomenon. However, recognition of Aspergillus
species requires the presence of characteristic fruiting body
with acute angle branching hyphae and spores.
The fruiting body provides clue about the particular fungus
and its species3,6. Determination of the length and width
of conidiophores, shape of vesicles, phialides and chains
of conidia are noted for the species characterization. In
our case the fruiting body resembles Aspergillus species.
Several authors emphasize that it is essential to rule out
contamination with the Aspergillus species due to use of
improperly sterilized spatulas in the colposcopic clinic
before diagnosing it as a true infection3,5. The hyphae
lying above the plane of the cervical cells and minimal
inflammation suggest that the fungi were not deposited
at the same time as the cervical cells thereby favouring
contamination of the slide5. In our case, the fruiting
body was characteristic of Aspergillus species and present
in the same plane with the cervical cells. Further, it was
associated with squamous cell carcinoma that might have
resulted in decreased immunity of patient and increased
susceptibility for Aspergillus species infection although
the systemic involvement could not be ruled out in our
case. Only one of the slides showed Aspergillus species
with few atypical squamous cells whereas the other slide
showed features of squamous cell carcinoma, which rules
out the spatula contamination. Aspergillus infection has
been reported in a postmenopausal female with features
of pelvic inflammatory disease, which resolved following
treatment but the patient presented later on with squamous
cell carcinoma of the cervix1.
The infection with Aspergillus species most commonly
transmitted by airborne conidia and the lung is the major
site of infection. 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 identifiable1. Cytological recognition of the fungus by
fluorescence microscopy is possible when it is not easy to
distinguish Aspergillus from other filamentous fungi7.
The identification of Aspergillus species in cervicovaginal
smears should prompt the clinician for further investigation
to look for systemic focus. The finding of concomitant
squamous cell carcinoma in our case suggests the
possibility of decreased immunity leading to infection with
Aspergillus species. The cervicovaginal pap smears findings
and the sterile precautions are helpful in diagnosing a
true Aspergillus species infection. Once the factors for
the contamination are excluded then the cervicovaginal
Pap smear finding of Aspergillus species facilitates an
early diagnosis and prompt treatment. This case further
concludes the rare finding of the Aspergillus species
infection in a patient harbouring squamous cell carcinoma
which was diagnosed on cervicovaginal pap smear.
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MM. Reproductive tract infections among married women in
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