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 ~  Abstract
 ~ Introduction
 ~  Materials and Me...
 ~ Results
 ~ Discussion
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ORIGINAL ARTICLE
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 314-316
 

Clinical and laboratory evidence of Trichomonas vaginalis infection among women of reproductive age in rural area


Department of Microbiology, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra - 442004, India

Date of Submission06-Feb-2012
Date of Acceptance17-Apr-2012
Date of Web Publication8-Aug-2012

Correspondence Address:
R P Fule
Department of Microbiology, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra - 442004
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.99493

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 ~ Abstract 

Background: Vaginitis is a commonly encountered complaint and one of the most frequent reasons for patient visit to obstetrician-gynaecologists. Three vaginal infections are frequent causes of a vaginal discharge: (1) bacterial vaginosis, (2) vulvovaginal candidiasis and (3) trichomonas vaginitis. Differences in the clinical presentation are helpful in diagnosis. Characteristic signs and symptoms for these three vaginal infections are distinct, but on many occasions, they are overlapping. The aim of the present study was to find the prevalence and correlation between the clinical spectrum and laboratory evidence of Trichomonas vaginalis infection by simple, reliable, confirmatory and specific method, i.e. microscopic examination of wet mount preparation and acridine stain of vaginal fluid. Materials and Methods: Irrespective of HIV status, a total of 156 women with vaginal discharge were studied for establishing diagnosis of genital tract infection. The cases of bacterial vaginosis and vulvovaginal candidiasis were excluded from the study. Vaginal speculum assisted high vaginal swabs were collected from women with discharge, during collection vagina was inspected for obvious signs. Results: Of the 156 women with vaginal discharge, 19 (12.06 %) showed T. vaginalis infection. All the women belonged to active reproductive age group, i.e. 20-40 years. Itching dysuria, and offensive, malodorous, thin, yellowish vaginal discharge were the main and consistent complaints. Only in 2 (1.52%) cases, vaginal speculum examination revealed erythema and punctuate haemorrhage, the so-called "strawberry' vagina. The pH was recorded to be >4.5. Conclusion: Clinical differentiation of various forms of infectious vaginitis is unreliable. The prevalence of T. vaginalis infection at 12.06% was found among rural young women of reproductive age using simple and reliable screening wet mount microscopy.


Keywords: Trichomonas vaginalis, vaginal discharge, vaginitis


How to cite this article:
Fule S R, Fule R P, Tankhiwale N S. Clinical and laboratory evidence of Trichomonas vaginalis infection among women of reproductive age in rural area. Indian J Med Microbiol 2012;30:314-6

How to cite this URL:
Fule S R, Fule R P, Tankhiwale N S. Clinical and laboratory evidence of Trichomonas vaginalis infection among women of reproductive age in rural area. Indian J Med Microbiol [serial online] 2012 [cited 2019 Dec 16];30:314-6. Available from: http://www.ijmm.org/text.asp?2012/30/3/314/99493



 ~ Introduction Top


Trichomonas vaginalis is a sexually transmitted flagellated protozoan and the most prevalent cause of vaginitis. Trichomoniasis occurs worldwide, with an estimated incidence of 180 million women afflicted per year. [1],[2],[3] It causes approximately one-third of all vaginal discharge complaints. [3] The parasite is common among women with sexually transmitted diseases (STDs) and co-infection rates with gonococci have been reported to be as high as 60%. The clinical spectrum can range from being asymptomatic to severe fulminant signs and symptoms. Approximately one-third of asymptomatic females become symptomatic within 6 months. [4]

The classic acute signs and symptoms include purulent yellowish-green, often frothy, malodorous, thin discharge, with burning, itching at the site, dysuria, and dyspareunia. The vulva may appear fiery red and oedematous. The speculum examination often reveals mucosal erythema and punctuate haemorrhage, the so called "strawberry" vagina and cervix.

Trichomonas vaginitis is one of the most common STDs among HIV-infected and un-infected women. Proportion of HIV-infected women diagnosed with T. vaginalis vaginitis ranges from 6 to 27%. [5] Women suffering from trichomoniasis are at extreme risk of acquiring other STDs. Diagnosis based on clinical presentation is often inaccurate. Consequently, any treatment based on such diagnosis may be inappropriate. Further, it has been reported that T. vaginalis infection may occur at any age and is seen in about 15% of women in sexually transmitted clinics, which can readily be identified in wet mount of vaginal discharge in the infected patients. [6] In India, the prevalence rate varies between 6 and 10%. [7] With this background, the present study was carried out to establish laboratory evidence of T. vaginalis infection among women with vaginal discharge.


 ~ Materials and Methods Top


Irrespective of HIV status, 156 women of reproductive age group attending Obstetrics and Gynaecology (OBGY) outpatient department of a tertiary care rural hospital of central India, from October 2010 to September 2011, were selected at random for the present study. The study was granted approval by institutional ethics committee.

The patients with complaints of vaginal discharge, itching, dysuria, dyspareunia, and foul odour were considered symptomatic. Vaginal speculum assisted vaginal swabs from lateral vaginal wall were collected from each patient. All patients belonged to rural area and low socio-economic group. Cotton tipped applicators were used to obtain vaginal fluid samples. At least two samples were collected in a sterile test tube that contained 0.2 ml of 5% glucose saline, as it shows better shape and motility for subsequent wet mount examination. This tube was maintained at body temperature for wet mount examination which was done within 10 minutes of collection of specimen. The applicator gently agitated in the saline and wet mount on clean slide was prepared and observed under microscope for motile trichomonads using 400×, to confirm the flagellar movement, morphological features and the number of T.vaginalis. Wet mounts were examined at least for 2 minutes. Similarly, dry unfixed smear was stained with acridine orange and was observed by fluorescent microscope.

The pH of vaginal discharge greater than 4.5 was recorded. Whiff test was done by adding 10% KOH to vaginal fluid on a slide emitting strong fishy odour. Vaginal fluid was also examined for polymorphonuclear leucocytes.


 ~ Results Top


All 156 women in the study group had vaginal discharge, of whom 69.87% had vaginal discharge with foul odour, 20.51% vaginal discharge plus itching, 5.76% vaginal discharge plus itching and dysuria, 2.56% vaginal discharge plus itching and dyspareunia and 1.28% had vaginal discharge with "strawberry" vagina. All the women belonged to active reproductive age group ranging from 20 to 40 years of age. A single case showed co-infection with gonococci. On wet mount examination, a total of 19 (12.06%) symptomatic women showed T. vaginalis. Vaginal pH >4.5 was recorded in 90 (57.69%) women and whiff test was positive in all women with pH >4.5. Leucocytes were observed in 50 (32.05%) women with vaginal discharge.


 ~ Discussion Top


The clinicians involved in women's health commonly encounter the complaint of vaginitis associated with vaginal discharge, which is one of the most frequent reasons for patient visit to obstetrician-gynaecologists. [8] Infectious vaginitis is a syndrome that is primarily caused by three different groups of microbial pathogens (bacteria, yeast and protozoan) that account for 90% of disease. Apart from bacterial vaginosis and vulvovaginal candidiasis, the protozoan T. vaginalis is the third leading cause of vaginitis, accounting for 20% of infections. In the present study, 19 (12.06%) patients having clinical presentation of female genital tract infection were positive for trichomonads on wet mount.

A very high prevalence of 47% was reported by Manson et al. [9] but the overall prevalence of T. vaginalis varies from place to place and from study to study, and is reported to range from 6 to 14.9% [Table 1]. [10],[11],[12],[13],[14],[15],[16] The prevalence of T. vaginalis infection reported in the present study is almost equivalent with that reported by de-Lemons et al[16] and more than that reported by other investigators using wet mount microscopy or other techniques like culture, Papanicolaou, acridine orange staining techniques.
Table 1: Prevalence of T. vaginalis reported earlier and the present study

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Diagnosis based on clinical presentation is often inaccurate; consequently, any treatment based on such diagnosis may be inappropriate. Therefore, laboratory evidence is necessary for confirmation of diagnosis. Clinical differentiation of various forms of infectious vaginitis is unreliable and the accurate diagnosis of trichomoniasis in patients of either sex depends on demonstrating the organism in genital specimen. Trichomonas may be identified in genital secretions using wet mount technique, which will detect them in most series, in about 60% of infected women.

Heine and McGregor [6] have indicated T. vaginalis is a re-emerging pathogen and infection may occur at any age and is seen in about 15% of women in STD clinic. De Lemos et al. [16] compared wet mount microscopy, culture and cytology for the diagnosis of T. vaginalis in HIV-positive and -negative women. They found the highest number positive by culture (13.9%), followed by cytology (13.5%) and wet mount microscopy (11.4%). According to Wiese et al., [17] the wet mount microscopy is considered as a highly specific diagnostic method (99.8%); however, the sensitivity is lower (58 -82%). The advantage of wet mount microscopy is its low cost, being most convenient and the widely used method for investigation of trichomoniasis in resource-constrained clinical laboratory setup.

The prevalence of trichomoniasis is underestimated in women attending OBGY clinic if the diagnosis is based on culture alone. A routine vaginal fluid wet smear examination in all women with discharge is essential. The results of wet mount, if examined within 10 minutes of collection of discharge, can yield positive results comparable with other techniques.

Despite the various techniques available for demonstration of trichomonads, wet mount with clinical evidence of trichomoniasis still remains the sole screening test in many OBGY clinics in the hands of a skilled microscopist. Microscopic examination of vaginal secretion by wet mount can be a reliable and inexpensive method for establishing the T. vaginalis vaginitis. Culture of vaginal swabs in cases of trichomonas infection does not yield significantly more information than microscopy alone. In the present study, wet mount and acridine orange stain showed similar results. It is therefore concluded that clinical presentation substantiated with laboratory evidence of trichomoniasis is of great help in the confirmation of diagnosis and to institute the therapy.

 
 ~ References Top

1.World health Organisation. Global prevalence and incidence of selected curable sexually transmitted infections. Overview and estimates. Geneva: World Health Organisation; 2001.  Back to cited text no. 1
    
2.Schwebke JR, BurgessD. Trichmoniasis. Clin Microbiol Rev 2004;17:794-803.  Back to cited text no. 2
    
3.Malla N, Kaul P, Sehgal R, Gupta I. The presence of dsRNA virus in Trichomonas vaginalis isolates from symptomatic and asymptomatic Indian women and its correlation with in vitro metronidazole sensitivity. Indian J Med Microbiol 2011;29:152-7.  Back to cited text no. 3
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4.Anderson JR. Genital tract infections in women. Med Clin North Am 1995;79:1271-98.  Back to cited text no. 4
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5.Cohn SE, Clark RA. Sexually transmitted diseases: HIV AIDS in women. Med Clin North Am 2003;87:971-95.  Back to cited text no. 5
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6.Heine P, McGregor JA. Trichomonas vaginalis: a re-emerging pathogen. Clin Obstet Gynecol 1993;36:137.  Back to cited text no. 6
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7.Kaur S, Khurana S, Bagga R, Wanchu A, Malla N. Trichomoniasis among women in north India: A hospital based study. Indian Sex Transm Dis and AIDS 2008;29:276-81.  Back to cited text no. 7
    
8.Lipsky MS, Waters T, Sharp LK. Impact of antifungal products on utilisation of health care services: evidence from physician visit. J Am Board Fam Pract 2000;13:178-82.  Back to cited text no. 8
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9.Manson PR, Super H, Fripp PJ. Comparison of four techniques for the routine diagnosis of Trichomonas vaginalis infection. J Clin Pathol 1976;29:154-7.  Back to cited text no. 9
    
10.Greenwood JR, Kirk-Hillaire K. Evaluation of acridine orange stain for detection of Trichomonas vaginalis in vaginal specimens. J Clin Microbiol 1981;14:699  Back to cited text no. 10
    
11.Krieger JN, Tam MR, Stevens CE, Nielsen IO, Hale J, Kiviat NB, et al. Diagnosis of Trichomoniasis: Comparison of conventional wet mount examination with cytologic studies, culture and monoclonal antibody staining of direct smear. J Am Med Assoc 1988;259:1223-7.  Back to cited text no. 11
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12.Stary A, Koch AK, Teodorowicz L. Detection of Trichomonas vaginalis on modified Columbia Agar in routine laboratory. J Clin Microbiol 2002;9:3277-80.  Back to cited text no. 12
    
13.Demirezen S, Korkmaz E, Beksac MS. Association between Trichomoniasis and bacterial vaginosis: Examination of 600 cervicovaginal smears. Cent Eur J Public Health 2005;13:96-8  Back to cited text no. 13
    
14.Rahman S, Garland S, Currie M, Tabrizi SN, Rahman M, Nessa K, et al. Prevalence of Mycoplasma genitalia in health clinic attendee complaining vaginal discharge in Bangla Desh. Int J STD AIDS 2008;19:772-4.  Back to cited text no. 14
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15.Madhivanan P, Bartman MT, Pasuti L, Krupp K, Arun A, Reingold AL, et al. Prevalence of Trichomonas vaginalis infection among young reproductive age women in India: implications for treatment and prevention. Sex Health 2009;6:339-44.  Back to cited text no. 15
    
16.deLemos PA, Gracia-Zapata MT, Guimaraes NM, Moris RG. Comparison of methods for identification of Trichomonas vaginalis in HIV positive and negative women. Int J Trop Med 2009;4:76-81.  Back to cited text no. 16
    
17.Wiese W, Patel SR, Patel SC, Ohl CA, Estrada CA. A meta-analysis of the Papanicolaou smear wet mount for the diagnosis of vaginal trichomoniasis. Am J Med 2000;108:301-8.  Back to cited text no. 17
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