A 21-year-old woman, gravida 0, comes to the office due to postcoital bleeding. She has been sexually active with her male partner for 6 months. The patient has been taking birth control pills since age 15, when she first became sexually active. The patient and her partner do not use condoms and have never been diagnosed with a sexually transmitted infection. The patient smokes a pack of cigarettes per day. Bimanual examination reveals a small mobile uterus and no cervical motion tenderness. Speculum examination shows a well-estrogenized vagina without lesions. The cervix has an area of erythema surrounding the external os and scant clear discharge. She has her first Papanicolaou smear, and the cytological finding is shown in the image below. Which of the following best describes the finding shown on this patient's slide?

Question

A 21-year-old woman, gravida 0, comes to the office due to postcoital bleeding.  She has been sexually active with her male partner for 6 months.  The patient has been taking birth control pills since age 15, when she first became sexually active.  The patient and her partner do not use condoms and have never been diagnosed with a sexually transmitted infection.  The patient smokes a pack of cigarettes per day.  Bimanual examination reveals a small mobile uterus and no cervical motion tenderness.  Speculum examination shows a well-estrogenized vagina without lesions.  The cervix has an area of erythema surrounding the external os and scant clear discharge.  She has her first Papanicolaou smear, and the cytological finding is shown in the image below.  Which of the following best describes the finding shown on this patient's slide?

Quizplus · Accepted Answer

11ec160b_391f_a8a9_9249_4f3a7daeb7c6_MD0001_00 This patient's Papanicolaou (Pap) smear shows a koilocyte, a sign of human papillomavirus (HPV) infection. A koilocyte is an immature squamous cell with dense, irregularly staining cytoplasm and perinuclear clearing, resulting in a halo. It also has an enlarged pyknotic nucleus where the chromatin has condensed as part of the apoptosis process, giving it a "raisinoid" appearance. HPV is a double-stranded, non-enveloped DNA virus that has a predilection for squamous epithelium of the skin and vagina/cervix. Infection with HPV may present as warts or intraepithelial neoplasia, as shown in the table above. Oncogenesis from HPV strains (eg, 16, 18) is attributed to viral proteins E6 and E7. E6 degrades p53 (tumor suppressor protein regulating the cell cycle) and E7 inhibits the retinoblastoma gene product Rb. Smoking increases the likelihood of an HPV infection developing into intraepithelial neoplasia and cancer. (Choice A) Actinomyces-like organisms (black arrow) appear as clusters of basophilic thin filaments that resemble "cotton candy" on a Pap smear; their presence can be an incidental finding in patients with intrauterine devices. (Choice B) Candida albicans is part of normal flora in many asymptomatic women. The organism can appear as pseudohyphae of budding yeast on a Pap smear. (Choice C) Clue cells are seen in Pap smears in the setting of bacterial vaginosis, which involves a change in vaginal flora from lactobacilli to anaerobic gram-negative rods (eg, Gardnerella vaginalis). Clue cells are squamous cells covered with rods to obscure normal epithelial margins. (Choices D and E) The endometrium consists of simple tubular glands within stroma. These cells resemble histiocytes and have small dark nuclei and no perinuclear clearing. They may be present on a Pap smear during menses. Glandular endocervical cells (black arrow) are columnar cells with a vacuolated or granular cytoplasm and prominent cell borders that form a honeycomb pattern when in clusters. Their presence in a Pap smear indicates adequate sampling. (Choice G) Parabasal cells are round cells with a basophilic cytoplasm, finely granular chromatin in their nuclei, no visible nucleoli, and a high nucleus-to-chromatin ratio ("fried eggs" with a large "central egg yolk"). They predominate in Pap smears from postmenopausal and postpartum women. Educational objective: Human papillomavirus (HPV) infection causes cutaneous and genital warts as well as benign and malignant intraepithelial neoplasia. Koilocytosis is a hallmark sign of HPV infection. Koilocytes are pyknotic, superficial or immature squamous cells with a dense, irregularly staining cytoplasm and perinuclear halo-like clearing. __________ References: Clinicopathological study of Papanicolaou (Pap) smears for diagnosing of cervical infections. (http://www.ncbi.nlm.nih.gov/pubmed/20949462)

A 21-Year-Old Woman, Gravida 0, Comes to the Office Due