Subclinical human papillomavirus infection of the cervix Makram M. Al-Waiz, PhD, MBChB, Rabab N. Al-Saadi, FICMS, MBChB, Zahida A. Al-Saadi, MRCOG,MBChB, Faiza A. Al-Rawi, FICPath, MBChB. ABSTRACT Objectives: A prospective study to investigate a group 3 (15%) showed moderate dysplastic changes, whilst 2 of Iraqi woman with proved genital vulval warts, to seek (10%) showed no dysplastic changes. Speculoscopy and evidence of human papillomavirus infection in apparently acetowhitening was positive in 11 (55%) and collated normal looking cervixes and to investigate the natural histological results showed evidence of human history of infection. papillomavirus infection in 9 patients (45%). As for the control group one case (5%) had evidence of human Methods: From December 1997 to August 1998, 20 papillomavirus infection. women with vulval warts were enrolled along with 20 aged-matched control cases without warts. Their ages Conclusions: Subclinical human papillomavirus ranged between 19-48 years with a mean of 30.4 years, (+/ infection is more common than was previously thought - standard deviation = 2.3) for patients and 18-48 years among Iraqi women. It may appear alone or in association with a mean of 29.7 (+/- standard deviation = 2.7) for the with vulval or exophytic cervical warts, or both, and may control group. General and gynecological examinations be more common than the clinically obvious disease. were carried out. Cervical swabs for associated genital Speculoscopy as an adjunctive method to colposcopy was infection, papilloma smears, speculoscopy and directed found to be a simple and an easy to perform technique. Its punch biopsies were carried out to detect subclinical combination with cytology gave relatively good results human papillomavirus infections of the cervix and when it was used as a triage instrument, and may have a associated intraepithelial neoplasm. more promising performance in the future. Result: Cytology results showed that 11 (55%) of Keywords: Human papillomavirus, cervix. patients had evidence of cervical infection by human papillomavirus, 6 (30%) showed mild dysplastic changes, Saudi Med J 2001; Vol. 22 (8): 694-697 n recent years interest in cervical infection by inconspicuous cervical lesions which are only visible I human papillomavirus (HPV), the agent by magnification.1-3 These lesions have been called responsible for genital warts, has been growing. flat condylomata, non condylomatous cervical warts, Condylomata acuminata of the cervix is a familiar or subclinical HPVinfection,4 terms which indicate condition which is associated with characteristic their essentially non papilliferous nature. The term cytological findings of koilocytosis, dyskeratosis and subclinical HPV infection has been ascribed to nuclear atypia. It is now apparent that these findings different issues by different authors. Some authors are present in many women who do not have call subclinical HPV infection those lesions that are exophytic condylomata. In these women, condyloma not visible on routine inspection but become visible acuminatum of the vulva is associated with by colposcopy after acetic acid, and, which on From the Baghdad Teaching Hospital, (Al-Waiz, Al-Saadi R, Al-Saadi Z) University of Baghdad and Saddam College of Medicine, Department of Pathology, (Al-Rawi) Baghdad, Iraq. Received 7th October 2000. Accepted for publication in final form 17th April 2001. Address correspondence and reprint request to: Dr. Makram M. Al-Waiz, Department of Dermatology and Venereology, College of Medicine, Baghdad University, PO Box 61269 Medical Collection Post Office, Postal Code Number 12114, Bab Al-Mua’dham, Baghdad, Iraq. Tel. +964 (1) 4254862. Fax. +964 (1) 4250243. 694 Human papillomavirus infection of the cervix ... Al-Waiz et al histology contain typical HPV induced changes. liberally washed with 5% acetic acid using a large There are others who used the term as identical to flat cotton swab or 4x4 gauze squares held in place for at warts. In a 3rd group however, the term subclinical least 60 seconds. With an approved low power (x4-6) HPV infection in both sexes has been applied for hand held optical magnification source, visual lesions, which become visible only by colposcopy examination was performed to detect the presence of (peniscopy) after acetic acid application, and, which acetowhite areas such as areas with bright whitening on light microscopy shows normal or minor epithelial and sharply defined borders. Three criteria for non- changes not consistent with flat condylomas.5 condylomatous HPV infection of the cervix (flat and subclinical) were evaluated, these included apparent Methods. The research and ethical committee thickness, degree of acetowhitening and surface approved this study, and patients consent was taken. contour. Directed punch biopsies from the acetowhite Patients. Twenty married female ladies with areas of the cervix were obtained. clinically evident external genital warts were selected Histopathological studies. Two biopsy specimens from the outpatient clinics of the Department of for histopathological study were obtained from every Dermatology and Veneriology and the Department of patient, an excision biopsy from one of the clinically Gynecology, Baghdad Teaching Hospital, University evident genital warts and a directed punch biopsy of Baghdad during the period from December 1997 from the acetowhite areas of the cervix. Each to August 1998. Twenty aged match ladies were specimen was formalin fixed processed, stained with recruited as a control group. From each patient a hematoxylin and eosin stains and examined under detailed medical history and physical examination light microscopy. was performed. Vaginal swabs and cervical smears were taken for direct examination and for culture and sensitivity tests. All patients had screening Results. Twenty women with vulval warts serological tests for syphilis venereal disease underwent evaluation during the course of the research laboratory (VDRL) and Trponema pallidum study. Cytological findings consistent with the hemagglutination antibody test (TPHA). Pediculosis presence of HPV infection in the cervix were pubis, molloscum contagiosum, and scabies were positive in 11 cases (55%), such as the presence of diagnosed by there clinical appearances. both koilocytes and dyskeratocytes associated with Cytological methods. Cervical and vaginal mild to moderate dysplasia. In 2 cases (10%) the smears were taken from each patient using the Ayer’s possibility of HPV infection could not be excluded. wooden spatulas, to collect cells from the There were rounded cells, with vacuolated cytoplasm squamocolumnar junction of the cervix and posterior but not typical raisin nucleus. Five cases showed fornix of the vagina. The samples were immediately only polymorphs, lymphocytes, mature epithelial spread on glass slides, fixed with 95% ethyl alcohol, cells with and without metaplastic cells, changes of stained with papanicolaou stains, subsequently acute or chronic cervicitis. In 2 cases, the cervical examined microscopically, and evaluated for the presence of the 2 main important cells, the Table 1 - Results of cervical cytology in women with vulval warts. koilocytes, and dyskeratocytes. Acetowhitening and speculoscopy. The patients were examined in the lithotomy position as to allow easy exposure of the cervix using a bivalve Findings/type of cells n % speculum. Speculoscopy as an alternative and additive screening technique to colposcopy based on Koilocytes, dyskeratocytes and mild dysplastic 6 30 morphologic and physical principles has been used. changes (CINI) Speculite is a chemiluminescent illumination source Koilocytes, dyskeratoctes moderate dyplastic 3 15 that is attached to the upper dilator blade of the changes (CINII) vaginal speculum during a pap smear gynecological Only koilocytes + dyskeratosis - no dysplasia 2 10 examination, intended as a general screening aid in Intermediate cells, rounded cells, vacuolated 2 10 the visualization of the acetowhite areas by a low cytoplasm, no typical koilocytosis power (x4-6) magnification, of vaginal and cervical mucosa that has been previously washed with acetic Lymphocytes, polymorphs, mature epithilial and 5 25 acid, 5% solution. A small plastic capsule containing metaplastic cells - acute or chronic cervicitis a mixture of non-toxic chemicals serves as a light Hypocellular smears 2 10 source (speculight B.W, Trylon corp. Torrance C.A.). After activation and attaching it to the upper blade of Total 20 100 the vaginal speculum, a diffuse cold light is produced which has 3 maximum at 430, 540 and 580nm CINI= cervical intraepithelial neoplasia grade I, CINII=cervical wavelengths giving a blue white effect. The capsule intraepithelial neoplasia grade II remains active for 15-20 minutes. The cervix was Saudi Med J 2001; Vol. 22 (8) 695 Human papillomavirus infection of the cervix ... Al-Waiz et al Table 2 - Correlation between acetowhite areas and histological sections 18 years with a mean of 16.8 years1 and 16-25 with typical koilocytic changes. years.6-7 This is probably due to early sexual practicing habits, and multiple partners leading to a higher chance of harboring the virus. Many women Acetowhite n % Histological sections with with vulval warts in this study had an associated positive areas typical koilocytic changes lower genital tract infection. The association of n% micro-organisms was similar to that found in other 8 Bright white with 12 60 9 75 studies. Condylomata acuminata of the cervix sharply