An Unexpected Urine Swimmer

JCHS-IQ-02-2018 An Unexpected Urine Swimmer Case Presentation A 60-year-old lady was regularly followed up by her primary care provider for diabetes mellitus and hypertension. During one of her visits, her urine full and microscopic examination (UFEME) was positive for blood (3+), leukocytes (3+), and bacteria (1+). In addition, her urine microscopy also revealed the finding as shown in Figure 1. She denied any genitourinary symptoms or fever, and her urine culture showed mixed growth of more than three types of organisms with colony count more than 105 CFU/ml, which was suggestive of contamination. Based on the light microscopy image below, what is the most likely diagnosis? Figure 1 Direct wet mount microscopy of the urine sample 62 Vol 3(2) (2018) 62 | jchs-medicine.uitm.edu.my | eISSN 0127-984X JCHS-IQ-02-2018 An Unexpected Urine Swimmer ANSWER TO JCHS-IQ-02-2018 Trichomoniasis Direct wet mount microscopy of the urine sample demonstrated 2-3 motile trophozoites of Trichomonas vaginalis (Figure 2). The organisms appear pear-shaped, 7-23 µm long (average 13 µm), have one nucleus, with 3-5 anterior flagella (not clearly visible in this image) and one posterior flagellum (arrows). The morphological characteristics are consistent with T. vaginalis. Figure 2 Direct wet mount microscopy of the urine sample revealed several motile organisms with flagella (black arrows) 63 Vol 3(2) (2018) 63-66 | jchs-medicine.uitm.edu.my | eISSN 0127-984X An Unexpected Urine Swimmer With a global estimate of 187 million cases worldwide, trichomoniasis is considered as one of the most common, non-viral-origin, sexually transmitted infections (STI) globally [1, 2]. It was estimated that 276.4 million incidents occur in 2008 and approximately 90% of these infections were among people residing in resource-poor areas [3]. In Malaysia, epidemiological data on trichomoniasis is relatively scarce. According to WHO (2001), the prevalence of trichomoniasis among 1,070 women attending antenatal clinics in Kuala Lumpur was 0.5%, and 1% among 208 sex workers. Nordin et al. [4] studied the prevalence of STD among 130 female drug abusers and found 19.2% prevalence for trichomoniasis. In an observational study of 380 women visiting a family planning (LPPKN) clinic and STD clinic in Kuala Lumpur, the prevalence of trichomoniasis was 0.36% at the LPPKN clinic and absent at the STD clinic [5]. Ajin et al. [6] conducted a study at the Sarawak General Hospital and found T. vaginalis in 7.7% (23/300) pap-smear specimens. More recently, Moktar et al. [7] reported zero incidence rate in low risk women attending the Obstetrics and Gynaecology Clinic of Universiti Kebangsaan Malaysia Medical Centre. Trichomonas vaginalis is a flagellated protozoan that ingests bacteria, red blood cells, and epithelial cells of the vagina [2]. Incubation time in the human host is between 4 and 28 days [8]. This protozoal parasite inhabits the lower genital tract of females and the prostate and urethra in males [9]. Human is the only known natural host for T. vaginalis and it is transmissible among humans mainly through sexual intimacy [10]. Trichomonas vaginalis has only the trophozoites stage (i.e., no cyst stage) in its life cycle. The trophozoite is 7 to 23 µm long (average 13 µm) and 5 to 15 µm wide [11, 12]. The axostyle is usually conspicuous and the undulating membrane extends halfway of the trophozoite’s length. The nuclear chromatin is evenly distributed. There are five flagella in total. Different conditions can alter the shape of the trophozoites. In cultures, the trophozoites tend to be more pear-shaped and oval. However, under unfavourable environment, the trophozoites may appear round-shaped with internalized flagella, representing either the pseudocyst form or a degenerating trophozoite form [12]. Majority of patients of both sexes infected with T. vaginalis are asymptomatic. Among those patients who presented with symptoms, the manifestations include vaginal discharge, dysuria, vulvar irritation, and abdominal pain [8, 13, 14]. Trichomoniasis has been associated with pregnancy complications [15]. Studies have shown a positive relationship between T. vaginalis and vaginitis, cervicitis, urethritis, bacterial vaginosis, candidiasis, herpes simplex virus (HSV), human immunodeficiency virus (HIV), Chlamydia, gonorrhoea, and syphilis [16]. This infection is also associated with malignant cervical neoplasia [17, 18]. Other reported complications include adnexitis, pyosalpinx, endometritis, infertility, low birth weight, and cervical erosion [8]. Strawberry cervix, also known as colpitis macularis, is observed in about 5 % of women [19]. In men, T. vaginalis has been reported as the causative agent for epididymitis, prostatitis, and decreased sperm cell motility [20]. Visualization of the motile trichomonas using direct wet mount microscopy of the vaginal discharge is the most used method to diagnose T. vaginalis. It is cheap and easy to perform, but insensitive [2]. A diagnosis of trichomoniasis may be overlooked as T. vaginalis can alter its shape or the characteristic structures may not be visible [12]. Delayed in transport, storage at 4°C, or freezing, and other abiotic factors that cause the parasite to lyse or loss the motility during sample examination could lead to false-negative results [21]. Broth culture method has better sensitivity than wet mount microscopy but it is more expensive and time consuming [22]. Newer detection techniques using point of care technology and polymerase chain reaction (PCR)-based tests are also available [2, 10]. Treatment of choice for trichomoniasis is metronidazole or tinidazole 2 g single dose. Alternatively, metronidazole 400–500 mg BID 7-day dose is also recommended [2]. 64 Vol 3(2) (2018) 63-66 | jchs-medicine.uitm.edu.my | eISSN 0127-984X An Unexpected Urine Swimmer Learning Points      Very few epidemiological studies on trichomoniasis have been carried out in Malaysia. It is a common parasitic infection yet receives little attention. The cases of trichomoniasis are rarely diagnosed in clinics and hospitals in Malaysia, probably due to underreporting or lack of experience / expertise in diagnosing this parasitic infection. Other than vaginal discharge and smears, T. vaginalis trophozoites can also be detected in urine. Trichomoniasis is associated with bacterial vaginosis, candidiasis, HSV, HIV, HPV, Chlamydia, gonorrhea, syphilis and cervical neoplasia. A case of incidental detection of asymptomatic trichomoniasis is presented herein. Note that nearly 50% of trichomoniasis cases are asymptomatic. REFERENCES 1. World Health Organization. Global incidence and prevalence of selected sexually transmitted infections– 2008. Geneva. 2012. http://www.who.int/reproductivehealth/publications/rtis/stisestimates/en/. Accessed 26 June 2018. 2. Kissinger P. Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. BMC Infect Diseases. 2015; 15: 307. 3. World Health Organization. Prevalence survey of sexually transmitted diseases among sex workers and women attending antenatal clinics: Malaysia: 1999-2000. 2001. pp. 1-14. 4. Nordin R, Isa AR, Abdullah MR. Prevalence of sexually transmitted diseases among new female drug abusers in a rehabilitation centre. Malaysian J Med Sci. 2001; 8(2): 9-13. 5. Amal RN, Aisah MY, Fatmah MS, Hayati MN. Trichomoniasis in cosmopolitan Malaysia: is it under control or is it under diagnosed? Southeast Asian J. Trop Med Public Health. 2010; 41(6): 1312. 6. Ajin HCA, Ghani MKA, Jufri NF, Sahalan AZ, Abdullah WO. Prevalence study of Trichomonas vaginalis by conventional pap smear at Sarawak General Hospital, Malaysia. Malaysian J. Health Sci. 2012; 10(1): 19-22. 7. Moktar N, Ismail NL, Chun PC, Sapie MA, Kahar NF, Suboh Y, Rahim NA, Ismail NA, Anuar TS. Trichomonas vaginalis infection in a low-risk women attended in Obstetrics and Gynaecology Clinic, Universiti Kebangsaan Malaysia Medical Centre. Asian Pac J Trop Biomed. 2016; 6(8): 702-5. 8. Petrin D, Delgaty K, Bhatt R, Garber G. Clinical and microbiological aspects of Trichomonas vaginalis. Clin Microb Rev. 1998; 11(2): 300-17. 9. Krieger JN. Trichomoniasis in men: old issues and new data. Sexually Transmitted Diseases. 1995; 22(2): 8396. 10. Schwebke JR, Burgess D. Trichomoniasis. Clinical Microb Rev. 2004; 17(4): 794-803. 11. John DT, Petri WA, Markell EK, Voge M Markell. Voge's Medical Parasitology. 9th ed. Elsevier Health Sciences. Elsevier Saunders. St. Loise, Mo., USA. 2006. pp. 22-78. 12. Garcia LS. Diagnostic Medical Parasitology. 5th ed. ASM Press. Washington, D.C., USA. 2007. pp. 123-129. 13. Sutton M, Sternberg M, Koumans EH, McQuillan G, Berman S, Markowitz L. The revalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clin Infect Diseases. 2007; 45(10): 1319-26. 14. Sena AC, Miller WC, Hobbs MM, Schwebke JR, Leone PA, Swygard H, Atashili J, Cohen MS. Trichomonas vaginalis infection in male sexual partners: implications for diagnosis, treatment, and prevention. Clin Infect Diseases. 2007; 13-22. 65 Vol 3(2) (2018) 63-66 | jchs-medicine.uitm.edu.my | eISSN 0127-984X An Unexpected Urine Swimmer 15. Klebanoff MA, Carey JC, Hauth JC, Hillier SL, Nugent RP, Thom EA, Ernest JM, Heine RP, Wapner RJ, Trout W, Moawad A. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. N Engl J Med 2001; 345(7): 487-93. 16. Allsworth JE, Ratner JA, Peipert JF. Trichomoniasis and other sexually transmitted infections: results from the 2001–2004 NHANES surveys. Sexually Transmitted Diseases. 2009; 36(12): 738. 17. Zhang ZF, Begg CB. Is Trichomonas vaginalis a cause of cervical neoplasia? Results from a combined analysis of 24 studies. International J Epidemiology. 1994; 23(4): 682-90. 18. Yap EH, Ho TH, Chan YC, Thong TW, Ng GC, Ho LC, Singh M. . Serum antibodies to Trichomonas vaginalis in invasive cervical cancer patients. Sexually Transmitted Infections. 1995; 71(6): 402-4. 19. Critchlow C, DeRouen T, Holmes KK. Vaginal Trichomoniasis. JAMA. 1989; 261: 571-6. 20. Martinez-Garcia F, Regadera J, Mayer R, Sanchez S, Nistal M. Protozoan infections in the male genital tract. J Urology. 1996; 156(2): 340-9. 21. Bellanger AP, Cabaret O, Costa JM, Foulet F, Bretagne S, Botterel F Two unusual occurrences of Trichomoniasis: rapid species identification by PCR. J Clin Microb. 2008; 46 (9): 3159-61. 22. Garber GE. The laboratory diagnosis of Trichomonas vaginalis. Canadian J Infectious Dis and Med Microb. 2005; 16(1): 35-8. Corresponding authors: 1 2 Chong Chin Heo & Nadzimah Mohd Nasir 1 Department of Microbiology and Parasitology, 2 Department of Pathology, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, 47000 Sungai Buloh, Selangor, Malaysia. Tel: +6-03-61267439 Fax: +6-03-61267073 Email: chin@salam.uitm.edu.my 66 Vol 3(2) (2018) 63-66 | jchs-medicine.uitm.edu.my | eISSN 0127-984X