British Journal of Obstetrics and Gynaecology September 1979. Vol. 86. pp 741-744
ABORTION ASSOCIATED WITH INTRAUTERINE INFECTION BY CANDIDA ALBICANS CASE REPORT BY
R. BUCHANAN,Senior Registrar in Pathology
M. J. SWORN,Consultant in Pathology AND
A. D. NOBLE, Consultant in Obstetrics and Gynaecology The Royaf Hampshire County Hospital, Winchester, Hampshire
Summary A 27-year-old patient who became pregnant whilst fitted with an intrauterine contraceptive device developed an intrauterine Candida albicans infection and aborted. The diagnostic (and other inconspicuous) features of C. Albicans infection in the fetus are described. The presence of the intrauterine contraceptive device may have predisposed to the establishment of the infection.
CASEREPORT A 27-year-old patient became pregnant whilst fitted with a copper T intrauterine contraceptive device. During the first trimester she was twice treated for vaginal thrush. When 25 weeks pregnant, she was admitted to hospital with painful uterine contractions and passing blood and mucus per vaginum. The fetus was alive and she was immediately treated with an intravenous infusion of ritodrine (50 mg in 500 ml 5 per cent dextrose). The following day she was pyrexial and developed a profuse white vaginal discharge. A high vaginal swab was taken and treatment started with intramuscular cephradine, 500 mg four times a day and subsequently ampicillin 250 mg four times a day. The swab later grew normal vaginal flora and Candida afbicans. Treatment with antibiotics and ritodrine was continued but intermittent fever, painful uterine contractions and a blood stained discharge persisted and the uterus remained tender. After three days the patient’s general condition deteriorated, there was malaise and vomiting and at 90 hours after admission the
fetal heart could not be heard. In view of these changes the infusion was stopped, the membranes were ruptured and seven hours later the patient aborted. Her general condition then rapidly returned to normal. The fetus was female and the crown-rump length was 17 cm. There were no external congenital abnormalities but the skin was brown with an irregular roughened surface over the back and head and there were two white, linear streaks on the face. The placenta weighed 252 g; it appeared grossly normal but on close examination of the cord, ill-defined roughened patches could be seen. Histological examination Surrounding the circumference of the cord there were granulomatous foci (Fig. 1). Some were close to the surface, others deeper in its substance. They possessed central necrotic areas containing fungal elements with the morphological appearances and staining reactions of C. albicans (Fig. 2), surrounded by pyknotic polymorphic and mononuclear leucocytes. Inflammatory cells penetrated the walls of 74 1
742
BUCHANAN, SWORN AND NOBLE
FIG.1
Granulomas in the umbilical cord showing central necrosis. (Haematoxylin and eosin x 8).
FIG.2
Non branching filaments and yeast forms of C. ulbicuns in the umbilical cord. (Methenamine silver x53).
UTERINE CANDIDA INFECTION 743
the umbilical vessels and extended through Wharton’s jelly towards the granulomatous foci. There was a diffuse chorioamnionitis but no granulomata or fungal elements were seen. The lungs showed an interstitial pneumonia. There were mononuclear and occasional giant cells within the alveoli and hyphae and spores could be demonstrated on silver staining. In the roughened areas of skin there were discrete microabscesses, often related to hair follicles (Fig. 3), in the centre of which spores were seen and spores were also present among the cells desquamating from the epithelia1 surface. There was a light chronic inflammatory cell infiltrate in the oesophagus but it was not focal and no fungi were demonstrated.
COMMENT It is possible that some cases of intrauterine Candida infections are being missed. In most reports only a diffuse chorioamnionitis is present. Specific lesions are found in the cord but since these are scattered, sampling errors may occur. Aterman (1 968) drew attention to the vahe of examining the cord in an oblique light to look for flat yellowish white lesions. They are of variable size but often very small. Recognition is obviously of great importance because intrauterine infection may result in involvement of the central nervous system, where delayed diagnosis and treatment may lead to death or permanent neurological damage (Chesney et al, 1978).
FIG.3 Skin showing a perifollicular microabscess. (Haematoxylin and eosin x 11).
744
BUCHANAN, SWORN AND NOBLE
Infection is generally assumed to be ascending and associated with premature rupture of membranes. In some cases, however, as in ours, such a history is not obtained. It has been postulated that a subclinical tear may become sealed off and so not be apparent (Blanc, 1961) or alternatively that penetration through intact membranes may occur (Dvorak and Gavaller, 1966). Amniotic fluid has been found to have antibacterial and antifungal activity (Jankowski et al, 1977) and possibly additional factors are necessary for the establishment of C . albicans. Pelvic inflammatory disease is a recognised complication of intrauterine devices and recently Actinomyces israeli, an organism previously considered a rare cause of genital tract inflammation, has been associated with their use (Bhagavan and Gupta, 1978). It is probably relevant, therefore, that an intrauterine contraceptive device was present in our patient as in
two other reported stillbirths associated with C. albicans infection (Ho and Aterman, 1970; Van der Harten, 1975). REFERENCES Aterman, K. (1968) : American Journal of CIinical Pathology, 49,798. Bhagavan, B. S . , and Gupta, P. K. (1978): Human Pafhology, 9,567. Blanc, W. A. (1961): Journal of Paediatrics, 59,473. Chesney, P. J., Justman, R. A., and Bogdanowicz, W. M. (1978): Johns Hopkins MedicaiJournai, 142,155. Dvorak, A. M., and Gavaller, B. (1966): New England Journal of Medicine, 274,540. Ho, C. Y., and Aterman, K. (1970): Ainerican Journalof Obstetrics) and Gynaecology, 106,705. Jankowski, R. P., Alkins, H. E., andGupta, K. G. (1977): Archivf i r Gyncikologie,222,275. Van der Harten, J. J. (1975): Archives of Diseases in Childhood,50,662.
ABORTION ASSOCIATED WITH INTRAUTERINE INFECTION BY CANDIDA ALBICANS CASE REPORT BY
R. BUCHANAN,Senior Registrar in Pathology
M. J. SWORN,Consultant in Pathology AND
A. D. NOBLE, Consultant in Obstetrics and Gynaecology The Royaf Hampshire County Hospital, Winchester, Hampshire
Summary A 27-year-old patient who became pregnant whilst fitted with an intrauterine contraceptive device developed an intrauterine Candida albicans infection and aborted. The diagnostic (and other inconspicuous) features of C. Albicans infection in the fetus are described. The presence of the intrauterine contraceptive device may have predisposed to the establishment of the infection.
CASEREPORT A 27-year-old patient became pregnant whilst fitted with a copper T intrauterine contraceptive device. During the first trimester she was twice treated for vaginal thrush. When 25 weeks pregnant, she was admitted to hospital with painful uterine contractions and passing blood and mucus per vaginum. The fetus was alive and she was immediately treated with an intravenous infusion of ritodrine (50 mg in 500 ml 5 per cent dextrose). The following day she was pyrexial and developed a profuse white vaginal discharge. A high vaginal swab was taken and treatment started with intramuscular cephradine, 500 mg four times a day and subsequently ampicillin 250 mg four times a day. The swab later grew normal vaginal flora and Candida afbicans. Treatment with antibiotics and ritodrine was continued but intermittent fever, painful uterine contractions and a blood stained discharge persisted and the uterus remained tender. After three days the patient’s general condition deteriorated, there was malaise and vomiting and at 90 hours after admission the
fetal heart could not be heard. In view of these changes the infusion was stopped, the membranes were ruptured and seven hours later the patient aborted. Her general condition then rapidly returned to normal. The fetus was female and the crown-rump length was 17 cm. There were no external congenital abnormalities but the skin was brown with an irregular roughened surface over the back and head and there were two white, linear streaks on the face. The placenta weighed 252 g; it appeared grossly normal but on close examination of the cord, ill-defined roughened patches could be seen. Histological examination Surrounding the circumference of the cord there were granulomatous foci (Fig. 1). Some were close to the surface, others deeper in its substance. They possessed central necrotic areas containing fungal elements with the morphological appearances and staining reactions of C. albicans (Fig. 2), surrounded by pyknotic polymorphic and mononuclear leucocytes. Inflammatory cells penetrated the walls of 74 1
742
BUCHANAN, SWORN AND NOBLE
FIG.1
Granulomas in the umbilical cord showing central necrosis. (Haematoxylin and eosin x 8).
FIG.2
Non branching filaments and yeast forms of C. ulbicuns in the umbilical cord. (Methenamine silver x53).
UTERINE CANDIDA INFECTION 743
the umbilical vessels and extended through Wharton’s jelly towards the granulomatous foci. There was a diffuse chorioamnionitis but no granulomata or fungal elements were seen. The lungs showed an interstitial pneumonia. There were mononuclear and occasional giant cells within the alveoli and hyphae and spores could be demonstrated on silver staining. In the roughened areas of skin there were discrete microabscesses, often related to hair follicles (Fig. 3), in the centre of which spores were seen and spores were also present among the cells desquamating from the epithelia1 surface. There was a light chronic inflammatory cell infiltrate in the oesophagus but it was not focal and no fungi were demonstrated.
COMMENT It is possible that some cases of intrauterine Candida infections are being missed. In most reports only a diffuse chorioamnionitis is present. Specific lesions are found in the cord but since these are scattered, sampling errors may occur. Aterman (1 968) drew attention to the vahe of examining the cord in an oblique light to look for flat yellowish white lesions. They are of variable size but often very small. Recognition is obviously of great importance because intrauterine infection may result in involvement of the central nervous system, where delayed diagnosis and treatment may lead to death or permanent neurological damage (Chesney et al, 1978).
FIG.3 Skin showing a perifollicular microabscess. (Haematoxylin and eosin x 11).
744
BUCHANAN, SWORN AND NOBLE
Infection is generally assumed to be ascending and associated with premature rupture of membranes. In some cases, however, as in ours, such a history is not obtained. It has been postulated that a subclinical tear may become sealed off and so not be apparent (Blanc, 1961) or alternatively that penetration through intact membranes may occur (Dvorak and Gavaller, 1966). Amniotic fluid has been found to have antibacterial and antifungal activity (Jankowski et al, 1977) and possibly additional factors are necessary for the establishment of C . albicans. Pelvic inflammatory disease is a recognised complication of intrauterine devices and recently Actinomyces israeli, an organism previously considered a rare cause of genital tract inflammation, has been associated with their use (Bhagavan and Gupta, 1978). It is probably relevant, therefore, that an intrauterine contraceptive device was present in our patient as in
two other reported stillbirths associated with C. albicans infection (Ho and Aterman, 1970; Van der Harten, 1975). REFERENCES Aterman, K. (1968) : American Journal of CIinical Pathology, 49,798. Bhagavan, B. S . , and Gupta, P. K. (1978): Human Pafhology, 9,567. Blanc, W. A. (1961): Journal of Paediatrics, 59,473. Chesney, P. J., Justman, R. A., and Bogdanowicz, W. M. (1978): Johns Hopkins MedicaiJournai, 142,155. Dvorak, A. M., and Gavaller, B. (1966): New England Journal of Medicine, 274,540. Ho, C. Y., and Aterman, K. (1970): Ainerican Journalof Obstetrics) and Gynaecology, 106,705. Jankowski, R. P., Alkins, H. E., andGupta, K. G. (1977): Archivf i r Gyncikologie,222,275. Van der Harten, J. J. (1975): Archives of Diseases in Childhood,50,662.
