Cervical Chaos: The Unexpected Amebic Guest

Dear Editor, A 48-year-old female, gravida 1, parity 1, presented with a 1-week history of foul-smelling vaginal discharge. She denied fever, abdominal pain, or dysuria. Menstrual cycles were regular with average flow. On admission, abdominal examination was unremarkable. Pelvic examination revealed foul-smelling necrotic discharge and a 3 cm × 2 cm ulcerated lesion on the anterior vaginal wall. Superficial irregularities were noted on both anterior and posterior vaginal walls across all segments. A provisional diagnosis of cervical carcinoma was considered. Under general anesthesia, detailed pelvic evaluation, endometrial and vaginal biopsies, and liquid-based cytology (LBC) of the cervix were performed. The uterus was anteverted, mobile, and nontender with free fornices. The vulva appeared normal. Rectal examination confirmed uterine anteversion with no parametrium, rectovaginal space, or rectal mucosa abnormalities. No active bleeding was noted. Histopathological analysis of hematoxylin and eosin-stained sections showed focal ulceration of the stratified squamous epithelium with exudate and granulation tissue. High-power magnification revealed neutrophils, eosinophils, karyorrhectic debris, and numerous amebic trophozoites containing ingested red blood cells [Figure 1a-e]. There was no dysplasia or malignancy. Periodic acid–Schiff staining confirmed amebic trophozoites [Figure 1f and g]. LBC Pap smear revealed dense inflammation with trophozoites, but no cytological abnormalities [Figure 1h]. High-risk human papillomavirus (HPV) testing (HPV-16/18) was negative. Endometrial biopsy was unremarkable. The patient was prescribed doxycycline 100 mg twice daily and metronidazole 400 mg twice daily for 14 days, along with pantoprazole 40 mg once daily for 5 days. She was advised on proper perineal hygiene. At 6-month follow-up, her symptoms had resolved.Figure 1: (a-c) Microphotographs showing focal ulceration of the stratified squamous epithelium, covered by exudate and granulation tissue. Squamous epithelium exhibiting no signs of dysplasia or malignancy (H and E, ×40); (d and e) High-power magnification showing exudate containing neutrophils, eosinophils, karyorrhectic debris, and numerous spherical amebic trophozoites with ingested red blood cells (H and E, ×100, ×400); (f and g) Periodic acid–Schiff stain highlighting the trophozoites (×100); (h) liquid-based cytology Pap smear showing dense inflammation with numerous trophozoites (PAP ×400, arrows)Amebiasis, caused primarily by Entamoeba histolytica, is endemic in regions like India and commonly presents as colitis or liver abscess. It spreads via the fecal–oral route through contaminated food or water. Genital amebiasis is rare and may mimic malignancy, including cervical carcinoma.[1-6] It presents most commonly with foul-smelling, bloody discharge, and ulcerative genital lesions are observed in about 8.1% of cases.[7] Diagnosis is typically made via cervical cytology (92% of cases) or biopsy. Risk factors include rectosigmoid infections, vulvovaginitis, perianal trauma, rectovaginal fistula, poor hygiene, and sexual activity. Autoinoculation from the anal region may occur even in the absence of gastrointestinal symptoms. Though the vaginal environment provides natural defense, mucosal disruption facilitates infection. Diagnostic workup should include repeated microscopy of pus, lesion biopsy, and stool studies. Histopathology shows intense inflammation and necrosis. Nuclear atypia may be present, but koilocytosis is absent. Immunoassays for E. histolytica stool antigen are sensitive and specific. Treatment involves metronidazole (750–800 mg three times daily for 5 days), followed by a luminal agent like diloxanide furoate (500 mg TID) or paromomycin (30 mg/kg TID for 10 days). Severe necrotizing cervicitis may require surgery. Sexual partners should be treated to prevent recurrence. This case highlights the importance of considering genital amebiasis in the differential diagnosis of vaginal or cervical ulcers, especially in endemic areas like India – even in the absence of gastrointestinal symptoms. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions Conceptualization, MAO, SR, SB and PA; Data Curation, MAO, SR, SB and DG and PA; Writing – Original Draft Preparation,MAO, SR, SB and PA; Writing – Review & Editing, MAO, SR, SB, DG and PA; Project Administration, SR, SB, DG and PA. All authors have read and agreed to the final version of the manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.