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Reply to: Microscopy and culture for Trichomonas vaginalis: Are both required?

Sir: We read the article by Cohen et al. with interest and agree with the conclusions of the authors to recommend that both microscopy and cultures are necessary to ascertain all women with trichmoniasis (TV). Although microscopy is popularly used for diagnosis, its sensitivity ranges from 60% to 70%. We speculate that persons with positive microscopy results may be those with potentially a higher burden of infection and that asymptomatic persons without physical signs of infection often have negative microscopy results. To test these hypotheses, a study was undertaken in the New Orleans HIV Outpatient Clinic to identify predictors for having positive microscopy results among women with TV. This study was a subset of a larger cross-sectional study examining multiple issues related to sexually transmitted infections among women living with HIV. Women were eligible for the larger parent study if they were at least 18 years of age and were scheduled to undergo a primary care gynaecological examination. The study was approved by the Tulane and Louisiana State University Health Science Center Institutional Review Boards, and informed consent was obtained from all study participants. Specimen collection for obtaining study specimens has previously been described. A total of 105 women were diagnosed with TV by having a positive In Pouch culture, of whom 48 (47.5%) had trichomonads visualized on microscopy reading. Patient symptoms, physical findings, and laboratory results are shown in Table 1. As demonstrated in the table, among women with TV, the wet mount preparation is significantly more likely to be positive in women with physical signs of infection, and laboratory findings demonstrating inflammation. Routine surveillance screening by culture identified a substantial number of TV cases among asymptomatic women with negative microscopy results in our population. It is particularly important that TV cases be identified among women living with HIV, given the known protective effect of TV treatment on HIV-1 RNA genital tract shedding.