Trichomonas vaginalis

In this lecture, we will be talking about one of the protozoa, Trichomonas vaginalis.

Our Trichomonas vaginalis story takes place outside a metro station. This poor boy is super
bored waiting for his babysitter. He's on a tricycle and he's moaning with boredom, so trike
and moaning for Trichomonas as in Trichomonas vaginalis. To keep the area clean,
management likes to keep a big barrel of bleach readily available at all times. Bleach is an
alkaline cleanser, so its pH is on the higher end. You can see that the container says pH
greater than 4.5. This refers to the pH of the vaginal discharge in Trichomonas vaginalis,
which is above 4.5, so on the more alkaline side of things relative to other causes of
abnormal discharge, which have a lower pH. Interestingly, this is not a hard and fast rule
when it comes to Trichomonas. That means if you think your patient has a Trichomonas
infection, but the pH is lower than expected, like 3.5, then assume it's Trichomonas and
ignore the pH because, in this case, seeing is believing. If you're looking at Trichomonas, you
know it's Trichomonas no matter what the pH says.
This man here thought the barrel of bleach was a drinking fountain. I guess he couldn't see
the label from his perspective. He was in for a shocking surprise when he accidentally
swallowed bleach. Poor guy. This shock caused him to knock back into the nearby trough.
This trough represents trophozoites, and Trichomonas vaginalis has a trophozoite form.
This is a microscopic image showing the trophozoite form of Trichomonas. You can see the
flagella on each of these trophozoites. These flagella make the organism very motile, and
this is an important image to remember, so commit it to memory.

You are probably wondering why the trough had strawberries written on the side of it. Well,
to keep passengers patient and happy as they wait for their ride, the metro station provides
complementary strawberries. You can see the strawberries flying into the air when the
trough was bumped. These strawberries make reference to the strawberry cervix that is
often seen on examination in patients with Trichomonas infections.
This guy over here was just innocently drinking his protein drink before all the ruckus
started. You can see the little trophozoites in his drink if you look closely. This protein drink
will help you remember that Trichomonas vaginalis is a protozoa—protein, protozoa.
The metro station also provides complementary alcohol to the passengers. Since this table
of alcohol was next to the strawberry trough, it got bumped too and is now spilling frothy
alcohol on the ground, drenching this poor woman. The frothiness represents the frothy
nature of the vaginal discharge on pelvic exam. The frothy vaginal discharge is often
described as yellow, just like the yellow alcohol you see here. So when you think of this
frothy yellow alcohol drenching this poor woman, think of frothy yellow discharge.
Now, this woman is a busy scientist, and she came here to pick up her little nephew while
his parents are away. So that tricycle kid who was moaning was waiting for this lady. She's
probably in a bad mood now, and that poor kid now has to deal with an angry babysitter on
top of being super bored. Anyways, this scientist woman needed to bring her microscope
with her when she came to pick up her nephew, and with all the chaos of rushing here and
getting drenched in frothy yellow alcohol, she dropped her microscope.
The microscope is now resting in that puddle of fluid, and this represents the fact that
Trichomonas can be diagnosed using saline microscopy. In saline microscopy, a sample of
that frothy yellow discharge is collected and placed under a slide, and it will produce an
image like this. You can see those little motile trichomonads moving around.

Here are the boy's parents leaving him behind. They are pretty happy to take off on their
vacation together. While this metro they're using to leave represents metronidazole, which
is used to treat Trichomonas vaginalis infections, the fact that both of these people are on
the metro together represents the fact that both partners should be treated, otherwise one
partner will just keep reinfecting the other. So again, this couple on the metro stands for
treating both partners with metronidazole.
Implicit in this idea is the fact that Trichomonas vaginalis is an STI. To represent this, we
have a scarlet letter on her shirt. This makes reference to the book "The Scarlet Letter"
about a woman who was required to wear a scarlet letter on her clothes to remind
everyone that she had sex. Kind of a weird story, but somewhat of a classic. Anyways, the
scarlet letter stands for STI, and being sexually transmitted means that this infection will just
get transmitted back and forth between husband and wife until they're both treated.
Now that we've covered the items in the image, let's do a question to apply what you've
learned.

A 30-year-old woman reports abnormal vaginal discharge for the past 5 days. She states that
the discharge is foamy and greenish-yellow in color. After obtaining a more detailed history,
she states that she recently became sexually active with a new partner. The physician
performs a speculum exam and appreciates an erythematous cervix. A sample of vaginal
discharge is then obtained and promptly examined under the microscope. Microscopy
reveals several protozoan organisms with noticeable flagella. Based on the information
provided, which of the following statements is most likely true?

A) She obtained the infection from her partner.

B) A pH of 3.7 would rule out Trichomonas vaginalis.

C) The pathogen is part of the normal vaginal flora.

Hopefully, from the question stem, you notice that this condition is consistent with
Trichomonas vaginalis. Evidence includes the foamy discharge—this could also be described
as frothy like the alcohol in the image. We are also told that the color is greenish-yellow,
which again is consistent with the yellow alcohol. Also, she recently became sexually active
with a new partner, and she has cervicitis because she has an erythematous cervix. If
visualized, the physician may describe the cervix as being strawberry red. The last clue is
that we see protozoan organisms with flagella on microscopy. With this in mind, the correct
answer is A) she obtained the infection from her partner.

Recall that Trichomonas vaginalis is an STI, and in the context of a new sexual partner, we
can blame him. Remember this sexually active couple here leaving behind their tricycle boy.

Now, choice B is incorrect because pH that doesn't fit the bill exactly can't compete with the
findings in the vignette. You can't rule out Trichomonas just because the pH doesn't fall
neatly above 4.5 like we'd expect. Choice C is incorrect because Trichomonas is not part of
the vaginal flora. However, this would be a true statement if we were talking about
Gardnerella vaginalis. Finally, choice D is incorrect because clue cells are found in
Gardnerella infections, not with Trichomonas infections. Even if clue cells were visualized,
based on the information we have, Trichomonas is a far more likely cause of her symptoms
than a Gardnerella infection. So clue cells would not tell us what's going on here. And that
should be all you need to know about Trichomonas vaginalis.