Clinical Pathologic Challenge Answer

Abstract

(continued from page 352) ANSWER Emphysematosa Vaginitis. Emphysematosa Vaginitis is a benign, uncommon inflammatory condition characterized by the presence of multiple gas-filled cysts in the submucosa of the upper vagina and ectocervix, in a pattern similar to pneumatosis of the intestines or bladder. These cysts contain gas similar to atmospheric air with a high concentration of carbon dioxide. Regarding the etiology, Trichomonas infection, and immunosuppressive disorders have been suspected.1,2 However, cases have been reported in pregnant women, and in patients with cardiovascular disease. Other organisms associated with this condition, Haemophilus vaginalis and Gardenerella vaginalis were also implicated.1–4 To date, the etiology and pathogenesis have not been fully elucidated. Clinically, most patients have symptoms of vaginitis with pruritus and discharge. Occasionally, patients complain of vaginal fullness and a bloody discharge. Symptoms are often short-lived and self-limited. The diagnosis can be made on physical examination and on plain radiography characterized by a myriad of gas-filled spaces in the subepithelial lining of the vaginal wall creating a distinct radiographic appearance.5,6 The cystic lesions are located in the mucosa of the vagina and exocervix and are usually found in the upper two thirds of the vagina.5,6 These gas-filled lesions may produce a popping sound when ruptured during a vaginal examination or sexual intercourse.1,7–9 The clinical differential diagnosis includes the benign cystic lesions of the vagina like inclusion cysts, Gartner duct cysts, and condyloma acuminatum, endometriosis, and solid tumors.1,2 Microscopically, the lesions are composed of variably sized cysts in the lamina propria. The cysts do not have a true epithelial lining. They contain hyalin material and foreignbody-type giant cells in the cyst wall, accompanied by sparse chronic inflammatory cell infiltrates. In most patients, vaginitis emphysematosa is an incidental finding which often spontaneously resolves. Alternatively, a simple excision of selected lesions can be curative. Dermatologists and pathologists should be equally aware of this unusual condition.