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Clue cells
Kaleem J. Khan, Rajul Shah, Manjyot Gautam, Sharmila Patil
Department of Dermatology, Venereology and Leprosy, Pad. Dr. D.Y. Patil Hospital, Nerul, Navi Mumbai, India

Correspondence:
Dr. Kaleem J. Khan, Al-Sana House, Behind Vidyanidhi School, JVPD Scheme, Mumbai - 400 049, India. E-mail: khankaleem@gmail.com

Clue cells were first described by Gardner and The normal vaginal squamous epithelial cells have
Dukes[1] in 1955 and were so named as these cells distinct cell margins and lack granularity. Clue
give an important “clue” to the diagnosis of bacterial cells are seen as squamous epithelial cells with a
vaginosis (BV). large number of coccobacillary organisms densely
attached in clusters to their surfaces, giving them
Clue cells are vaginal squamous epithelial cells a granular appearance. The edges of squamous
coated with anaerobic Gram-variable coccobacilli epithelial cells, which normally have a sharply
Gardnerella vaginalis.[2] defined cell border, become indistinct or stippled
[Figure 1]. Polymorphonuclear leukocytes (PMNs)
PATHOGENESIS can also be demonstrated on the normal vaginal
wet mount preparation [Figure 2]. The vaginal
An increase in vaginal pH occurs due to alteration discharge of patients with BV is notable for its lack
in normal flora characterized by a decrease in of PMNs, typically 1 or less than 1 PMN per vaginal
lactobacilli [3] (Doderlein bacilli) and increase in epithelial cell.
bacteria such as G. vaginalis, Mycoplasma hominis
and anaerobes such as Mobiluncus, Bacteroides and
Peptostreptococcus species.
CLINICAL SIGNIFICANCE
The detection of clue cells is the most useful single
Factors that cause these changes in flora are poorly procedure for the diagnosis of BV. Presence of more
understood; however, the postulates[4,5] include the than 20% clue cells in vaginal discharge is included
menstrual cycle, concomitant infections, sexual in Amsel’s[6] criteria for the diagnosis of BV. Other
activity, contraceptive methods and antibiotic use. criteria for the diagnosis of BV include:
! milky, homogeneous, adherent discharge;
Thus, an increase in local pH is favorable to the ! vaginal pH greater than 4.5;
growth of bacteria causing BV. These bacteria adhere ! positive Whiff test, i.e. typical fishy odor on addition
to the surface of epithelial cells leading to the of one or two drops of 10% KOH to vaginal discharge
formation of clue cells. and
! few or no lactobacilli.

DEMONSTRATION OF CLUE CELLS
The presence of any three of the above five
Clue cells can be demonstrated by microscopic conditions is considered diagnostic.
examination of vaginal wet mount preparation.
The sensitivity and specificity of more than 20%
From the speculum, an appropriate amount of clue cells on wet mount[7] for diagnosis of BV is 81%
vaginal discharge is transferred on the glass slide and 99%.
and a droplet of normal saline is added directly.
The preparation is covered with a coverslip and The identification of clue cells can also be done
examined under a light microscope at 100× (low on Papanicolaou smear sampled from the posterior
power) and 400× (high power) magnifications. fornix with sensitivity[8] and specificity of 90% and

How to cite this article:
Khan KJ, Shah R , Gautam M, Patil S. Clue cells. Indian J Sex Transm Dis 2007;28:108-9.

108 Indian J Sex Transm Dis 2007; Vol. 28, No. 2

Kemapunmanus M.160:132-3. No. Diagnostic criteria and microbial and 1. Curless E.74:14-22. Scott TG. Evaluation of two clinical protocols for the management 2. Mandal D. et al. 6. Davick PR. 5.63:47-53. Prevalence of hydrogen peroxide. 8. Chandeying V. Spiegel CA. Bacterial vaginosis in a district Source of Support: Nil. May 02. Vaginitis. Totten PA. Eschenbach DA.org on Monday. Amsel R. Smyth CJ. respectively.100. Saidi SA. Platz-Christensen JJ. Eschenbach D. Young. Rowe P. Genitourin Med 1987.206]  ||  Click here to download free Android application for t Khan. Geater A. Int J STD AIDS 1994:5:405-8. 2011. 7. Skov S.: Clue cells Figure 1: Gram stained smear showing coccobacillary organisms attached Figure 2: Wet mount preparation showing vaginal epithelial cells having in clusters on the cell surface. Chen KC.69:962-76. Klebanoff SJ. making the border indistinct or stippled organisms attached on the cell surface resulting in a granular look to the cells. Sundstrom E. Am J Obstet Smith K. [Downloaded free from http://www. producing Lactobacillus species in normal women and women with bacterial vaginosis. Nonspecific vaginitis. defined specific infection previously classified “Nonspecific” vaginitis. Bondeson L. In vitro adhesiveness and biotype of women with vaginal discharge in southern Thailand. Dukes CD.ijstd.337:1896-903. N Engl J Med 1997. Detection of bacterial vaginosis in Papanicolaou smears. Keane CT. Haemophilus vaginalis vaginitis: A newly epidemiologic associations. IP: 164. cells in vaginal discharges. 2 109 . et al. J Clin Microbiol 1989. Critchlow CM. Holmes REFERENCES KK.74:194-201. Am J Obstet Gynecol 1955. The cytoplasm appears fuzzy 97%. Law M. Gardner HL. Williams BL. Sex Transm of Gardnerella vaginalis strains in relation to the occurrence of clue Infect 1998. microbiology and anaerobes.1. 28. Sobel JD. genitourinary medicine department: Significance of vaginal Indian J Sex Transm Dis 2007. 3. Am J Med 1983. Gynecol 1989. 4. Conflict of Interest: None declared.27:251-6. Larsson PG. Vol.