Neonatal Trichomonas Vaginalis:

Report of Three Cases and Review

of the Literature
Farouk L. AI-SaIihi, M.D., John P. Curran, M.D.,
and Jung-Shung Wang, M.D.

From the Newborn Service, Margaret Hague Maternity Hospital, and the Department of Pediatrics,
Medical Center, Jersey City, New Jersey

ABSTRACT. The presence of Trichomonas ye- pose of this article is to present the mci-
ginalir organisms was surveyed in 984 newborns
dence of T. vaginalis among nonselected
by direct examination of wet smears from the
newborn population and to report three
vestibulum vaginae and by both direct examination
and culture method in 333. The incidence of T. cases of neonatal trichomoniasis. The cor-
vaginalis was 0. 1% by the direct examination alone relation between neonatal monilial infec-
and 0.6% by direct and culture method. Case re- tion and T. vaginali is also discussed.
ports of three neonates with T. vaginalis are pre-
sented. The present survey and previously reported
MATERIALS AND METHODS
series suggest that neonatal infection with T.
vaginalis can exist in three forms: latent, mild, The patients in this study consisted of
and virulent. Patients in two of the three cases three groups of female newborns. Group
reported in this article had concomitant monilial 1 included full-term newborn infants de-
infection which resisted therapy until the tricho- livered consecutively at the Margaret
monads were eliminated. Pediatrics, 53: 196, 1974,
Hague Maternity Hospital. Group 2 con-
TRICHOMONAS vAGINALIS, VAGINITIS, NEWBORN,

VULVO-VAGINITIS.
sisted of premature babies who remained
in the Premature Unit from the time of
birth to discharge. Group 3 was composed
of consecutive newborn infants up to 28
days of age who attended the Neonatal
The most important trichomonad infest- Clinic and were not included in group
ing man is Trichomortas vaginalis. Named 1 or 2.
Trico-monas vaginale by Donne1 who first The vestibulum vaginae of all infants
described the organism in 1836, it was was swabbed with a cotton swab and two
designated Trichomonas vaginalis by Ehren- methods of study were used. In method 1
berg’ in 1838. Dock,3 in 1896, was the first the swab was immediately placed in a test
to report it in the United States. In 1931, tube containing 0.5 ml of isotonic saline.
Cornell et al.4 reported T. vaginalis in a 3- The tube was then placed in a water bath
year-old patient. Trussell et al.,5 in 1942, at 37 C for five minutes, just prior to micro-
first reported infection by this flagellate in scopic examination of a direct smear by
a newborn. Since the original observations, at least two examiners, using both high and
a voluminous literature has accumulated low power objectives. The slide was read
dealing with T. vaginitis in adult females. as negative if no motility or trichomonads
Infection is seen infrequently before men- were noted. Positive preparations were
arche, and T. vaginalis as a parasite in stained with Giemsa for detailed morpho-
newborns is rarely reported.’’ The pur- logic identification of the organism. All

(Received May 14; revision accepted for publication August 10, 1973.)
ADDRESS FOR REPRINTS: ( F.L.Al-S. ) Margaret Hague Maternity Hospital, 88 Clifton Place,
Jersey City, New Jersey 07304.

Psnwrmcs, Vol. 53, No. 2, February 1974

Downloaded from www.aappublications.org/news
196 by guest on December 8, 2018
 ARTICLES 197

specimens were examined within 30 mm- showed cloudy vaginal discharge, diaper rash,
utes from the time of collection. and oral thrush, Nystatin was administered, and
the patient responded partially. Examination of the
In method 2 the swab was immediately
vaginal smears on the 19th day revealed T.
innoculated into Diamond’s medium,1’ #{176}
vaginalis. She was treated with metronidazole. No
which was incubated at 37 C for 48 to 96 parasite could be detected 24 hours after the initi-
hours. A wet smear was prepared from the ation of the therapy. The direct vaginal smear
culture medium and examined as in examination of the mother was negative for T.
vaginalis. Examination of the infant two weeks after
method 1.
discharge showed no evidence of trichomonads.

RESULTS
DISCUSSION
Of the 984 infants studied, 819 were in
Clinically apparent infection of the new-
group 1, 57 in group 2 and 108 in group 3.
born infant with T. vaginalis is rarely re-
In group 1, 333 newborn infants were ex-
ported (Table 2). Shaffer and Avery’4 make
amined by both the direct and culture
no mention of this flagellate as a cause of
methods; the other 486 babies in group 1
neonatal infection. Resistance to infection
and all patients in group 2 and 3 were
in premenarchal girls and postmenopausal
examined by the direct smear method only.
women is related to the environmental
Trichomorias vaginalis was identified in
characteristics of the hypoestrogenic vagina,
only one of the 984 newborn infants from
such as a high pH and relative lack of
all groups examined by the direct smear
glycogen. Under the influence of maternal
technique. Two babies with this parasite
estrogens, the vaginal smear of the new-
were found among the 333 neonates from
born female resembles that of an adult
group 1 examined by both direct smear and
woman, with abundant glycogen and thick
culture. Various clinical data are summar-
epithelium. On about the fourth day, fol-
ized in Table I.
lowing growth of Doderlein’s bacilli, the pH
CASE REPORTS averages 4.8 and remains so until the sec-
Case 1 ond week of life, when the acidity begins
to gradually decrease. By the third to sixth
L.G.,a white infant, weighed 3,890 gm at birth.
The mother had no history of T. vaginalis. At 40 week of life, vaginal pH is normally neu-
hours of age direct examination and culture of the tral or slightly alkaline. During the period
vaginal swab revealed T. vaginali.s by the culture of maternal estrogen influence, the new-
method only; she had no vaginal discharge. Re-
born is more susceptible to infection with
examination of the swabs on the 6th, 14th, and
T. vaginalis than at any time prior to the
28th days of life revealed no trichomonads.
Vaginal swab from the mother was unavailable. onset of puberty.
The incidence of T. vaginalis among
Case 2
female newborn infants varies with the
W.M., a Negro infant, weighed 2,900 gm at
population surveyed and the methods of
birth. The mother had no T. vaginalfs. At 56 hours
of age direct examination and culture revealed
diagnosis employed ( Table II ). Trussell
T. vaginalis. She had whitish vaginal discharge. et al.5 found 5% of the infants of 41 infected
Re-examination of the vaginal swab on the 14th mothers to be harboring trichomonads dur-
day revealed T. vaginalis by both methods and ing the first 8 days of life. Komorowska
also
was
on the
administered.
same day she
Examination
had oral
at
thrush.
the age
Nystatin
of 3
et al.8 found T. vaginalis in 6 ( 17%) of 35

weeks and 7)i weeks revealed diaper rash and

female infants less than 3 weeks of age with
yellowish vaginal discharge from which T. vagin- vaginal discharge. Feo15 was unable to dem-
alis could be found. The patient was treated with onstrate the parasite by wet smear in 102
metronidazole. Re-examination at the age of 83 Negro neonates 1 to 5 days of age. Coronel
and 93 weeks were negative for T. vaginalis. and Lillo,7 Glowinski et al.,9 and Heller et
Case 3t al.16 studied the incidence of T. vaginalis
S.C., a 12-day-old Negro infant weighing 3,750 among nonselected female newborn infants.
gm at birth, was admitted because of irritability Coronel and Lillo examined 30 infants by
and temperature of 101 F. The mother had vaginal the direct method and culture and reported
discharge. Examination of the patient’s urine re-
vealed many trichomonads. A urine sample ob-
tamed by suprapubic tap failed to reveal ilagel- . Supplied by William B. Leathem, Ph.D.,
lates. The vaginal swab revealed numerous T. Eaton Laboratories.
vaginalfr. On the seventh day of admission she t Not included in the survey.
Downloaded from www.aappublications.org/news by guest on December 8, 2018
198 NEONATAL TRICHOMONAS VAGINALIS

TABLE I

VARIOUS CLINICAL DATA FROM PRESENT SURVEY

Maternal
Total Race Neonatal history of Neonates
No. of Postnatal Clinic Przcate - Vaginal TV. With T.
Patients Age White Negro Discharge and-or vaginitis
Irritating
Vaginitis

Group 1 819 2-4 528 291 554 265 148 13 2

Group 2 57 3-28 39 18 31 26 6 1 0
Group 3 108 7-28 108 0 ?* ?* ?* ? 0
Total 986 2-28 675 309 ?* ?* ?* ? 2

* Unknown.

an incidence of p.6%. Glowinski reported an borns were studied, 333 by direct smear
incidence of 2% in a group of 50 neonates and culture and 651 by direct smear only.
examined by the direct method. In a study of The patient in case 1 demonstrated T.
50 children 12 days to 13 1/2 years of vaginalis by culture at 40 hours of age. The
age, Heller et al. found no trichomonads patient in case 2 was found to be infected
by direct smear from neonates or infants. by both methods at 56 hours. Thus the
In the present survey 984 nonselected new- incidence of T. vaginalL among the 984

TABLE II

SUMMARY OF REPORTED CASES OF TRICHOMONIASIS NEONATORUM

Refer- Post- Maternal

ence natal Clinical Picture Method of Diagnosis T. Remarks
No. Age vaginalis

5 1 -8 ?* Vaginal smear + t Survey of 41 babies born to mothers

with T. vaginalis

6 1 7, 28 Vaginal discharge Vaginal smear ?*

Vulvovaginitis

7 1, 15, ?* Vaginal smear ?* Survey of 30 nonselected newborn

30 & culture infants

8 1-21 Vaginal discharge Vaginal smear ?* Survey of 35 newborn infants with

& culture vaginal discharge

9 4-6 Vaginal discharge Vaginal smear + t Survey of 31 girls & boys whose
mothers had T. vaginalis & survey
of 50 girls & boys whose mothers
were not selected.

10 19 Abdominal disten- Urine examina- 0

tion, palpable tion
kidneys

11 9 ?* ?* +t

12 9 Colpitis Vaginal smear + t

* Unknown.

t Present.
Not present.

Downloaded from www.aappublications.org/news by guest on December 8, 2018

 ARTICLES 199

neonates surveyed was 0.1% by direct smear those of vaginitis, with a cloudy, white
and 0.6% by culture. The higher incidence vaginal exudate; however, Littlewood and
of T. vaginalis in neonates and older infants Kohler’#{176} have reported apparent urinary
reported from Central Europe and South tract infection by T. vaginaUi in a prema-
American studies in comparison to this ture infant, and suggest that infection with
survey may be related to two factors : (1) this flagellate should be considered when
in less industrialized countries there is a persistant pyuria is present in early in-
prevalence of breast-feeding in contrast to fancy. Kean19 reported T. vaginalis as a
the United States, with the possibility that common parasite in the adult female
estrogen transmitted to the infant in the urethra, and in this location the organisms
breast milk sustains conditions in the vagina may predispose a newborn infant to the
more receptive to trichomonads; and (2) development of bacterial infection of the
increase availability of and participation in urinary tract. Neonatal T. vaginalis infec-
antepartum care in highly industrialized tion as a cause of irritability, fever, or other
countries, with elimination of the organisms signs and symptoms has not been estab-
from the maternal genital tract prior to lished. Two of the three infants described
delivery. in this report (cases 2 and 3) presented
In most instances the source of T. Va- with excessive vaginal discharge and irri-
ginalis infection in the newborn infant is tability. One newborn infant (case 3 ) also
direct vulvovaginal contamination from an experienced fever.
infected mother. Maternal infection may The occurrence of concomitant monilial
be inapparent and the presence of T. and trichomonal infections has been re-
vaginalis might not be detected by a single ported in adults, and Lang et iil.20 ob-
examination of the mother in the post- served that when only one organism was
partum 17 In addition to direct noted by direct examination, the other
genital contamination, it is possible that organism was often obtained by culture.
the newborn infant may be infected from The patients in cases 2 and 3 of this report
her own meconium or feces following in- developed oral and cutaneous moniliasis
gestion of trichomonads during delivery. At during the period that T. vagirzalLi was
birth, the acidity of the gastric contents is present. The monilial infections resisted
essentially neutral and T. vaginalis could therapy until the trichomonads were
survive passage through the neonatal in- eliminated.
testinal tract in viable form. Boggess18 has Crother2’ reported successful treatment
reported the frequent occurrence or recur- of two infants with T. vaginalis with metro-
rence of T. vag1nali in adult patients with nidazole. Metronidazole, 50 mg orally
achlorhydria or hypochlorhydria. every 8 hours for five days, was admin-
Review of the literature and the results istered to patients in cases 2 and 3 of this
of the present study suggest that neonatal report, and was found to be effective and
infection with T. vagirzalis may be “latent” well tolerated by both newborn infants.
( transient carrier ), with very few organ- We suggest that treatment of newborn in-
isms and no clinical signs; “weak,” with fants infected with T. vaginalLs is indicated
moderate numbers of trichomonads and if any of the following criteria is present:
slight vaginal discharge; or “virulent,” with (1) the infection is weak or virulent, (2)
many organisms, vaginitis, and excessive the infant is 3 weeks of age or older, (3)
discharge. If the infection is “latent,” only persistent pyuria is noted, ( 4 ) concomitant
the culture method is likely to demonstrate monilial infection is resistant to treatment,
the presence of T. vaginali. In a “weak” and (5) other causes of irritability, failure
infection the number of organisms may be to thrive, or having a fever cannot be dem-
so low that a direct smear will be negative, onstrated.
but trichomonads will be demonstrated by REFERENCES
culture. In “virulent” infections the diag- 1. Donne, M. A. : Animacules observes dans les
nosis will almost always be made with cer- matires purulent et le produit de secretion
tainty by direct examination. des organes genitau.x de l’homme et de la
femme. C. R. Acad. Sci., 3:385, 1836.
When infection occurs in the neonate, 2. Ehrenberg, C. C.: Die Infusion-thierchen als
clinical manifestations have usually been volkommene Organismen: Em Buck in das
Downloaded from www.aappublications.org/news by guest on December 8, 2018
200 NEONATAL TRICHOMONAS VAGINALIS

tie fere organische Leben der Natur (p. Akush. Ginek., 5:62, 1966.
331 ). Leipzig: L. Voss, 1838. 12. Sander, S.: Eitrige vulvovaginitis bei einem
3. Dock, C. : Trichomonas as a parasite of man. neugeborenen Madchen als seltene Frm
Amer. J. Med. Sci., 111:1, 1896. einer Trichomonas vaginalis-Infektion und
4. Cornell, E. L., Goodman, L. J., and Mathies, thre Behandlung. Z. Kinderheilk., 98:364,
M. M.: The culture, incidence and treat- 1967.
ment of Trichomonas vaginalis. Amer. J. 13. Diamond, L. S. : The establishment of various
Obstet. Gynec., 22:360, 1931. trichomonads of animals and man in axenic
5. Trussell, R. E., and Wilson, M. E., in coopera- cultures. J. Parasit. 43:488, 1957.
tion with Longwell, F. H., and Laughlin, 14. Schaffer, A. J., and Avery, M. E.: Diseases of
K. A.: Vaginal trichomoniasis, complement the Newborn, ed. 3. Philadelphia: W. B.
fixation, puerperal morbidity and early in- Saunders Company, 1971.
fection of the newborn infants. Amer. J. 15. Feo, L.
G. : The incidence of Trichomonas
Obstet. Gynec., 44:292, 1942. vaginalis in the various age groups. Amer.
6. Theopold, W. : Vulvovaginitis beim saugling J. Trop. Med., 5:786, 1956.
durch Trichomonas vaginalis. Mschr. Kin- 16. Heller, R. H., Joseph, J. M., and Davis, H. J.:
derheilk., 96:226, 1948. Vulvovaginitis in the premenarcheal child.
7. Coronel, L., and Lillo, F. : Epidemiologia de J. Pediat., 74:370, 1969.
la Trichomoniasis urogenital de la nina. Bol. 17. Binder, S.: Vaginal trichomoniasis in a 2-
Soc. Chile. Obst. Ginec., 25:367, 1960. month-old child. Obstet. Gynec., 21:354,
8. Komrowska, A., Kurnatowska, A., and Lin- 1963.
iecka, J. : Wystepowanie rzesistka pochwo- 18. Boggess, J. W., Jr. : Hypochlorhydria and
wego ( Trichomanas vaginalis Donne ) u achlorhydria in relation to recurrent Tn-
dziewczat w zaleznosci od warunkow chomonas vaginalis vaginitis. Med. Res.,
higieniczynch. Wiad. Parazyt., 8:247, 143:112, 1936.
1962. 19. Kean, B. H. : Urethral trichomoniasis in the
9. Glowinski, M., Golab, H., and Norska, I.: female, possible common denomination in
Zakazenie matki rzesistkiem pochwowym w recurrent Trichomonas vaginalis vaginitis
ciazy a wystepowanie rzesistka u nowo- and recurrent bacterial cystitis. Amer. J.
rodka. Wiad. Lek., 18:825, 1965. Obstet. Gynec., 70:397, 1955.
10. Littlewood, J. M., and Kohler, H. G. : Urinary 20. Lang, W. R., Fritz, M. A., and Menduke, H.:
tract infection by Trichomonas vaginalis in The bacteriologic diagnosis of trichomonal,
a newborn baby. Arch. Dis. Child., 41:693, candidal and combined infections. Obstet.
1966. Gynec., 20:788, 1962.
11. Bodnarenko, B. I. : A case of Trichomonas 21. Crowther, I. A. : Trichomonas vaginitis in in-
vulvovaginitis in the newborn. PediaL fancy. Lancet, 1 : 1074, 1962.

Downloaded from www.aappublications.org/news by guest on December 8, 2018

Neonatal Trichomonas Vaginalis : Report of Three Cases and Review of the Literature
Farouk L. Al-Salihi, John P. Curran and Jung-Shung Wang
Pediatrics 1974;53;196

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/53/2/196
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its
entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on December 8, 2018

Neonatal Trichomonas Vaginalis : Report of Three Cases and Review of the Literature
Farouk L. Al-Salihi, John P. Curran and Jung-Shung Wang
Pediatrics 1974;53;196

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/53/2/196

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1974 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on December 8, 2018