J Infect Chemother xxx (2017) 1e6

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Journal of Infection and Chemotherapy

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Original Article

Influence of co-infection complicated with human papillomavirus on

cervical intraepithelial neoplasia development in patients with
atypical squamous cells of undetermined significance
Hisami Kiseki a, *, Yutaka Tsukahara a, Natsumi Tajima b, Ayako Tanaka b, Aya Horimoto b,
Naohiko Hashimura a
a
Department of Obstetrics and Gynecology, Kohseichuo General Hospital, Tokyo, Japan
b
Department of Clinical Laboratory, Kohseichuo General Hospital, Tokyo, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Aim: Human papillomaviruses (HPV) infection is a primary cause of the development of cervical pre-
Received 7 April 2017 cancerous lesions and cervical cancer. However, the influence of other infections on intraepithelial
Received in revised form neoplasia (CIN) development has not been fully elucidated. We evaluated the association between co-
26 July 2017
infection and CIN development in subjects with atypical squamous cells of undetermined significance
Accepted 14 August 2017
(ASCUS).
Available online xxx
Method: Data for ASCUS subjects who had undergone testing for high risk HPV (HR-HPV) and patho-
logical diagnosis were analyzed. From the CIN grade, HR-HPV and vaginal infection (VI) data, both the
Keywords:
Atypical squamous cells of undetermined
relationship between HPV infection and CIN development and the influence of co-infection on CIN were
significance retrospectively evaluated.
Cervical intraepithelial neoplasia Results: Data for 56 ASCUS subjects who had undergone HR-HPV testing and cytological diagnosis were
Human papillomavirus analyzed. Positive rates were HPV (73.2%), HPV16 (21.4%), HPV18 (7.1%), and HPV16 and/or 18 (26.8%).
Vaginal infection Seventeen of the subjects were diagnosed as having one or more VI pathogen; the major pathogens
found were Candida spp., Gardnerella vaginalis, group B streptococcus, coagulase negative Staphylo-
coccus, and Chlamydia trachomatis. The rate of CIN 2 or worse (
CIN 2) was significantly higher in
subjects positive for HPV16 compared with HPV negative subjects, and was significantly higher in
subjects with a VI complicated with HPV compared to those without a VI. Univariate and multivariate
logistic regression analysis identified positive for HPV16 and/or 18 and positive for VI to be significant
variables for
CIN 2.
Conclusion: Our results indicate that having a vaginal infection complicated with HR-HPV affects the
development of CIN in subjects with ASCUS cytology.
© 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases.
Published by Elsevier Ltd. All rights reserved.

1. Introduction undetermined significance (ASCUS) for cervical cancer screening

High-risk human papillomaviruses (HR-HPV) infection is a pri-
mary cause of the development of cervical precancerous lesions
and cervical cancer [1e3]. According to the 2001 Bethesda System,
the current standard diagnostic criteria for cervical cytology that is
followed in Japan, the United States, and Europe, HR-HPV testing is
recommended for cases of atypical squamous cells of
* Corresponding author. Department of Obstetrics and Gynecology, Kohseichuo
General Hospital, 1-11-7 Mita, Meguro-ku, Tokyo, Japan.
E-mail address: chamy0503@jcom.home.ne.jp (H. Kiseki).
[4e8]. The ATHENA (Addressing the Need for Advanced HPV Di-
agnostics) study conducted in the United States reported that the
absolute risk (AR) for high grade cervical intraepithelial neoplasia
(
CIN2) were 14.0% and 31.5% in ASCUS subjects testing positive for
HR-HPV or HPV 16, respectively [9]. On the other hand, zur Hausen
et al. and others have reported that HR-HPV infection is an
important factor but not the sole cause of cervical cancer [10,11].
Several reports have indicated that other infections complicated
with HPV associate with CIN development via inflammatory
response, immune alteration, or genomic alteration [11e16].
However, the relationship between CIN development and co-

http://dx.doi.org/10.1016/j.jiac.2017.08.008
1341-321X/© 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kiseki H, et al., Influence of co-infection complicated with human papillomavirus on cervical intraepithelial
neoplasia development in patients with atypical squamous cells of undetermined significance, J Infect Chemother (2017), http://dx.doi.org/
10.1016/j.jiac.2017.08.008
2 H. Kiseki et al. / J Infect Chemother xxx (2017) 1e6

infection has not been fully elucidated. In this study, we retro-
spectively investigated the association between co-infection
complicated with HPV and CIN grade in subjects with ASCUS
cytology who had undergone HR-HPV testing.
2. Patients and methods
2.1. Patients
Data for ASCUS subjects who had undergone HR-HPV testing
and pathological diagnosis from January 2014 to July 2015 at
Kohseichuo General Hospital in Tokyo were collected. Data for
subjects who had suffered a total hysterectomy were excluded. This
study was conducted in accordance with the ethical principle of the
Declaration of Helsinki and was approved by the institutional re-
view board of Kohseichuo General Hospital.
samples were stained using hematoxylin-eosin (HE), and a defini-
tive diagnosis was performed by two independent pathologists.
Samples from subjects who had increased vaginal discharge,
discomfort in external genitalia, or other symptoms of infection
were tested. All specimens were first cultured on blood agar and
chocolate agar and tested using ID test HN-20 Nissui (Nissui
Pharmaceutical Co., Ltd. to identify Corynebacterium, E. coli, and
Enterococcus. GV, GBS, and CNS were identified by an additional
culture test using Gardnerella agar® (SYSMEX bioMerieux Co., Ltd.),
Seroiden Strepto Kit Eiken® (Eiken Chemical Co., Ltd.), and USAGI
plasma Eiken® (Eiken Chemical Co., Ltd.), respectively. Chlamydia
trachomatis was identified by PCR using cobas® 4800 system CT/NG
(Roche Diagnostics). Gonorrhoeae was identified by using the
Thayer-Martin agar HN-20 Nissui culture test. Candida was iden-
tified by culture test using CHROM agar® (Kanto Kagaku). Herpes
was identified by EIA using HSV IgG (SRL).

2.2. Methods 2.3. Statistics

From the data of the study population, CIN grade, HR-HPV and Descriptive statistics were expressed as n (%), median [inter-
vaginal infection (VI) were examined. The relationship between quartile range]. A chi-square test or Fisher's exact test was per-
HPV infection and CIN development and the influence of co- formed for comparisons of the categorical variables. Factors
infection on CIN were retrospectively evaluated. influencing
CIN 2 were evaluated using univariate and multi-
variate logistic analysis; age, HPV16/18 infection, HPV other in-
2.2.1. HPV infection and CIN fections, and VI were used as independent variables. The alpha was
To evaluate the relationship between HPV infection and CIN, the set at 0.05 and all p values were two-sided. Statistics was
absolute risks (ARs) for CIN 2 and CIN 3 were calculated according
to HR-HPV genotypes, and the composition ratios of HPV genotypes
according to CIN grade were determined. In addition, we compared Table 1
Patient characteristics.
the rates of subjects with <CIN 2 and
CIN 2 between subjects with
HR-HPV negative (HPV) and those with HPV positive (HVPþ) n 56
according to genotype: HPV16, HPV18, 12 other HPV genotypes Age, median [inter quartile range] 33.5 [28.25, 41.0]
Age group, n (%)
(HPV 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) (HPV other),
 30 19 (33.9%)
and HPV16 and/or 18. 31e40 22 (39.3%)

40 15 (26.8%)
2.2.2. Influence of co-infection on CIN development HR-HPVa screening, n (%)
The rates of
CIN 2 were compared between the presence and HPV 15 (26.8%)
HPVþ 41 (73.2%)
absence of a VI complicated with HPV infection. To evaluate the i. HPV16þ/18/other 5 (8.9%)
influence of a VI on CIN development, the odds ratios of age, HPV, ii. HPV16þ/18þ/other 1 (1.8%)
and VI for
CIN 2 were calculated using univariate and multivar- iii. HPV16þ/18/otherþ 6 (10.7%)
iate logistic regression analysis. A positive VI (VIþ) designation iv. HPV16/18þ/other 1 (1.8%)
v. HPV16/18þ/otherþ 2 (3.6%)
included testing positive for Gardnerella vaginalis (GV), Group B
vi. HPV16/18/otherþ 26 (46.4%)
streptococcus (GBS), coagulase negative staphylococcus (CNS), HPV16þ: i, ii, iii 12 (21.4%)
Corynebacterium sp. (Corynebacterium), Escherichia coli (E. coli), HPV18þ: ii, iv, v 4 (7.1%)
Enterococcus sp. (Enterococcus), Chlamydia trachomatis (chla- HPV16 þ and/or 18þ: i, ii, iii, v, vi 15 (26.8%)
mydia), Neisseria gonorrhoeae (gonorrhoeae), Candida spp. HPV other þ: iii, v, vi 34 (60.7%)
VIb infection, n (%)
(candida), or genital herpes (herpes). VI 39 (69.6%)
VIþ 17 (30.4%)
2.2.3. Diagnostic methodology Bacterial infection
The cytological results were classified according to the 2001 Bacteria 46 (82.1%)
Bacteriaþ 10 (17.9%)
Bethesda System [4]. HR-HPV testing and pathological diagnosis
GVþ 5 (8.9%)
were performed according to the Clinical Guidelines for Obstetrical GBSþ 4 (7.1%)
Practice in Japan, revised in 2017 [5]. Cytology samples from cer- CNSþ 3 (5.4%)
vical and vaginal tissue and endocervical material using a sterilized Corynebacteriumþ 2 (3.6%)
cyto-pick were collected and stained using the Papanicolaou (PAP) E.coliþ 1 (1.8%)
Enterococcusþ 1 (1.8%)
staining method after fixing with alcohol (conventional method). STDc infection
Definitive cytological diagnosis was performed by three indepen- STD 52 (92.9%)
dent cytologists using samples screened by two independent STDþ 4 (7.1%)
cytoscreeners. Chlamydiaþ 3 (5.4%)
Gonorrhoeaeþ 1 (1.8%)
HR-HPV infection including HPV16, HPV18, and HPV other was
Other infection
examined using the cobas 4800 HPV test® (Roche Diagnostics) Candidaþ 8 (14.3%)
using cervical samples collected using the same method as for Herpesþ 1 (1.8%)
cytology in subjects with ASCUS cytology within two weeks of their a
High-risk human papillomavirus.
diagnosis. A punch biopsy was performed within four weeks of the b
Vaginal infections (bacterial infection, STD, or other infections).
initial visit using colposcopy in HPV þ subjects. Pathological c
Sexually transmitted disease.

Please cite this article in press as: Kiseki H, et al., Influence of co-infection complicated with human papillomavirus on cervical intraepithelial
neoplasia development in patients with atypical squamous cells of undetermined significance, J Infect Chemother (2017), http://dx.doi.org/
10.1016/j.jiac.2017.08.008
 H. Kiseki et al. / J Infect Chemother xxx (2017) 1e6 3

Table 2
Absolute risk for CIN by HPV genotype.

CINa
2 CIN 3

No. of patients ARb [95%CI] No. of patients AR [95%CI]

All patients 11/56 19.6 [11.3e31.8] 3/56 5.4 [1.8e14.6]

HPVc 2/15 13.3 [3.7e37.9] 0/15 0 [0e20.4]
HPVþ 9/41 22 [12e36.7] 3/41 7.3 [2.5e19.4]
i. HPV16þ/18/other 3/5 60 [23.1e99.2] 1/5 20 [3.6e62.4]
ii. HPV16þ/18þ/other 0/1 0 [0e79.3] 0/1 0 [0e79.3]
iii. HPV16þ/18/otherþ 3/6 50 [18.8e81.2] 1/6 16.7 [3e56.4]
iv. HPV16/18þ/other 0/1 0 [0e79.3] 0/1 0 [0e79.3]
v. HPV16/18þ/otherþ 0/2 0 [0e65.8] 0/2 0 [0e65.8]
vi. HPV16/18/otherþ 3/26 11.5 [4e29] 2/26 7.7 [2.1e24.1]
HPV16þ: i, ii, iii 6/12 50 [25.4e74.6] 2/12 16.7 [4.7e44.8]
HPV18þ: ii, iv, v 0/4 0 [0e49] 0/4 0 [0e49]
HPV16 þ and/or 18þ: i, ii, iii, iv, v 6/15 40 [19.8e64.3] 2/15 13.3 [3.7e37.9]
HPV otherþ: iii, v, vi 6/34 17.6 [8.3e33.5] 2/34 5.9 [1.6e19.1]
a
Cervical intraepithelial neoplasia.
b
Absolute risk.
c
High-risk human papillomavirus.

performed using JMP, Version 12.0 (SAS Institute Inc., Cary, NC, 13.3% and 22.0%, respectively; The AR for
CIN 2 by genotype were
USA) software. 50.0%, 40.0%, and 17.6% for HPV16þ, HPV16 and/or 18þ, and HPV
otherþ, respectively. Table 3 shows CIN grades and HR-HPV infec-
3. Results tion status. The rates for
CIN 2 were significantly higher in
HPV16 þ subjects compared to HPV subjects (p ¼ 0.0381). In the
3.1. Patients characteristics evaluation of the combinations of HPV genotypes, significant dif-
ference was found in the rates of
CIN 2 between HPV and
Of the 4724 women who underwent cervical cytology from HPV16þ/18/other (p ¼ 0.0369). No significant differences were
January 2014 to July 2015, 377 showed ASCUS, 151 of which had found in the rates for
CIN 2 in the comparisons between other
undergone HR-HPV testing. Cervical biopsy was performed in 56 of groups. Fig. 1 shows the CIN grade and composition ratios of HPV
the 151 subjects. Table 1 shows the patient characteristics. The genotypes. The composition ratios of subjects with HPV16 þ and
median age was 33.5 y.o.; positive rates for HPVþ, HPV16, HPV18, HPV16 þ and/or 18 þ increased as CIN grade rose as shown by data
HPV16 and/or 18 were 73.2%, 21.4%, 7.1%, and 26.8%, respectively. for HPV16 þ as follows: CIN (10.5%), CIN 1 (15.4%), CIN 2 (50.0%),
One or more VI pathogen was found in 17 patients, the major ones and CIN 3 (66.7%) and for HPV16 þ and/or 18 þ as follows: CIN
being Candida (n ¼ 8, 14.3%), GV (n ¼ 5, 8.9%), GBS (n ¼ 4, 7.1%), CNS (10.5%), CIN 1 (26.9%), CIN 2 (50.0%), and CIN 3 (66.7%).
(n ¼ 3, 5.4%), and Chlamydia (n ¼ 3, 5.4%).
3.1.2. Influence of VI for CIN
3.1.1. HPV infection and CIN Table 4 shows the rates of <CIN2 and
CIN 2 according to the
Eleven subjects (19.6%) out of 56 were found to have
CIN 2 presence or absence of VI in subjects with the same HPV genotype
(Table 2). The AR of
CIN 2 for HPV and HPV þ subjects were infection. The rate of
CIN 2 was significantly higher in subjects
with VI complicated with HPV compared with those without VI
Table 3 (p ¼ 0.0498). Although no significant difference was found, the rate
CIN grade and HR-HPV infection status.
of
CIN 2 was relatively higher in subjects with VI complicated
n <CINa 2, n (%)
CIN 2, n (%) p with HPV16 þ and/or 18 þ compared with those without VI
Total 56 45 (80.4%) 11 (19.6%) (p ¼ 0.0889). Univariate analysis showed that having HPV16 þ and/
HPVb 15 13 (86.7%) 2 (13.3%) 0.4722 or 18 þ was the only significant variable for
CIN 2. However,
HPV+ 41 32 (78.0%) 9 (22.0%) multivariate analysis showed that both HPV16 þ and/or 18 þ and VI
HPV 15 13 (86.7%) 2 (13.3%) 0.0369
were significant variables for
CIN 2, and adjusted odds ratios
i. HPV16+/18/other 6 3 (50.0%) 3 (50.0%)
HPV 15 13 (86.7%) 2 (13.3%) 1.0000 for
CIN 2 were 6.78 (p ¼ 0.0147) for HPV16 þ and/or 18 þ and
ii. HPV16+/18+/other 1 1 (100.0%) 0 5.56 (p ¼ 0.0282) for VIþ (Table 5).
HPV 15 13 (86.7%) 2 (13.3%) 0.0747
iii. HPV16+/18/other+ 6 3 (50.0%) 3 (50.0%)
HPV 15 13 (86.7%) 2 (13.3%) 1.0000 4. Discussion
iv. HPV16/18+/other 1 1 (100.0%) 0
HPV 15 13 (86.7%) 2 (13.3%) 1.0000 We evaluated the influence of co-infection with HR-HPV and VI
v. HPV16/18+/other+ 2 2 (100.0%) 0 on the development of CIN in subjects with ASCUS cytology. The
HPV 15 13 (86.7%) 2 (13.3%) 0.8657
vi. HPV16/18/other+ 26 23 (88.5%) 3 (11.5%)
rate of
CIN 2 was significantly higher in HPV16 þ subjects
HPV 15 13 (86.7%) 2 (13.3%) 0.0381 compared with HPV subjects and was significantly higher in
HPV16+: i, ii, iii 12 6 (50.0%) 6 (50.0%) VI þ subjects complicated with HPV compared with those without
HPV 15 13 (86.7%) 2 (13.3%) 1.0000 VI. Multivariate logistic analysis identified that HPV16 þ and/or
HPV18+: ii, iv, v 4 4 (100.0%) 0
18 þ and VI were significant variables for
CIN 2.
HPV 15 13 (86.7%) 2 (13.3%) 0.0986
HPV16+ and/or 18+: i, ii, iii, iv, v 15 9 (60.0%) 6 (40.0%) The AR for
CIN 2 was found to be 22.0%, 50.0%, and 40.0% for
HPV 15 13 (86.7%) 2 (13.3%) 0.7065 subjects with HPVþ, HPV16þ, and HPV16 þ and/or 18þ, respec-
HPV other+: iii, v, vi 34 28 (82.4%) 6 (17.6%) tively. In the ATHENA study, ARs for
CIN 2 were 14.0%, 31.5%, and
a
Cervical intraepithelial neoplasia. 24.4% for subjects with HPVþ, HPV16þ, and HPV16 þ and/or 18þ,
b
High-risk human papillomavirus. respectively [9]. In the present study, the ARs were found to be

Please cite this article in press as: Kiseki H, et al., Influence of co-infection complicated with human papillomavirus on cervical intraepithelial
neoplasia development in patients with atypical squamous cells of undetermined significance, J Infect Chemother (2017), http://dx.doi.org/
10.1016/j.jiac.2017.08.008
4 H. Kiseki et al. / J Infect Chemother xxx (2017) 1e6

Fig. 1. CIN grade and composition ratios of HPV genotypes. CIN, cervical intraepithelial neoplasia; HPV, high-risk human papillomavirus.

relatively higher than those reported by the ATHENA study. The

Table 4 subjects enrolled in this study were required to undergo patho-
CIN grade and co-infection status. logical diagnosis according to cytodiagnosis results. Thus, the study
n <CINa 2, n (%)
CIN 2, n (%) p population data might result in relatively higher ARs. However,
Total 56 45 (80.4%) 11 (19.6%)
previous reports showed that rates of
CIN 2 in ASCUS patients
HPVbþ: with HPV16 þ and/or 18 þ were from 17.0% to 43.0% [9,17,18] and
c
VI  29 25 (86.2%) 4 (13.8%) 0.0498 our results were within the reported ranges. In addition, as
VIþ 12 7 (58.3%) 5 (41.7%) mentioned above, the composition ratios of HPV16 þ and/or
i. HPV16þ/18/other
18 þ increased relative to rise in CIN grade and the proportions
VI 2 2 (100%) 0 1.0000
VIþ 3 0 3 (100%) were similar to those previously reported [9]. Thus, we considered
ii. HPV16þ/18þ/other the study subjects reflect the general population of ASCUS patients
VI 1 1 (100%) 0 e and were not a biased population.
VIþ 0 0 0 Previous reports have shown a relationship between HPV and
iii. HPV16þ/18/otherþ
VI 4 2 (50%) 2 (50%) 1.0000
candida [11,19e23], chlamydia [19e24], herpes [10], or gonor-
VIþ 2 1 (50%) 1 (50%) rhoeae [25]. In addition, an association between vaginal microbiota
iv. HPV16/18þ/other and HPV infection or subsequent development of CIN have been
VI 1 1 (100%) 0 e reported [26e28]. GV [23,29], GBS [30e32], CNS [33], Corynebac-
VIþ 0 0 0
terium [34], E. coli [34,35], and Enterococcus [36] and were sug-
v. HPV16/18þ/otherþ
VI 2 2 (100%) 0 e gested to have an effect on vaginal microbiota. Therefore, we
VIþ 0 0 0 investigated the comprehensive influence of the abovementioned
vi. HPV16/18/otherþ pathogenic microbes on CIN development. Multivariate logistic
VI 19 17 (89.5%) 2 (10.5%) 0.7901 analysis identified a diagnosis of VI to be a significant variable
VIþ 7 6 (85.7%) 1 (14.3%)
HPV16þ: i, ii, iii
for
CIN 2. The following two mechanisms are presumed to have
VI 7 5 (71.4%) 2 (28.6%) 0.2424 an association between VI and CIN development. One is that HPV
VIþ 5 1 (20%) 4 (80%) infections or VI lead to increased susceptibility to another infection.
HPV18þ: ii, iv, v The other is that co-infection of HPV and another pathogen coop-
VI 4 4 (100%) 0 e
eratively affects the development of CIN. Previous reports have
VIþ 0 0 0
HPV16 þ and/or 18þ: i, ii, iii, iv, v shown that there is a significant association between HPV and
VI 10 8 (80%) 2 (20%) 0.0889 Candida infections [19e23]. Although no mechanism has been
VIþ 5 1 (20%) 4 (80%) established, some pathogenic and virulent species of Candida are
HPV otherþ: iii, v, vi known to cause protein degradation and enhance antigenic
VI 25 21 (84%) 4 (16%) 0.6746
response leading to mucosal injury and endogenous invasion [10].
VIþ 9 7 (77.8%) 2 (22.2%)
a
Regarding chlamydia infection, Samoff et al. reported that, if a cell is
Cervical intraepithelial neoplasia.
b infected with Chlamydia trachomatis, entry of HPV to the basal layer
High-risk human papillomavirus.
c
Vaginal infection (GV, GBS, CNS, Corynebacterium, E. coli, Enterococcus, chla- is facilitated by microscopic epithelial injuries. As the HPV viral
mydia, gonorrhoeae, or herpes). particles accumulate, derangement of the host immunity occurs,

Please cite this article in press as: Kiseki H, et al., Influence of co-infection complicated with human papillomavirus on cervical intraepithelial
neoplasia development in patients with atypical squamous cells of undetermined significance, J Infect Chemother (2017), http://dx.doi.org/
10.1016/j.jiac.2017.08.008
 H. Kiseki et al. / J Infect Chemother xxx (2017) 1e6 5

Table 5
Odds ratios for
CIN 2.
Unadjusted Adjusted
Odds ratio [95% CI] p Odds ratio [95% CI] p
Age (/years old) 1.05 [0.97e1.12] 0.2081 1.07 [0.99e1.17] 0.0907
HPVa16 þ and/or 18þ 4.80 [1.20e20.40] 0.0270 6.78 [1.45e39.60] 0.0147
HPV otherþ 0.73 [0.19e2.87] 0.6422 1.17 [0.26e5.83] 0.8357
VIbþ 3.71 [0.95e13.31] 0.0599 5.56 [1.20e31.44] 0.0282
a
High-risk human papillomavirus.
b [8] Wright Jr TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. 2006
Vaginal infection (GV, GBS, CNS, Corynebacterium, E. coli, Enterococcus, chla-
mydia, gonorrhoeae, or herpes).
manifested by a shift in the immune response from T-helper cell
type I which has been reported to be important in the clearance of
HPV lesions to T-helper cell type II [24]. As mentioned above, many
reports have shown a relationship between HPV infection and
other pathogenic microbes. Thus, the infectious milieu caused by a
single infection may serve as a gateway for infection from other
pathogens. Other reports have shown that co-infection of HPV and
other pathogens leads to the development of cervical neoplasia
[11,22]. Chumduri et al. reported that, as a result of the disturbance
and the influence of persistent infection, cells escape the control of
the cell signaling mechanisms, which can lead to neoplastic change
[37]. Several reports have shown that Chlamydia infection affects
tumorigenesis by causing host genomic abnormality [12e14,37].
Regarding persistent infection, Kojima et al. reported that the
number of intraepithelial integrin aEb7þ T cells in cervical mucosa
associates with spontaneous regression of CIN [38]. These reports
indicate that co-infection may affect CIN development via cervical
mucosal immunity change leading to persistent infection and
tumorigenesis. The above indicates that VIs affect CIN development
via transmissibility, mucosal immunity, and/or infection
persistency.
The present study has several limitations. First, this is a retro-
spective study and it is impossible to eliminate all confounding
factors and bias. Second, the number of patients is small and the
statistical analysis was restricted. Third, the VI in the subjects
included various pathogens and, thus, analysis was restricted to
evaluate the effect of a specific pathogen. The results of this study
need to be interpreted with consideration of the above.
5. Conclusion
Our results indicate that vaginal infections complicated with
HR-HPV affects CIN development in subjects with ASCUS cytology.
Conflicts of interest
The authors declare that there are no conflicts of interests.
Acknowledgments
The authors would like to thank Tetsuhiko Yokoyama at AMY
Information and Planning for providing supporting statistics.
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Please cite this article in press as: Kiseki H, et al., Influence of co-infection complicated with human papillomavirus on cervical intraepithelial
neoplasia development in patients with atypical squamous cells of undetermined significance, J Infect Chemother (2017), http://dx.doi.org/
10.1016/j.jiac.2017.08.008