key: cord-0902827-z5m93gfe authors: Ondič, Ondrej; Černá, Kateřina; Kinkorová‐Luňáčková, Iva; Němcová, Jana; Mejchar, Bořivoj; Chytra, Jan; Bouda, Jiří title: SARS‐CoV‐2 RNA may rarely be present in a uterine cervix LBC sample at the asymptomatic early stage of COVID 19 disease date: 2021-05-31 journal: Cytopathology DOI: 10.1111/cyt.12995 sha: e9fdaef6629b1a81dc2d7af2c85324ac65ef4e73 doc_id: 902827 cord_uid: z5m93gfe OBJECTIVE: Currently, it is thought that uterine cervix mucosal samples present a low risk of SARS‐CoV‐2 exposure. So far, there is no evidence of SARS‐CoV‐2 detection in Papanicolaou (Pap) smears. Nevertheless, clinicians could be exposed unaware to the coronavirus while performing and handling a Pap smear. We aimed to retrospectively evaluate the presence of SARS‐CoV‐2 RNA in cervical liquid‐based cytology (LBC) samples in women who tested positive for a nasopharyngeal COVID‐19 PCR test. METHODS: From our laboratory database, we identified patients with data on a cervical cancer screening LBC sample paired with a positive nasopharyngeal COVID‐19 PCR test. Relevant LBC samples taken within an incubation period of 14 days and post‐onset RNA shedding interval of 25 days were subsequently tested for SARS‐CoV‐2 RNA using RT‐PCR tests. RESULTS: The study group consisted of 102 women. Of those, 23 LBC samples were tested. SARS‐CoV‐2 RNA was detected in one LBC sample from a 26‐year‐old asymptomatic woman taken six days before reporting headaches and knee arthralgia with a positive nasopharyngeal SARS‐CoV‐2 RT‐PCR test. CONCLUSIONS: It is possible to detect SARS‐CoV‐2 RNA in cervical LBC samples at an early asymptomatic stage of COVID‐19. In general, this finding is infrequent in asymptomatic women who tested SARS‐CoV‐2 positive within an incubation of 14 days and a post‐onset RNA shedding period of 25 days. We fully support the current thinking that cervical LBC samples from asymptomatic women pose a low risk of SARS‐CoV‐2 exposure and can be handled in the frame of good microbiological practice and procedures. bronchoscopic samples, blood, teardrops) and an intermediate-risk group (pleural and pericardial effusion, urine), with all the other specimens falling into a low-risk category. Currently, uterine cervix mucosal samples are considered to present a low risk of SARS-CoV-2 exposure. 8 So far, there is no evidence of SARS-CoV-2 detection in Pap smears. Nevertheless, clinicians, nurses, and cytotechnologists could be unaware that they were exposed to coronavirus while performing and handling a Pap smear. To the best of our knowledge, the infectious potential of Pap smears has not been studied yet. We aimed to retrospectively evaluate the presence of SARS-CoV-2 RNA in cervical LBC samples in women whose nasopharyngeal swabs tested positive for SARS-CoV-2. At Biopticka laboratory we performed a cross-search of the Pap smear database with a regular yearly workload of some 800 000 tests and the COVID-19 PCR test database with more than 155 000 tests performed, peaking at 3522 tests per day on 23 October 2020 (overall positivity rate 21.8%). Patients with a cervical cancer screening liquid-based cytology (LBC) sample taken from 01 October 2020 to 19 November 2020 and paired with a recorded positive COVID-19 PCR test were identified. LBC was evaluated using the ThinPrep Imaging system with Image processor (Hologic). The study was performed with the approval of the local ethical committee. Nasopharyngeal swabs (COVID-19 PCR test) were taken by trained staff at a dedicated sampling room using a collection kit containing a flexible brush, and virus transport and preservation medium (Biologix). The viral RNA from the sample was isolated from 300 µL of the media using a Maxwell® RSC Viral Total Nucleic Acid Purification kit on a Maxwell automated system (Promega). Real-time PCR detection of the SARS-CoV-2 virus was performed on a CFX96 ™ detection system using Allplex™ SARS-CoV-2 Assay (Seegene, South Of all cases, only those presenting with a biologically relevant time interval between cervical and nasopharyngeal sampling determined by incubation and post-onset RNA shedding period were analysed. An incubation period's exact time interval was set to 14 days following the recommended safety limit suggested by Backer et al based upon the actual calculated incubation period of 2.11-11.1 days. 11 The time interval of 25 days for possible postonset RNA shedding was based on Liu et al, who reported that mild cases were found to have an early viral clearance, with 90% of these patients repeatedly testing negative on RT-PCR by day ten post-onset. In severe cases, they observed the RNA shedding as late as day 25 post-onset. 12 We identified 102 women aged 20 to 64 years with data on To the best of our knowledge, this is the first dedicated study reporting the presence of SARS-CoV-2 RNA in a Pap test sample. The RNA of SARS-CoV-2 has frequently been detected in some human tissues and body fluids, including the upper and lower respiratory tract, teardrops, blood, faeces, and perianal skin. Likewise, but less frequently, it has been found in pleural and pericardial effusions and urine. [13] [14] [15] [16] [17] It has rarely been reported in ascites, 18 cerebrospinal fluid, 19 semen, 20 and maternal milk. 21 Of interest, maternofoetal transmission of some other human coronaviruses has been reported. 22 If not paired with virological in vitro study, isolated interpretation of all the above-mentioned findings is equivocal. Likewise, the TA B L E 1 Regular cervical cancer screening liquid-based cytology (LBC) samples from 23 women taken 2 to 10 d before or 8 to 14 d after SARS-CoV-2 positive nasopharyngeal swab test using RT-PCR method Positive cervical LBC sample is highlighted in red. detection of SARS-CoV-2 RNA in the LBC Pap test sample presented by this study does not equate to detecting a viable virus with infectious potential. 23 To limit possible SARS-CoV-2 exposure, high-grade ethanol should be added to any non-ethanol-based fixation medium when handling pulmonary and oral LBC samples that fall into a high-risk category. [8] [9] [10] This approach is not warranted in the case of low-risk samples, including PreservCyt-containing vials for cervical LBC. 8 We sincerely appreciate the daily efforts of members of our COVID-19 testing team. Also, we are grateful for our colleagues' assistance at the IT department, who continuously lend us their expertise and kindly supported this project. The authors have no conflicts of interest to declare. The data that support the findings of this study are available from the corresponding author upon reasonable request. Ondrej Ondič https://orcid.org/0000-0002-4038-5641 Global impact of the COVID-19 pandemic on cytopathology practice: results from an international survey of laboratories in 23 countries Impact of the COVID-19 pandemic on cytology practice: an international survey in the Asia-Pacific region Impact of COVID-19 pandemic on functioning of cytopathology laboratory: Experience and perspective from an academic centre in New York Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases European Centre for Disease Prevention and Control. Infection prevention and control and preparedness for COVID-19 in healthcare settings -Sixth update CEN Workshop AGREEMENT. CWA 15793 -Laboratory biorisk management Interventional cytopathology in the COVID-19 era Biosafety in the preparation and processing of cytology specimens with potential coronavirus (COVID-19) infection: perspectives from Taiwan Cytologic and histologic samples from patients infected by the novel coronavirus 2019 SARS-CoV-2: An Italian institutional experience focusing on biosafety procedures Juggling the COVID-19 pandemic: a cytopathology point of view Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China Viral dynamics in mild and severe cases of COVID-19 Clinical and virological data of the first cases of COVID-19 in Europe: a case series Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy: a two-centre descriptive study Viral presence and immunopathology in patients with lethal COVID-19: a prospective autopsy cohort study Pulmonary pathology and COVID-19: lessons from autopsy. The experience of European Pulmonary Pathologists Post-mortem viral dynamics and tropism in COVID-19 patients in correlation with organ damage SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients Cerebrospinal fluid features in patients with coronavirus disease 2019 and neurologic manifestations: correlation with brain magnetic resonance imaging findings in 58 patients A systematic review on the investigation of SARS-CoV-2 in semen Detection of SARS-CoV-2 in milk from COVID-19 positive mothers and follow-up of their infants Materno-fetal transmission of human coronaviruses: a prospective pilot study Understanding COVID-19: what does viral RNA load really mean? Additional supporting information may be found online in the Supporting Information section. How to cite this article SARS-CoV-2 RNA may rarely be present in a uterine cervix LBC sample at the asymptomatic early stage of COVID 19 disease