Answer: Giardia intestinalis (lamblia, duodenalis) cysts
This was a very fun case because the finding of Giardia cysts was completely unexpected. As mentioned in the history, this patient was being evaluated by an anal pap smear due to the presence of papular anal lesions which were clinically thought to be condyloma accumulatum (genital warts, caused by human papillomavirus or HPV).
Patients that have anal-receptive intercourse are at known risk for HPV associated lesions, dysplasia, and malignancy, and therefore screening for HPV-associated cytopathologic changes is commonly performed. As noted by MicrobeMan and Anonymous, there were some atypical appearing cells (such as the large bi-nucleated pink structure in the center of the slide) indicating that there were some HPV changes present in this case.
This case was signed out as "Squamous Epithelial Cell Abnormality. Atypical squamous cells of undetermined significance. Organisms consistent with Giardia intestinalis."
Of note, the patient denied any gastrointestinal symptoms including diarrhea. So the giardiasis appears to be an incidental finding!
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