Lindsay H. Morrell
History of present illness
A 30-year-old gravida 2, para 2 woman presented with com- plaint of 3 days of vaginal pruritis and discharge. She describes the discharge as white and thick. She has not had symptoms like this before and has not used any over-the- counter medications to attempt to relieve her symptoms. She is sexually active with one partner and uses condoms irregu- larly. Her last menstrual period was seven days prior to presentation. She has a history of chlamydia five years prior, which was treated. She has no other history of sexually transmitted infections.
She has type 2 diabetes mellitus that is controlled with metformin. She takes no other medications. She has no other medical problems.
Physical examination
General appearance:Well-appearing woman in no apparent distress
Vital signs:
Temperature: 37.0°C Pulse: 86 beats/min
Blood pressure: 133/68 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 100% on room air BMI: 33 kg/m2
HEENT:Unremarkable Neck:Supple
Cardiovascular:Regular rate and rhythm without murmurs, rubs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, obese, nontender, nondistended, no inguinal adenopathy
Pelvic:
Speculum: Thick lumpy white discharge coating vaginal sidewalls (Fig. 9.1), no cervicitis or mucopurulent discharge, no blood in vault
Bimanual: No cervical motion tenderness or adnexal masses, uterus small, mobile, anteverted
Extremities:No clubbing, cyanosis, or edema Neurologic:Nonfocal
KOH prep:Was performed (Fig. 9.2). Saline wet mount did not show clue cells or trichomonads
Vaginal pH:4.0
How would you manage the patient?
This patient had uncomplicated vaginal candidiasis. This patient was prescribed miconazole 4% cream intravaginally for 3 days. Her pruritis and vaginal discharge improved.
Vaginitis
Vaginitis is a common reason for seeking care. The differential diagnosis for a patient that presents with complaints of abnor- mal discharge includes trichomonas, vulvovaginal candidiasis, bacterial vaginosis, gonorrhea, chlamydia and physiologic discharge. Vulvovaginal candidiasis accounts for 17–39% of vaginitis [1], and it’s estimated that 75% of sexually active women will have vulvovaginal candidiasis at least once in their lifetime [2]. The most common organism causing vulvovaginal candidiasis isCandida albicans, which causes more than 90%
of cases [2,3]. The remaining 10% of cases are caused by
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 9.1 Speculum examination of patient with symptomatic vaginal discharge.
Note the thick white curd-like discharge adherent to the vaginal sidewalls.
nonalbicans Candida sp., most commonly Candida glabrata.
More rare species include Candida parapsilosis, Candida tro- picalis, andCandida krusei[2].
Signs and symptoms include pruritis, vaginal burning, dyspareunia, external dysuria and abnormal discharge. On physical examination, vulvar or vaginal erythema and edema, as well asfissures and excoriations may be present [4]. Specu- lum examination typically reveals thick white curd-like dis- charge that coats the vaginal sidewall and cervix. Symptoms and signs can vary significantly, and many patients do not have the classic curd-like discharge.
Mycolic diagnosis is made by collecting a sample of dis- charge during a pelvic examination and applying 10% KOH solution. Applying KOH solution results in lysis of epithelial cells and bacteria, making yeast more easily identifiable on the
slide. A saline wet mount can also show yeast, though visual- ization may be more difficult. Microscopy shows budding yeast or branching pseudohyphae. Vaginal pH is typically normal (<4.5). The diagnosis is confirmed in a symptomatic patient by a KOH or saline wet mount that demonstrates yeast, hyphae, or pseudohyphae [4]. A yeast culture may be con- sidered in a symptomatic patient with a negative wet mount and no other identifiable cause. Cultures can also useful in cases of candidiasis refractory to standard treatments. Cultures should not be sent in asymptomatic women since yeast can be part of the normal vaginal flora in 10–20% of women [4].
A negative culture rules out yeast as a cause.
The Centers for Disease Control and Prevention (CDC) classifiesCandidainfections as complicated and uncomplicated [4]. Most cases of vaginal candidiasis are uncomplicated. Cases are typically considered uncomplicated if they are sporadic or infrequent, occurring three or less times in a year. Symptoms tend to be mild to moderate. In uncomplicated cases, patients are not immunocompromised and the organism causing the vaginitis is likelyC. albicans[4]. Uncomplicated vaginal candi- diasis typically responds well to topical azole therapy for treat- ment (Table 9.1). The recommended treatment of vulvovaginal candidiasis in pregnancy is topical azoles for seven days.
Cases are considered complicated if they are recurrent (four or more episodes per year), or the patient has severe symptoms.
They often involve nonalbicans species. Vulvovaginal infections occurring in women with uncontrolled diabetes, debilitation, or immunosuppression are also classified as complicated. Compli- cated infections occur in less than 5% of women. Yeast culture should be sent in complicated infections to confirm the diagno- sis and to assist in determining the treatment. While this patient had diabetes, it was well controlled and this was herfirst episode of candidiasis. Culture was not indicated, and management as uncomplicated candidiasis is appropriate.
Table 9.1 Treatment of uncomplicatedCandida vaginitis*
Drug Formulation Application
OTC intravaginal agents
Butoconazole 2% Vaginal cream, 5 g Intravaginally for 3 days
Clotrimazole 1% Vaginal cream, 5 g 2% Vaginal cream, 5 g
Intravaginally for 7–14 days Intravaginally for 3 days
Miconazole 2% Vaginal cream, 5 g 4% Vaginal cream, 5 g 100 mg Vaginal supp.
200 mg Vaginal supp.
1200 mg Vaginal supp.
Intravaginally for 7 days
Intravaginally for 3 days
1 Supp. daily for 7 days
1 Supp. daily for 3 days
1 Supp., once Tioconazole 6.5% Vaginal ointment,
5 g 1 App. vaginally,
once Prescription intravaginal agents
Butoconazole 2% Vaginal cream, single dose bioadhesive product, 5 g
Intravaginally for 1 day
Nystatin 100 000 U Vaginal tablet 1 Tablet daily for 14 days Terconazole 0.4% Vaginal cream, 5 g
0.8% Vaginal cream, 5 g 80 mg Vaginal supp.
1 App. vaginally for 7 days 1 App. vaginally for 3 days 1 Supp. daily for 3 days
Prescription oral agent
Fluconazole 150 mg Oral tablet 1 Tablet, single dose
* Modified from Centers for Disease Control and Prevention [4].
App., applicatorful; OTC, over-the-counter; sup., suppository.
Fig. 9.2 KOH preparation from sample of discharge of patient with vaginal itching. Prominent hyphae consistent withCandida vaginitisis visible in the center of the image. (Image provided by Aaron Hill.)
Case 9: A 30-year-old woman with vaginal itching
Treatment of nonalbicans candidiasis is less likely to respond to topical azole therapy [1]. Prolonged intravaginal therapy in combination with oralfluconazole is often recom- mended [1,4] (Fig. 9.3). Oral fluconazole 150 mg weekly for 6 months can be given for prevention of recurrent infections [5,6]. Fluconazole-resistant C. albicans infection has been increasing in incidence, likely due to the increase in prolonged use of fluconazole for recurrent infections [3]. The CDC recommends prolonged use of a nonfluconazole azole therapy for 7–14 days for treatment of resistant and recurrent non- albicans infections [4]. According to a recent meta-analysis, nystatin and flucytosine, as well as several azole therapies including terconazole, intraconazole, clotrimazole, ketocona- zole, buconazole, and miconazole as monotherapies may be efficacious [7]. In this situation, antifungal sensitivities may assist in determining which azole therapy to prescribe.
An alternative to these therapies, 600 mg boric acid gelatin capsule intravaginally daily for 2 weeks, has shown success [7] and is recommended as treatment in cases of recurrence after prolonged use of azole therapy [4]. Despite its efficacy, boric acid can have more adverse effects compared to azole therapy. These adverse effects include a vaginal burning sensation (<10% of cases), watery discharge, and vaginal erythema [7].
Key teaching points
Vulvovaginal candidiasis is a common cause of vaginitis with signs and symptoms including vulvar and vaginal erythema, pruritis, external dysuria, dyspareunia, and abnormal discharge.
The majority of cases of vulvovaginal candidiasis are uncomplicated: infrequent or sporadic occurring three or less times per year, with mild to moderate symptoms. They are likely caused byCandida albicansand respond to topical azoles.
Candidiasis is considered complicated if it recurs four or more times per year with severe symptoms. Complicated infections are often caused by nonalbicans candidiasis and occur in patients with immunosuppression, diabetes, or other severe illness.
Culture can be helpful in recurrent vulvovaginal candidiasis or infections that are refractory to standard therapies.
Boric acid 600 mg intravaginally daily for 2 weeks is the recommended treatment for refractory vulvovaginal candidiasis. Weeklyfluconazole 150 mg for 6 months can be used for prevention in patients with recurrent
vulvovaginal candidiasis.
References
1. American College of Obstetrics and Gynecology. Vaginitis. Practice Bulletin No. 72.Obstet Gynecol2006;107:1195–206.
2. Sobal J. Vulvovaginal candidosis.Lancet 2007;369:1961–71.
3. Marchaim D, Lemanek L, Bheemreddy S, Kaye K, Sobel J. Fluconazole-resistant Candida albicansvulvovaginitis.Obstet Gynecol2012;120(6):1407–13.
4. Centers for Disease Control and Prevention.Sexually Transmitted Diseases Treatment Guidelines, 2010.
Diseases Characterized by Vaginal Discharge. Available athttp://www.cdc.
gov/std/treatment/2010/vaginal- discharge.htm#a3.
5. Rosa M, Silva B, Pines P, Silva F, Silva N, Silva F, et al. Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic
review and meta-analysis.Eur J Obstet Gynecol Reprod Biol2013;167:132–6.
6. Sobel J, Wiesenfeld H, Martens M, et al.
Maintenancefluconazole therapy for recurrent vulvovaginal candidiasis.
New Engl J Med2004;351:876–83.
7. Iavazzo C, Gkegkes I, Zarkada I, Falagas M. Boric acid for recurrent vulvovaginal candidiasis: the clinical evidence.J Women’s Health2011;20 (8):1245–55.
Recurrent vulvovaginal candidiasis
Alternative therapy Fluconazole 150 mg by mouth
every third day for 3 doses
Persistence/Recurrence Boric acid 600 mg vaginally daily for 2 weeks
Maintenance therapy
Maintenance therapy Fluconazole 150mg weekly for 6 months Prolonged therapy
Send yeast culture of vaginal discharge
Topical azole therapy for 7–14 days
Fluconazole 150mg weekly for 6 months
Fig. 9.3 Recurrent vulvovaginal candidiasis treatment algorithm. Choice of antifungal may be guided by the results of culture and sensitivities.