A 42-year-old woman comes to the office for an annual examination. The patient feels well and has regular menses with no abnormal bleeding. She has a new vaginal discharge but no vulvar pruritus or pelvic pain. The patient is sexually active and has had only women partners. Her current relationship began 6 months ago. She has no chronic medical conditions and takes no medications.
Vital signs are normal. BMI is 31 kg/m². There is no vulvar erythema. Microscopic examination of the vaginal discharge reveals the following:

Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old woman comes to the office for an annual examination. The patient feels well and has regular menses with no abnormal bleeding. She has a new vaginal discharge but no vulvar pruritus or pelvic pain. The patient is sexually active and has had only women partners. Her current relationship began 6 months ago. She has no chronic medical conditions and takes no medications.
Vital signs are normal. BMI is 31 kg/m². There is no vulvar erythema. Microscopic examination of the vaginal discharge reveals the following:

Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_97e6_6971_853d_8733821ea37c_MD0002_00 Vulvovaginal candidiasis (VVC) is common because Candida (red arrow) exists as normal vaginal flora. However, overgrowth and invasion of the vaginal cells creates symptomatic VVC, leading to vaginal discharge, pruritus, dysuria, and dyspareunia. Examination findings include vulvovaginal erythema and clumpy white discharge. Pseudohyphae (typically not seen with Candida glabrata) and budding yeast can be visualized on wet-mount microscopy. Potassium hydroxide (KOH) or Gram stain can be added to facilitate visualization of fungal elements. Vaginal culture may be helpful in women with atypical (eg, negative microscopy, mixed vaginitis), severe, or recurrent episodes of VVC. Treatment of uncomplicated VVC (eg, ≤3 episodes per year, immunocompetent, mild symptoms) is a single course of an oral (eg, fluconazole) or topical (eg, miconazole, clotrimazole) antifungal agent. Complicated infections require longer courses of treatment, and strains other than Candida albicans may be resistant to azoles. (Choice A) Bacterial vaginosis is more common in women who have sex with women. It presents with a thin, malodorous vaginal discharge; a pH of >4.5; an amine odor (ie, whiff test); and clue cells on microscopy. clue cells (Choice B) Mycoplasma genitalium causes cervicitis and pelvic inflammatory disease. Mycoplasma is an atypical bacterium (ie, not visible on Gram stain) as it lacks a cell wall. (Choice C) Symptomatic patients with Neisseria gonorrhoeae typically have acute cervicitis (eg, mucopurulent cervical discharge) or pelvic inflammatory disease (eg, pelvic pain, fever). In addition, they have associated pruritus, intermenstrual bleeding, and cervical friability. An abundance of polymorphonuclear leukocytes and Gram-negative diplococci are visualized on microscopy. cervicitis (Choice D) Trichomonas vaginitis presents with vulvovaginal pruritus; a green, frothy vaginal discharge; and motile, flagellated protozoa on microscopy. protozoa Educational objective: Vulvovaginal candidiasis is a common cause of vaginal discharge and pruritus. Diagnosis is confirmed by pseudohyphae and budding yeast on microscopy. Treatment is with a single dose of oral fluconazole or a topical azole. __________ References: Treatment of vulvovaginal candidiasis: a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/25770305) Vulvovaginal candidiasis: epidemiology, microbiology and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/26690853)

A 42-Year-Old Woman Comes to the Office for an Annual