A 19-year-old nulligravid woman comes to the emergency department due to abnormal vaginal discharge for the last 2 weeks. The patient has douched twice with no change in the discharge. She had an episode of postcoital vaginal bleeding a few days ago, followed by return of the abnormal yellow discharge. Her last menstrual period was 3 weeks ago. The patient is sexually active and has had the same partner for 6 months; they use the withdrawal method for contraception. Physical examination shows yellow cervical discharge. The cervix is friable and bleeds easily on cotton tip manipulation. Urine pregnancy test is negative. Nucleic acid amplification testing is not available. A sample of the discharge is obtained for microscopic examination. Which of the following is the most likely microscopic finding in this patient?

Question

A 19-year-old nulligravid woman comes to the emergency department due to abnormal vaginal discharge for the last 2 weeks.  The patient has douched twice with no change in the discharge.  She had an episode of postcoital vaginal bleeding a few days ago, followed by return of the abnormal yellow discharge.  Her last menstrual period was 3 weeks ago.  The patient is sexually active and has had the same partner for 6 months; they use the withdrawal method for contraception.  Physical examination shows yellow cervical discharge.  The cervix is friable and bleeds easily on cotton tip manipulation.  Urine pregnancy test is negative.  Nucleic acid amplification testing is not available.  A sample of the discharge is obtained for microscopic examination.  Which of the following is the most likely microscopic finding in this patient?

Quizplus · Accepted Answer

11ec25c8_d9da_ba64_bc81_ff4cf6bb9c67_MD0003_00 This patient has acute cervicitis, which is most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Inflammation of the cervix can result in abnormal vaginal discharge and postcoital bleeding due to contact irritation of the cervix. Classic findings include mucopurulent cervical discharge and an edematous, friable cervix that bleeds with manipulation. The gold standard diagnostic test for acute cervicitis is nucleic acid amplification testing (NAAT). NAAT has high sensitivity and specificity for C trachomatis and N gonorrhoeae detection and has replaced older, less sensitive techniques (eg, culture, microscopy). Light microscopy is not helpful in the diagnosis of acute cervicitis as C trachomatis is an obligate intracellular pathogen and, therefore, no organisms are visualized. In addition, microscopy also has low sensitivity in identifying the gram-negative intracellular diplococci of N gonorrhoeae on endocervical smears, especially in asymptomatic patients. (Choice A) Clue cells are vaginal epithelial cells coated by bacteria characteristic of bacterial vaginosis. Douching is a risk factor for bacterial vaginosis, which presents with malodorous, thin, watery discharge and no cervical inflammation. (Choice B) Hyphae seen on potassium hydroxide (KOH) microscopy are diagnostic for Candida vaginitis. Patients with Candida infections typically present with vulvovaginal pruritus and thick, clumpy, white discharge. (Choice D) Spirochetes, the agents of syphilis, cannot be seen by light microscopy, and direct visualization requires dark-field microscopy. Patients with syphilis present with a painless chancre and lymphadenopathy, not cervical discharge. (Choice E) Trichomonads, flagellated protozoans, are a less common cause of acute cervicitis. Patients with trichomoniasis may have an erythematous cervix with punctate lesions (eg, strawberry cervix) and a frothy, green discharge. Educational objective: Microscopy is not used in the diagnosis of acute cervicitis due to its low sensitivity and inability to detect the most common pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae. Nucleic acid amplification testing is the gold standard for diagnosis. References: The utility of wet prep in predicting Neisseria gonorrhoeae and Chlamydia trachomatis. (http://www.ncbi.nlm.nih.gov/pubmed/22595630)

A 19-Year-Old Nulligravid Woman Comes to the Emergency Department Due