A 17-year-old girl comes to the office for evaluation of vaginal discharge requiring the use of a panty liner. She has had this discharge intermittently for the past few months and notices it returns after menses end. The last menstrual period ended a week ago. For the last 6 months, she has been sexually active with a new partner and uses condoms for contraception. The patient has no medical problems or previous surgeries. She takes no medications and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 78/min. On pelvic examination, the external genitalia have no erythema or edema. There is copious white, mucoid, odorless vaginal discharge. Microscopic examination reveals a predominance of squamous cells and rare polymorphonuclear leukocytes. Which of the following is the most likely diagnosis?

Question

A 17-year-old girl comes to the office for evaluation of vaginal discharge requiring the use of a panty liner.  She has had this discharge intermittently for the past few months and notices it returns after menses end.  The last menstrual period ended a week ago.  For the last 6 months, she has been sexually active with a new partner and uses condoms for contraception.  The patient has no medical problems or previous surgeries.  She takes no medications and does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 78/min.  On pelvic examination, the external genitalia have no erythema or edema.  There is copious white, mucoid, odorless vaginal discharge.  Microscopic examination reveals a predominance of squamous cells and rare polymorphonuclear leukocytes.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d9f9_db5b_bc81_bd0815851a8e_MD0003_00 Physiologic leukorrhea is a white, odorless cervical discharge composed of cervical mucus, normal vaginal flora, and vaginal squamous epithelium. Increasing amounts of this normal vaginal discharge typically occurs midcycle (eg, 10-14 days after previous menses) as estrogen levels increase prior to ovulation, and then regresses (as seen in this patient). Physiologic leukorrhea presents without manifestations of infection such as pruritus, erythema, pain, or a malodorous discharge. Prior to the diagnosis of physiologic leukorrhea, other causes of increasing vaginal discharge must be excluded. Polymorphonuclear leukocytes on microscopic examination are evidence of a local immune response (eg, inflammation) to infection. This patient has rare polymorphonuclear leukocytes on microscopy, ruling out all infectious etiologies as the cause of her discharge. (Choice A) Bacterial vaginosis is characterized by a malodorous discharge that is noted after menses or intercourse. Wet mount microscopy typically reveals squamous epithelial cells with adherent bacteria (eg, clue cells). clue cells (Choice B) Candidiasis presents with white vaginal discharge, vulvar pruritus, and erythema on examination. Hyphae are present on microscopy with potassium hydroxide preparation of the discharge. erythema Hyphae (Choices C and D) Acute cervicitis is typically caused by Chlamydia trachomatis and Neisseria gonorrhoeae. When symptomatic, patients have intermenstrual or postcoital spotting and a mucopurulent cervical discharge. Microscopy shows abundant, rather than rare, polymorphonuclear leukocytes. (Choice F) Trichomoniasis typically presents with vulvovaginal pruritus in addition to a malodorous, green vaginal discharge. Motile protozoa and an abundance of polymorphonuclear leukocytes are visualized on microscopy. protozoa Educational objective: Physiologic leukorrhea is a white, odorless mucoid cervical discharge that typically occurs midcycle due to increasing estrogen levels prior to ovulation. Microscopic examination of the discharge reveals no evidence of inflammation or infection (eg, rare polymorphonuclear leukocytes). References: Management of persistent vaginitis. (http://www.ncbi.nlm.nih.gov/pubmed/25415165)

A 17-Year-Old Girl Comes to the Office for Evaluation of Vaginal