A 26-year-old woman comes to the office due to greenish vaginal discharge and vulvar pruritus that started several days ago. The patient had an uncomplicated vaginal delivery 2 months ago and is breastfeeding her infant exclusively. She completed a course of antibiotics for lactational mastitis 2 weeks ago. The patient has no chronic medical conditions and has had no surgeries. She was treated for a Chlamydia trachomatis cervicitis during high school. Sexually transmitted infection screening performed at the initial prenatal visit was negative. The patient is in a monogamous relationship with her boyfriend of 3 years. She is taking a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F) and blood pressure is 100/60 mm Hg. BMI is 30 kg/m². Vulvar edema and erythema are present. Pelvic examination reveals a nontender, anteverted uterus and no adnexal masses. Speculum examination shows punctate hemorrhages on the cervix. Which of the following is the most appropriate treatment for this patient?

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Explanation: 11ec2b69_bfcd_35ae_8f63_e3abc6a30f1f_MD0005_00 This patient's presentation is consistent with trichomoniasis, a sexually transmitted infection caused by the protozoa Trichomonas vaginalis. The infection may be asymptomatic or present with a malodorous, frothy, yellow-green vaginal discharge; vulvovaginal pruritus and erythema; dyspareunia from vaginal inflammation; and postcoital bleeding. Punctate hemorrhages can be seen in the vagina and/or on the cervix. Examination of the vaginal fluid typically shows an elevated pH (>4.5) and motile flagellated organisms on wet mount microscopy. motile flagellated organisms The first-line antibiotic regimen is single-dose oral metronidazole 2 g. However, metronidazole enters breast milk and may cause loose stools and candidiasis in exposed infants. Although 1 dose of metronidazole is not an indication for complete cessation of breastfeeding, breast milk produced immediately after treatment has a significant concentration of metronidazole (Choice D). To minimize infant exposure, breastfeeding should be discontinued; breast milk should be expressed and discarded for 24 hours after dose administration. (Choice A) Doxycycline is indicated for the treatment of Chlamydia trachomatis cervicitis, which presents with a mucopurulent cervical discharge and a friable cervix. There is no associated vulvar pruritus. In addition, doxycycline is not recommended during breastfeeding as it is excreted in breast milk and may cause tooth discoloration and enamel hypoplasia in the infant. (Choice B) Oral fluconazole treats Candida vulvovaginitis, a sequela of antibiotic use, which presents with vulvovaginal pruritus and erythema. However, Candida vulvovaginitis typically presents with a thick, white, clumpy discharge and a nonfriable cervix. Fluconazole is excreted in breast milk; however, breastfeeding can continue as there are no known adverse effects. (Choice E) When treating trichomoniasis vaginal metronidazole therapy has lower cure rates (<50%) than oral therapy. Vaginal therapy does not treat concomitant urethral and periurethral gland infections, leading to inadequate treatment.Educational objective: Trichomoniasis is characterized by vulvovaginal pruritus and erythema; a frothy, yellow-green discharge; and punctate hemorrhages in the vagina or on the cervix. Single-dose oral metronidazole is the preferred treatment. To avoid infant exposure, breast milk should be expressed and discarded for 24 hours after dose administration. References: Trichomoniasis - are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide? (http://www.ncbi.nlm.nih.gov/pubmed/28357378) Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. (http://www.ncbi.nlm.nih.gov/pubmed/26242185) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

A 26-Year-Old Woman Comes to the Office Due to Greenish