A 20-year-old woman comes to the office due to increasing vaginal discharge and vulvar pruritus. The patient has had vaginal discharge for the past 4 days. She is sexually active with multiple partners and uses oral contraceptive pills. Vital signs are normal. Pelvic examination is performed, and wet mount microscopy of a vaginal swab is shown in the exhibit.
Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 20-year-old woman comes to the office due to increasing vaginal discharge and vulvar pruritus.  The patient has had vaginal discharge for the past 4 days.  She is sexually active with multiple partners and uses oral contraceptive pills.  Vital signs are normal.  Pelvic examination is performed, and wet mount microscopy of a vaginal swab is shown in the exhibit. 
 Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec160b_37f7_5587_9249_c3256bafd37d_MD0001_00 This patient with vulvar pruritus and vaginal discharge has candidal vulvovaginitis, an infection typically caused by overgrowth of Candida albicans. C albicans is a yeast and component of normal vaginal flora; however, alterations in the balance of normal vaginal flora can allow for excessive Candida proliferation and symptomatic infection. These imbalances can occur due to increased estrogen levels, such as with estrogen-containing contraceptive use or pregnancy. Additional predisposing factors include recent antibiotic use, immunosuppression (eg, systemic corticosteroids), sexual activity, and diabetes mellitus (particularly if poorly controlled). With C albicans overgrowth, patients develop vulvovaginal inflammation that can result in erythema; pruritus; and a thick, white, clumpy vaginal discharge. Diagnosis is made via wet mount microscopy, which typically shows pseudohyphae with budding yeast and true hyphae. Treatment of vulvovaginal candidiasis is with azole antifungal medications (eg, fluconazole), which decrease ergosterol synthesis and disrupt fungal cellular membrane formation. (Choice A) Acyclovir is used to treat herpes simplex virus infection, which can occasionally cause multinucleated giant cells to be visualized on cervical cytology, but not wet mount microscopy. Herpes simplex virus is a rare cause of cervicitis, and patients typically have concomitant, painful vulvovaginal vesicles. (Choices B and D) Ceftriaxone is used to treat Neisseria gonorrhoeae infection, and doxycycline is used to treat Chlamydia trachomatis infection. These bacteria typically cause acute cervicitis with mucopurulent cervical discharge and a friable cervix, rather than vulvovaginitis. Neither pathogen is easily visualized on wet mount microscopy because C trachomatis has an unusual peptidoglycan cell wall and N gonorrhoeae is intracellular. (Choices C and F) Clindamycin and metronidazole are used to treat Gardnerella vaginalis, an anaerobic bacterium that causes bacterial vaginosis (BV). BV can be identified by clue cells, which are vaginal epithelial cells covered in bacteria. Metronidazole also treats Trichomonas vaginalis, a protozoan infection characterized by frothy, yellow-green vaginal discharge and motile, flagellated trichomonads on wet mount microscopy. Educational objective: Vulvovaginal candidiasis typically presents with thick, white, clumpy vaginal discharge; vulvovaginal erythema and pruritus; and pseudohyphae on wet mount microscopy. Treatment is with an antifungal medication (eg, fluconazole). __________ References: Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Pseudohypha budding patterns of Candida albicans. (http://www.ncbi.nlm.nih.gov/pubmed/19347739) Vaginitis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29671516)

A 20-Year-Old Woman Comes to the Office Due to Increasing