A 32-year-old woman comes to the office due to several days of vaginal itching and discharge. She also has pain with sexual intercourse. The patient has had no fever, chills, abdominal pain, urinary frequency, or dysuria. In the past year she has had 2 new male sexual partners. She takes oral contraceptives and uses condoms on most occasions. The patient has no chronic medical conditions and has had no surgeries. She takes no other daily medications. The patient drinks several glasses of wine each week but does not smoke or use illicit drugs. Her last menstrual period was 3 weeks ago. Temperature is 36.7 C (98 F) and blood pressure is 100/60 mm Hg. Pelvic examination shows vulvar and vaginal erythema and a small amount of vaginal discharge with a pH of 4. Which of the following is the most likely causal organism?

Question

A 32-year-old woman comes to the office due to several days of vaginal itching and discharge.  She also has pain with sexual intercourse.  The patient has had no fever, chills, abdominal pain, urinary frequency, or dysuria.  In the past year she has had 2 new male sexual partners.  She takes oral contraceptives and uses condoms on most occasions.  The patient has no chronic medical conditions and has had no surgeries.  She takes no other daily medications.  The patient drinks several glasses of wine each week but does not smoke or use illicit drugs.  Her last menstrual period was 3 weeks ago.  Temperature is 36.7 C (98 F) and blood pressure is 100/60 mm Hg.  Pelvic examination shows vulvar and vaginal erythema and a small amount of vaginal discharge with a pH of 4.  Which of the following is the most likely causal organism?

Quizplus · Accepted Answer

11ec25c8_d9f8_c9e9_bc81_2bfa476ce9fd_MD0003_00 This patient's vulvovaginal erythema and vaginal discharge are consistent with candida vulvovaginitis, an infection typically due to overgrowth of Candida albicans. C albicans is part of the normal vaginal flora in women; however, symptomatic infection can be triggered by alterations in the vaginal flora balance, allowing abnormal Candida proliferation. These alterations can occur due to increased estrogen levels (eg, estrogen- containing contraceptives, pregnancy), as seen in this patient. Additional predisposing factors include recent antibiotic use, immunosuppression (eg, systemic corticosteroids), sexual activity, and diabetes mellitus (particularly if poorly controlled). With Candida overgrowth, patients develop vulvovaginal inflammation that can result in vulvar pruritus (sometimes with excoriations), dyspareunia, and dysuria. Candida does not alter the acidity of the vagina; therefore, the discharge has a normal vaginal pH (3.8-4.5). Pseudohyphae, hyphae, and budding yeast are typically visualized on wet mount microscopy; however, microscopy can be negative. In these patients, a vaginal culture can be used for diagnosis. Treatment options include oral (eg, fluconazole) and intravaginal (eg, clotrimazole) antifungals. (Choices B, D, and E) Chlamydia trachomatis, Mycoplasma genitalium, and Neisseria gonorrhoeae are causes of acute cervicitis, which can present with dyspareunia and discharge. However, patients typically have a mucopurulent cervical discharge that may be accompanied by dysuria (eg, urethritis) or abdominal pain (ie, pelvic inflammatory disease). There is no associated vulvovaginal erythema. acute cervicitis (Choice C) Gardnerella vaginalis, a cause of bacterial vaginosis, presents with vaginal discharge; however, it is typically a thin, grey, "fishy-smelling" discharge that has a pH >4.5. There is no associated dyspareunia or vulvovaginal erythema. (Choice F) Trichomonas vaginalis is a unicellular, flagellated protozoan that causes vaginal discharge; however, it is typically a green, frothy discharge with a pH >4.5. Educational objective: Candida vulvovaginitis is caused by overgrowth of Candida albicans and typically presents with vulvovaginal erythema, vaginal pruritus, and discharge with a normal vaginal pH (3.8-4.5). Treatment options include oral (eg, fluconazole) and intravaginal (eg, clotrimazole) antifungals. References: Vulvovaginal candidiasis: epidemiology, microbiology and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/26690853) Vaginitis: diagnosis and treatment (http://www.ncbi.nlm.nih.gov/pubmed/29671516) Vaginitis: beyond the basics. (http://www.ncbi.nlm.nih.gov/pubmed/28499528)

A 32-Year-Old Woman Comes to the Office Due to Several