Case 9 – A 35-year-old woman with vaginal discharge

A 35-year-old G1P1 woman presents to her gynecologist complaining of white vaginal discharge with a “cheesy” consistency, itching, and discomfort. Her last menstrual period was 3 weeks ago, and she does not report any new sexual partners. She uses an intrauterine device (IUD) for contraception. Her temperature is 37°C (98.6°F), heart rate is 80/min, and blood pressure is 125/80 mm Hg. Speculum examination reveals erythematous and slightly edematous external genitalia. The vaginal walls are coated with a thick, white discharge, but the cervix appears normal, and the IUD string is visible from the os. A sample is taken, two slides are made, and the pH is determined to be 4.0. The saline-prepared slide shows only epithelial and inflammatory cells, while the potassium hydroxide-treated slide shows pseudohyphae and budding yeasts. There was no odor noted upon treatment with potassium hydroxide.

What is the most likely diagnosis?

Vulvovaginal candidiasis. Classic symptoms are the white, odorless, “cheesy” discharge and vulval swelling, itching, and discomfort. The wet mount, showing the presence of budding yeasts and pseudohyphae, confirms the diagnosis.

What other conditions should be included in the differential diagnosis?

The two other common causes of vaginitis are bacterial vaginosis and trichomoniasis.
Bacterial vaginosis is caused by Gardnerella vaginalis and other anaerobes that are usually suppressed by the dominance of Lactobacillus spp. The most common symptom is a discharge with an unpleasant, “fishy” odor. Wet mount in G. vaginalis infection shows epithelial cells with adherent bacteria (“clue cells”), without the presence of inflammatory cells. Preparation with potassium hydroxide reveals the characteristic amine odor (the “whiff test”).

Trichomoniasis is a sexually transmitted disease caused by the Trichomonas protozoa. The classic presentation is a frothy green discharge. Diagnosis is made by visualizing the motile protozoa on saline wet mount

Less common causes of vaginitis include atopic and contact dermatitis.

What are the common risk factors for this condition?

Associated risk factors of vulvovaginal candidiasis include”

1. Antibiotic use
2. Diabetes mellitus
3. Immunosuppression (steroids, HIV)
4. Oral or barrier contraceptive use
5. Pregnancy

What is the pathophysiology of this condition?

Like Gardnerella, Candida spp. (most commonly C. albicans) are part of the normal vaginal flora. However, when the vaginal pH changes or normal vaginal flora are eradicated by antibiotics, Candida rapidly replaces normal flora and symptoms arise. It can be transmitted sexually, but is not considered a sexually transmitted disease

What is the most appropriate management for this patient?< /span>

This patient has an uncomplicated infection, and her options include 3-7 days of topical azole treatment or single-dose oral fluconazole. A complicated infection is one in a diabetic, immunosuppressed, or pregnant patient; in a patient with a history of recurrence (?4/year) or severe symptoms; or disease caused by a Candida species other than C. albicans. Treatment of complicated infection requires 14 days of a topical azole or 2 days of fluconazole. Fluconazole is contraindicated in pregnancy, and 7 days of topical therapy is recommended.

By Melissa Rosenstein, MD, Resident in Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco Medical Center; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.