CCS Interactive Case 7

Question 1

39 y/o F, presents to office complaining of thick, white vaginal discharge, vulvar pruritis over the past week. Finished course of ABX for a UTI 1 week ago, uses inhaled betamethasone and albuterol for asthma. LMP 25 days ago. Afebrile, HDS

DDx

Answer 1

Vaginitis - vaginal candidiasis (steroids, ABX predispose, characterized by vaginal itching, white curd-like discharge); DDx includes bacterial vaginosis, trichomonas, PID

Question 2

Exam steps?

Answer 2

General
Genital
Abdominal
Extremities/spine

Question 3

Exam shows vulvar erythema, edema, thick, adherent, white curd-like discharge w/white patches along vaginal walls

Exam findings of the other two types of vaginitis?

Answer 3

Consistent with vaginal candidiasis

BV - white/gray vaginal discharge, fishy odor

Trichomonas - frothy yellow-green discharge, strawberry cervix

Question 4

Work-up?

Answer 4

Vaginal pH
Microscopy ("wet mount")
Gram stain, vagina
Pap sear
UA
Vaginal and cervical cultures (more specific for candida/trich than microscopy) - GC culture, chlamydia culture

If high-ris sexual behavior, syphilis, HIV, hepatitis B, other STDs

Question 5

Vaginal pH >4.5 vs. pH <4.5?

Answer 5

> 4.5 - BV or trichomoniasis

<4.5 - candidiasis

Question 6

Wet mount findings in candidiasis vs. trichamonas vs. BV?

Answer 6

C - hyphae

Trich - motile trichomonads

BV - clue cells

Question 7

Results: vaginal pH = 4.2, hyphae on wet mount

Answer 7

Definitive dx of candidal vaginitis

Question 8

Dx candidiasis?

Answer 8

White curdy patches with inflammatory signs on exam, hyphae on KOH prep

Inflammatory cells on Gram stain

Question 9

Rx candidiasis?

Answer 9

Oral and topical anti-fungal drugs achieve comparable cure rates -> miconazole/clotrimazole suppositories or vaginal cream for 2 weeks or a single dose of oral fluconazole

Question 10

Dx trichomonas?

Answer 10

Frothy yellow-green vaginal discharge, strawberry cervix

Question 11

Rx trichomonas?

Answer 11

Metronidazole 500 mg BID for 7 days or 2 g single dose
Avoid alcohol (disulfiram-like reaction)
Rx required for partner
Safe sex counseling

Question 12

Dx BV?

Answer 12

Fishy smell, clue cells on wet mount, white/grey discharge

No inflammatory signs on exam; no inflammatory cells on gram stain

Question 13

Rx BV?

Answer 13

Metronidazole (oral or topical), no need to treat partner

Question 14

Sequence?

Answer 14

Focused physical
Order: vaginal pH, wet mount, vaginal gram stain, Pap smear, GC culture, chlamydial culture, UA
Clock: advance by 20 minutes; note pH and wet mount results consistent with candidiasis
Order: miconazole, vaginal, continuous + counseling (patient education, safe sex, no alcohol)
Location: home
Clock: schedule appointment in 2 weeks
Case ends
Final orders: none

Dx: candida vulvovaginitis