Review Question - QID 220792

Candida albicans Treatment Medical QID: 220792 (M2.OMB.4872)

QID 220792 (Type "220792" in App Search)

A 22-year-old woman presents to her gynecologist with a 2 week history of vaginal itching. She started experiencing the symptoms after she started having sexual intercourse with a new boyfriend. She initially ignored the symptoms but became concerned when she started having pain with sexual intercourse. She has also noticed vaginal discharge. She denies abdominal pain, increased urinary frequency, or dysuria. She has no other medical problems and the only medication she takes is oral contraceptives. The patient does not smoke, drinks alcohol socially, and does not use illicit drugs. Her temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 65/min, and respirations are 13/min. Pelvic examination is significant for vulvar and vaginal erythema, as well as thick, cottage cheese-like discharge. A urine pregnancy test is negative. Wet mount microscopy is performed and shown in Figure A. Which of the following is the most appropriate treatment for this patient's most likely diagnosis?

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Azithromycin

0/1

Clindamycin

0/1

Fluconazole

100%

1/1

Metronidazole

0/1

Nystatin

0/1

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This patient, who presents with vaginal pruritus, thick cottage cheese-like vaginal discharge, vulvovaginal erythema, and pseudohyphae visualized on wet mount microscopy, most likely has uncomplicated vulvovaginal candidiasis. The most appropriate treatment for this disease is oral fluconazole.

Candida albicans is a fungal organism that is a normal part of the vaginal flora in women. Overgrowth of this organism can cause symptomatic vulvovaginal inflammation. Symptoms include vulvar pruritus, dyspareunia, dysuria, and thick cottage cheese-like discharge. Candida does not alter the pH of the vagina so the discharge will have a normal vaginal pH (3.8-4.5). Wet mount microscopy will typically visualize pseudohyphae and budding yeast. Infections are usually uncomplicated, but can be complicated if patients are pregnant or immunocompromised. Treatment of uncomplicated infections is with either oral fluconazole or topical antifungals.

Pappas et al. review the evidence regarding the management of vulvovaginal candidiasis. They discuss how topical antifungals can be used for the treatment of uncomplicated cases. They recommend considering oral fluconazole as a possibility for uncomplicated vulvovaginal candidiasis.

Figure/Illustration A is a vaginal wet mount showing a cluster of pseudohyphae (red circle). These findings are classically seen in patients with candidal vulvovaginitis.

Incorrect Answers:
Answer 1: Azithromycin, a macrolide antibiotic, can be used to treat infections with Chlamydia trachomatis in pregnancy. Patients with Chlamydia cervicitis may present with malodorous vaginal discharge. These patients will have multiple white blood cells on wet mount microscopy rather than pseudohyphae.

Answer 2: Clindamycin, a lincosamide antibiotic, can be used to treat bacterial vaginosis (BV). Patients with BV usually present with thin, gray-white, fishy-smelling discharge without associated dyspareunia or vulvovaginal erythema. In addition, a wet mount would show clue cells (Gardnerella vaginalis adhering to the edge of vaginal epithelial cells).

Answer 4: Metronidazole may be used to treat both BV and infection with the protozoan Trichomonas vaginalis. Trichomoniasis presents with vaginal inflammation, dyspareunia, thin, yellow-green, frothy discharge. Wet mount microscopy in trichomoniasis directly visualizes the protozoan, and would not be expected to show pseudohyphae.

Answer 5: Oral nystatin, a polyene antifungal, may be used to treat oropharyngeal candidiasis. Nystatin has poor bioavailability and an oral formulation does not effectively treat vulvovaginal candidiasis. However, a vaginal suppository or vaginal tablets of nystatin can be used to treat vulvovaginal candidiasis.

Bullet Summary:
Candida vulvovaginitis presents with pseudohyphae on wet mount and should be treated with fluconazole.