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Differential Diagnosis

The Case:Sherry is a sexually active teenager. She had a vaginal infection about a year ago and developed similar symptoms again last week including itching, burning, a pasty white odourless vaginal discharge as well as red and inflamed tissues. Last year, she saw a doctor in a walk-in clinic and he gave her vaginal inserts which cleared up the problem but she cannot remember what they were called. She has been taking tetracycline for acne, once daily for two years. She has been douching r9455

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Differential Diagnosis

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    8. Differential Diagnosis

    9. Differential Diagnosis (1/9) Infectious Conditions Candida Vulvovaginitis Trichonomas Vaginitis Bacterial Vaginosis Cervicitis Non Infectious Conditions Atrophic Vaginitis Desquamative Inflammatory Vaginitis Vaginal Cancer Chemical Irritant Vaginitis Mechanical Irritant Vaginitis

    10. Differential Diagnosis (2/9) Conditions Immediately Ruled Out In Sherry’s Case: Cervicitis Atrophic Vaginitis Desquamative Inflammatory Vaginitis Vaginal Cancer

    11. Differential Diagnosis (3/9) Conditions which are more consistent with Sherry’s Signs and Symptoms: Trichonomas Vaginitis Bacterial Vaginosis Candida Vulvovaginitis Chemical Irritant Vaginitis Mechanical Irritant Vaginitis

    12. Trichonomas Vaginitis (4/9) Cause: T. Vaginalis (protozoan). Sexually transmitted. Characteristics: Fishy smell. Yellow or green frothy discharge. Sherry does not have a green frothy vaginal discharge with a fishy. odour.

    13. Bacterial Vaginosis (5/9) Cause: Gardnerella and other anaerobes Characteristics: Fishy odour Thin watery or milky discharge Discharge is grey to yellow in color Sherry does not have a grey to yellow vaginal discharge with a fishy odour.

    14. Candida Vulvovaginitis (6/9) Cause: Candida albicans (80-90%) Candida glabrata Candida tropicalis Characteristics: No odour Discharge appears dry and curdy “cottage cheese like” Discharge is thick with grey or white color. Burning, pruritis & erythema. Candida Vulvovaginitis is consistent with Sherry’s condition

    15. Mechanical Irritant Vaginitis (7/9) Common Causes: Vigorous sexual intercourse Inadequate lubrication during sex Foreign bodies in vagina i.e. diaphragm, tampons Mechanical trauma to vagina Characteristics: Red, tender, sore genitalia She is using a diaphragm, an irritant, which may be exacerbating her candida infection.

    16. Chemical Irritant Vaginitis (8/9) Common Causes: Exposure of vulva or outer vagina to chemical irritants Minipads, spermicides Antiseptics, povidone-iodine Soaps, sprays perfumes Douches, deodorants, latex condoms Tampons, diaphragm and foreign bodies Topical antibiotic & anti-inflammatory creams Tight occlusive clothing Sherry uses a douche and a diaphragm irritant which may be exacerbating her candida infection.

    17. Diagnosis (9/9) Sherry is suffering from a Candida Vulvovaginitis infection exacerbated by both chemical and mechanical irritants.

    18. Pathophysiology (1/2) normal microorganisms in mature vagina: Lactobacilli, Staphylococci, Streptococci Candida species Lactobacilli acidophilus: hydrogen peroxide-producing (pH 3.8-4.2), suppresses proliferation of other microorganisms when conditions in the vagina change, the overgrowth of host organisms or the colonization of acquired pathogens can occur

    19. Pathophysiology (2/2) three main types of vaginitis: bacterial vaginosis (about 50% vaginitis cases) Gardnerella bacteria or a mixed anaerobic infection trichomoniasis (about 20% vaginitis cases) Trichomonas vaginalis candidiasis (about 25% vaginitis cases) C. albicans (80-92%) remaining cases: C. glabrata and C. tropicalis

    20. Candidiasis Signs and Symptoms main symptom: intense pruritis in the vulvovaginal area unusual vaginal discharge patterns often reported symptoms may be more severe before menses and may abate with the beginning of menstruation

    22. Risk Factors (1/2) women in childbearing years high estrogen states uncontrolled or poorly controlled diabetes mellitus Antibiotics (broad spectrum)

    23. Risk Factors (2/2) Immunosuppression (e.g.: AIDS, Corticosteroids) Stress Tight fitting clothing, synthetic undergarments High-sugar diets Chemical irritants Mechanical irritants In summary, anything that upsets the micro-organism balance within the vagina can potentially play a role in the development of candidasis.

    24. 3b) What is the timing of the problem relative to the current and recent past drug use? (eliminate drugs that are inconsistent in terms of time frame) tetracycline for acne once daily x 2 years douching 2-4 times a week x 1 year Sherry’s vaginitis symptoms started while she was using tetracycline and a Summer’s Eve® disposable douche product.

    25. 3c) What drugs can cause these signs and symptoms and how do they cause them (dose-related or ADR) (consider all potential drugs based on the pathophysiology of the problem and the literature) Antibiotics high-estrogen oral contraceptives and HRT immunosuppressants, corticosteroids, and cytotoxic drugs spermicides and douches

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