38. Vaginitis Differentiation Normal Trichomoniasis Candidiasis Bacterial Vaginosis Symptom presentation Itch, discharge, 50% asymptomatic Itch, discomfort, dysuria, thick discharge Odor, discharge, itch Vaginal discharge Clear to white Frothy, gray or yellow-green; malodorous Thick, clumpy, white “cottage cheese” Homogenous, adherent, thin, milky white; malodorous “foul fishy” Clinical findings Cervical petechiae “strawberry cervix” Inflammation and erythema Vaginal pH 3.8 - 4.2 > 4.5 Usually < 4.5 > 4.5 KOH “whiff” test Negative Often positive Negative Positive NaCl wet mount Lacto-bacilli Motile flagellated protozoa, many WBCs Few WBCs Clue cells ( > 20%), no/few WBCs KOH wet mount Pseudohyphae or spores if non- albicans species
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42. Clue cell Clue cell on Gram stain and saline wet mount of vaginal discharge (on >20% cells) Bacteria adhered to epithelial cells; most reliable single indicator
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Notas del editor
The vagina is a dynamic ecosystem that normally contains approximately 10 9 bacterial colony forming u/gm of vaginal fluid The normal flora is dominated by lactobacilli, but include a variety of other organisms, some potential pathogens, at lower levels Other common bacteria streptococcal species, Gm neg bacteria, G. vaginalis and anaerobes Lactic acids and other organic acids are metabolized from glycogen by the lactobacilli maintaining the vaginal pH between 3.8 and 4.2 The acidic environment inhibits the overgrowth of bacteria and other organisms with pathogenic potential The normal vaginal discharge is clear to white, odorless, and of high viscosity.
Lactobacillus-hydrogen peroxide producing, normally present in sufficient amounts Prevotella (genera, Bacteroides genus) commonly assoc with oral cavity. Prevotella species also indicated in women with BV. Mix of Gram-variable coccobacilli. Mobiluncus is an anaerobic bacteria, 2 subspecies: curtisii and mulieris. More often recovered from blacks and always occurs with other orgs assoc with BV. Gardnerella normally present in vaginal flora (looks the same as Bacteroides on Gram stain) Mycoplasma found more often in women w/ BV than w/o BV and may have a symbiotic relationship w/ Gardnerella or act alone.
-- So what is the causation? -- Why is the number of recurrences so high? -- Not sufficient data to conclude whether it is sexually transmitted or not. -It remains unclear whether recurrence is due to the use of antibiotics that do not eradicate infection or to reinfection from sex partners. 7 -- Important connections between characterization factors (see picture) - Initiation factor of BV remains a mystery, although an important inter-relation between lactobacilli, hydrogen peroxide production, vaginal pH, and overgrow of BV associated bacteria is present. 6 --In particular, let’s look further into the aspect of OVERGROWTH OF BV ASSOCIATED BACTERIA 6) Wilson, J. Managing recurrent bacterial vaginosis. Sex Transm Infect 2004;80:8-11. 7) Bradshaw CS, Morton AN, Hocking J, Garland SM, Morris MB, Moss LM, Horvath LB, Kuzevska I, Fairley CK. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis 2006;193:1478-86.
Gram stain and screening. Quantification of bacterial morphotypes (Lactobacillus, Gardnerella and Bacteriodes spp (Prevotella), and Mobiluncus. Not reliant on sypmtoms so it is a more sensitive test, better at diagnosing asymptomatic cases. More specific than wet mount for finding clue cells. Gram stain is best way to see Mobiluncus. 0 6 10
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