Alexander McMillan1, 2
Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk
University of Edinburgh, Edinburgh, Uk
Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer
Two years later Margaret (Case 11) returns to the surgery. Over the past 18 months she has had at least ten episodes of vulval itch. She tells you that she has purchased both topical and oral antifungal preparations from her local pharmacist. Although these treatments have given some relief for a few weeks, nothing seems to “fix my problem permanently.” She is still using the combined contraceptive pill and has had no pregnancies. Her husband is symptomless. What would you do next?
Two years later Margaret (Case 11) returns to the surgery. Over the past 18 months she has had at least ten episodes of vulval itch. She tells you that she has purchased both topical and oral antifungal preparations from her local pharmacist. Although these treatments have given some relief for a few weeks, nothing seems to “fix my problem permanently.” She is still using the combined contraceptive pill and has had no pregnancies. Her husband is symptomless.
25.1 What Would You Do Next?
In the first instance, it is important to confirm the diagnosis of recurrent candidiasis, as other conditions can mimic this infection (see Case 11). At this consultation she is symptomless and you establish that she has not used potential irritants or allergens before the onset of the pruritus.
You examine her for lesions suggestive of genital dermatoses, but the vulva appears normal and the vaginal mucosa is healthy.
At this stage it is pointless to culture for Candida spp., as these fungi are often present in the normal vagina, and a positive culture cannot tell if her symptoms are indeed attributable to candidiasis.
You invite her to attend the surgery should symptoms recur and before she has taken any treatment.
Margaret returns 2 weeks later. The vulval irritation had recurred the day previously. You find marked vulval erythema; the walls of the vagina are inflamed, and there are white adherent plaques (Fig. 25.1). You think the appearance is that of candidiasis, but you wish to confirm the diagnosis. How is this done?
White plaques adherent to vaginal wall.
A specimen of vaginal material is taken with a cotton wool-tipped applicator stick and sent to the laboratory in the appropriate transport medium (for example, Amies’). Some of the material is emulsified in a drop of potassium hydroxide solution and examined microscopically for fungi. Alternatively, a Gram-stained smear is prepared and examined for the Gram-positive fungal hyphae, pseudohyphae, or spores (Fig. 25.2). 1
Pseudohypha of Candida albicans.
Although budding yeasts may be seen, hyphae are not a feature of infection with C. glabrata, a fungus that is becoming more common as a cause of vaginal candidiasis and that has reduced susceptibility to the azole antifungal drugs. Other species of Candida that may infect the vagina include C. parapsilosis, C. tropicalis, and C. krusei; the majority of these fungi show reduced susceptibility to azole antifungal drugs.
Although culture with speciation of the isolate is not generally undertaken in the management of women with acute candidal vulvovaginitis, recurrent disease may be associated with Candida species with reduced susceptibility to azoles (see Case 26), and in these cases, such testing is warranted. Antifungal susceptibility testing of C. albicans isolated from women with recurrent vulvovaginitis is rarely helpful.
Having taken the vaginal specimen, you treat Margaret with a single oral dose of fluconazole and invite her to return in 2 weeks time when the laboratory results will be available.
You subsequently receive the report that shows infection with C. albicans.
25.2 What Treatment Would You Offer Margaret?
Recurrent vulvovaginal candidiasis (RVVC) may be defined as four episodes of mycologically proven candidiasis within 12 months and affects fewer than 5% of women. Although some women have recognizable factors that predispose to RVVC, the majority of affected individuals do not (idiopathic recurring vulvovaginitis). For many years it was proposed that the condition represented re-infection either from the gastrointestinal tract or from a sexual partner. This theory has now been abandoned in favor of one that suggests that organisms are not completely eliminated by treatment and that patients have relapsing vaginitis as a result of a change in the normal protective host defense mechanisms. The finding that the identical strain type of C albicans causes most sequential episodes and that very high re-colonization rates are found within 1 month of a short-term therapy supports this hypothesis.
Reductions in local immune responses, however, are more likely to be important in pathogenesis.
Good clinical trials of treatment for this distressing condition are lacking and guidelines are empirical. When the diagnosis is established, treatment is initiated with any of the antifungal preparations noted above, as you have already done. (Either vaginal preparations or oral azoles may be used, but, as the response to single-dose therapy with the latter is sometimes unsatisfactory, a course of therapy lasting for 7–14 days should be given [fluconazole should be prescribed as a 50 mg capsule, given orally once daily]. When vaginal pessaries or intra-vaginal cream is used, cream should also be applied to the vulval skin.) Maintenance treatment is initiated immediately after resolution of symptoms. This may be with
The length of treatment must be tailored to the individual patient, but is unlikely to be less than 6 months. At the end of this period it is worth discontinuing therapy to assess outcome. Further therapy may be necessary.
There is no evidence that treatment of the sexual partner influences recurrence.
All pathogenic Candida species multiply by the production of buds from a thin-walled ovoid blastospore (yeast cell). A hypha is a long microscopic tube made up of multiple fungal cell units divided by septa. Hyphae arise as branches of existing hyphae or by the germination of spores. A pseudohyphaarises by a budding process in which each generation of buds remains attached to its parent; the buds of the first and subsequent generations are narrow elongated cells that do not resemble the parent blastospore. The end-to-end aggregation of elongated blastoconidia or pseudohypha are distinguished from true hyphae in that there are constrictions at the septal junctions.