[Vulvovaginitis caused by Candida spp. and Trichomonas vaginalis in sexually active women]

Vulvovaginitis accounts for 20 to 30% of gynecological diseases and it is observed in women from 20 to 30 years of age. It has a higher frequency in women using oral contraceptives and during the third trimester of pregnancy. The aim of this research was to assess the prevalence of Candida spp and Trichomonas vaginalis in patients with the diagnosis of vulvovaginitis from the Gynecology Service in Hospital Universitario "Ruiz y Páez" in Ciudad Bolívar and Hospital "Raúl Leoni" in San Félix (Bolívar State, Venezuela). Two hundred women with symptoms of vulvovaginitis were examined, and samples were taken from the uterocervical cul-de-sac. Each patient was asked to fill a questionnaire. The following studies were made in each sample: a) fresh wet mount examination, b) orange acridine and Giemsa stains for Trichomonas and c) culture for the identification of yeasts. The latter were identified by means of the germinal tube assay, resistance to actidione and the presence of clamidospores in rice-cream agar and sugar utilization test, using the commercial kit ID32C (BioMérieux). Only in 57 women of 200 patients with vulvovaginitis the causative agent was demonstrated; Candida spp was present in 84.2% (n = 48) and Trichomonas vaginalis in 14% (n = 8). A single case of Zygosaccharomyces spp (1.8%) was detected. The age group mainly affected was that of 25-35 years old, the 38.6% of the studied population. Candida species detected were: C. albicans in 87% of cases (n = 42), C. glabrata, in 10.42% (n = 5), and C. guillermondii, in 2.08 (n = 1). Vaginal flux, vulvar pruritus and leucorrhoea were observed in significant number of patients with vulvovaginal candidiasis. The use of antibiotics was considered predisposing factor for Trichomonas vaginalis infection. The relationship between age and the etiological agent was not statistically significant. Due to the low specificity of clinical manifestations of infections caused by Candida spp and Trichomonas vaginalis, we conclude that performing the etiologic diagnosis of vulvovaginitis is necessary in order to take the appropriate therapeutic and preventive measures, specially in those patients with a recurrent disease.

Susceptibility profile of vaginal yeast isolates from Brazil

Vaginal specimens for culture were obtained from two hundred and five immunocompetent, non-hospitalized patients selected among all women attending the Gynecology and Obstetric Ambulatory Clinic of the University of Espírito Santo, Brazil, during a 2-year period (From 1998 to 1999). Patients were checked for signs and symptoms of vulvovaginitis and previous use of topical and systemic antifungal drugs. Yeast isolates were identified by classical methods and the antifungal susceptibility profile was determined according to NCCLS microbroth assay. The prevalence of vaginal yeast isolates from asymptomatic women was 25% (30/121) and 60% (50/84) among patients with symptoms of vulvovaginitis. Candida albicans was the most frequently isolated species in both groups (46% and 90%, respectively), followed by C. glabrata (13% and 6%, respectively). All isolates were susceptible to amphotericin B. Only ten isolates had dose dependent susceptibility (DDS) or resistance to azoles; and seven of these were non-albicans species. Based on our results we suggest that species identification and antifungal susceptibility testing need not be routinely performed in immunocompetent women, and may be reasonable only for the minority of patients with complicated vulvovaginal candidiasis that fail to respond to therapy.

Perineal group A streptococcal disease in a pediatric practice

OBJECTIVE

This study was designed to document the frequency and define the clinical, epidemiologic, and microbiologic characteristics of perineal disease caused by group A beta-hemolytic streptococci (GAS) in a pediatric practice in which increased numbers of cases had been observed.

METHODS

Clinical, epidemiologic, and microbiologic data were collected on all culture-confirmed cases of perineal GAS disease during the calendar year 1997. GAS isolates from clinical cases and a comparison group of children with GAS pharyngitis were analyzed by T typing, emm gene analysis, and pulsed-field gel electrophoresis (PFGE).

RESULTS

Twenty-three cases of GAS perineal disease were diagnosed during 4530 office visits in 1997. Thirteen cases had perianal disease, 8 had vulvovaginal infection, and 2 were infected at both sites. No cases of penile disease were identified. Infections peaked in late winter and early spring and affected children with an average age of 5 years with a range of perineal, gastrointestinal, and genitourinary symptoms. Analysis of T and emm types showed the majority (82%) of perineal isolates to be T 28 emm 28, showing 2 closely related PFGE patterns. In contrast, the pharyngeal isolates were distributed among 6 different T and emm types.

CONCLUSION

Perineal infection caused by GAS may be a relatively common diagnosis in a pediatric or family practice setting. There may be specific GAS types that have a tropism for perineal tissues but the mechanism of infection is yet to be established.

Contagious agalactia of small ruminants: current knowledge concerning epidemiology, diagnosis and control

Contagious agalactia of small ruminants is a syndrome which principally affects the mammary glands, joints and eyes. The main causal agents are Mycoplasma agalactiae in sheep, and M. agalactiae, M. mycoides subsp. mycoides large colony type and M. capricolum subsp. capricolum in goats. In addition, M. putrefaciens can produce a similar clinical picture, particularly in goats. Contagious agalactia occurs on all five continents and is often enzootic. The evolution of the infection tends to be chronic in affected animals and herds. Symptomless shedding of mycoplasmas, mainly in the milk, may persist for a long time. These insidious infections, associated with carriage in the ears of healthy animals, are difficult to diagnose and to control. The main mode of transmission between flocks is related to the sale of carrier animals and contact during transhumance, whereas transmission within a flock occurs through contact, suckling and milking. This review discusses the clinical features, epidemiology, treatment, prevention and control of the disease.

Vulvovaginitis during childhood and adolescence

STUDY OBJECTIVE

To evaluate cases of vulvovaginitis treated in our institutions.

DESIGN

Follow-up of 1,778 cases of vulvovaginitis to investigate the prevalence of various pathogens involved in the disease.

SETTING

Divisions of pediatric and adolescent gynecology, university hospitals of Crete and Athens, Greece.

PARTICIPANTS

Girls 1-18 years old seen at the clinics of the above institutions.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Vaginal culture, cytology, and vaginoscopy.

RESULTS

Vulvovaginitis was encountered in 61.8% of the gynecological problems seen during childhood and adolescence. Infections were usually located in both the vulva and the vagina (56.9%). The main symptoms were vaginal discharge (53%), erythema (33%), and pruritus (27%). Candida spp (23.0%), beta-hemolytic Streptococci group B (15.0%), and Enterococci spp (10.0%) were the most frequent pathogens involved in the disease.

CONCLUSIONS

Vulvovaginitis is a common disease during childhood and adolescence. Effective treatment, reassurance, and appropriate consultation based on the prevention of relapses are the most important steps for the management of the disease.

[Microbiological study of vulvovaginitis in premenarcheal girls]

BACKGROUND

A prospective microbiological study of the vaginal swab specimens from premenarcheal girls with clinical diagnosis of vulvovaginitis was done from the 1st of September 1991 to the 31st of August 1994.

PATIENTS AND METHODS

Vaginal secretions from premenarcheal girls with clinical findings were examined. Most important pathogenic agents were investigated and if there was an inflammatory reaction in the Gram stain and a heavy growth on culture, other potentially pathogenic agents were considered also.

RESULTS

In 70 (28.7%) of the 262 patients a potentially pathogenic microorganism was found: eight cases (3.0%) due to Streptococcus pyogenes, four cases (1.5%) due to Candida albicans. Only in one case Neisseria gonorrhoeae was isolated. Among the uncertain etiologic agents, Haemophilus influenzae was the most frequently isolated (7.6%). In 25 (12.6%) of the 198 patients Enterobius vermicularis ova were visualized.

CONCLUSIONS

Streptococcus pyogenes was the most frequently related organism with the vulvovaginitis syndrome among the traditionally established pathogens. The role of Haemophilus influenzae should be considered due to the high prevalence of isolation in this group of patients. We consider that differential diagnosis with Enterobius vermicularis infestation should be done in all cases.

The high vaginal swab in general practice: clinical correlates of possible pathogens

Clinical features, diagnosis and treatment of 286 women whose high vaginal swabs (HVS) submitted by their general practitioners showed pure, heavy growth of Staphylococcus aureus, beta haemolytic streptococci groups A, C or G, Streptococcus milleri, Streptococcus pneumoniae or Haemophilus influenzae were analysed. Women with group A, C and G streptococci frequently had clinical vulvovaginitis and although the numbers were too small for statistical confirmation, S. pneumoniae and H. influenzae appeared to cause clinical disease as well. The association of S. aureus or S. milleri with clinical vulvovaginitis was much less convincing. It seems relevant for laboratories to report sensitivities for group A, C and G streptococci. Further research is needed to determine the pathogenicity of S. pneumoniae and H. influenzae.

The serotypes of Streptococcus pyogenes present in Britain during 1980-1990 and their association with disease

A total of 16,909 cultures of Streptococcus pyogenes (Lancefield group A) isolated in Britain during 1980-90 were examined for T- and M-protein antigens. One or other M antigen was detected in 92.6% of the strains. The numbers of isolates of some serotypes, such as M3 and M12, did not show great variation from year-to-year, whereas there were nationwide epidemics, extending over several years, caused by strains of serotypes M1 and M49. Isolates of serotypes M1 and M3 were associated particularly with invasive disease and fatal infections. Representatives of serotypes M80, M81 and the provisional types PT180, PT1658 and PT5757 were isolated most often from cases of pyoderma. Erythromycin resistance was detected in 30 serotypes but one half of all of the resistant isolates belonged to serotype M4.

[Clinical results of pediatric gynecologic consultation at the Heidelberg University Gynecologic Clinic]

During the research period from January 1984 through June 1991 649 patients between the age of 0 and 16 were examined. Divided into 13 diagnostic groups the vulvovaginitis occurred most frequently with 30.6%. The predominant causal agents were E. coli (18.1%) and streptococci B (11.5%). Almost 24% did not show any agents. Aside from malformations of the genitals (6%), the genital bleedings (8.3%), genital tumours (2.7%), the search for anticonceptives (7.5%), examinations by specialists (8.1%) and borderline surgical problems, cycle disorders (14.7%) were most frequent. Among the cycle disorders dysmenorrhea and oligomenorrhea were predominant. The hormonal inhibition of growth was also checked very carefully. Thus the necessity of well-aimed training of children's gynaecology becomes dear. Our results stress the importance of an intensive disciplinary contact between gynaecologists who are interested in pediatrics and pediatricians.

[Vulvovaginitis in premenarche girls. A preliminary study]

The study population consisted of 832 premenarcheal girls. Vaginal cultures are performed on 40 premenarcheal girls suffering from vulvovaginitis. All were less than 7 years old. This patients were seen in primary cares. In 23 cases (57.5%) E. coli was isolated, Enterococcus (30%), mixed flora (10%) and G. vaginalis (2.5%). Common clinical characteristics were pruritus (97.5%), vaginal discharge (67.5%). Dysuria and abdominal pain constituted accompanying symptoms. Only in one case masturbation was observed.

Streptococcus pyogenes vulvovaginitis in children in Nottingham

Isolates of Streptococcus pyogenes from vaginal swabs of children with vulvovaginitis received at Nottingham Public Health Laboratory during 1986-9 were studied. A total of 159 isolates was made during the 4 years, increasing from 17 in 1986 to 64 in 1989 and accounting for 11% of all vaginal swabs received from children. The numbers of throat swabs yielding S. pyogenes also showed an increase from 974 in 1986 to 1519 in 1989. A winter peak of isolates was noted for both vaginal swabs and throat swabs. A total of 98 strains from vaginal swabs were serotyped: 22 different types were identified, 61% of which were the common types M4, M6, R28 and M12. Erythromycin sensitivity was done on 89 strains; 84% were highly sensitive (MIC less than 0.03 mg/l). There are no other reports of such large numbers in the literature; the reason for seeing this increase in Nottingham is unclear.

Round table on infectious bovine rhinotracheitis/infectious pustular vulvovaginitis virus infection diagnosis and control

The current situation of infectious bovine rhinotracheitis/infectious pustular vulvovaginitis infection in various European countries is reviewed. Whilst some have a high serological prevalence and use live virus vaccines to control the disease, others have a low prevalence and two countries (Denmark and Switzerland) have national eradication schemes which are almost complete. Serology remains important for diagnosis although other tests such as delayed cutaneous hypersensitivity may have a role to play. New tests such as polymerase chain reaction may find increasing application where high sensitivity is required, such as the detection of virus in semen.

Papillomavirus and vulvovaginal neoplasia

Cumulative evidence strongly implicates human papillomavirus (HPV) in the genesis of squamous neoplasia of the lower female genital tract, including the vulva. The association of HPV with neoplasms at that site includes the relationship of specific HPV types with neoplasms and evidence that those HPV DNA types can transform epithelial cells in vitro. The capacity for in vitro transformation has been isolated to specific regions of the HPV genome. That may be unique in cancer-associated viruses. Nevertheless, epidemiologic evidence points to additional factors, including immunologic, habitual and environmental, that may play an important role in the development of lower genital tract carcinomas. In particular, the marked differences in mean age and other variables between women with vulvar precancers and invasive cancer suggest that the evolution of invasive cancer involves more than HPV infection alone. Hence, the prevention of invasive vulvar cancer in older age groups will require an understanding of the unique host factors that render a small group of women susceptible to the disease in the face of an epidemic of HPV infection in the population at large.

Clinical evaluation of terconazole. United states experience

Terconazole is the first of a new class of antifungal agents, the triazoles. The results of numerous European studies have demonstrated the efficacy and safety of this agent in both cream and suppository form in the treatment of vulvovaginal candidiasis. Recently, results of short- and long-term analyses in the United States confirmed the efficacy and safety of 0.4% terconazole cream and 80-mg terconazole suppositories. In short-term evaluations (eight to ten days after therapy), 0.4% terconazole cream was as effective as 2.0% miconazole nitrate cream and significantly superior microbiologically in one study. The clinical cure rates with terconazole cream ranged from 87.3% to 95.5% and the microbiologic cure rates, from 76.9% to 91.1%. Thirty- to 35-day microbiologic relapse rates with terconazole cream ranged from 10.4% to 22.2%. In the short-term evaluations of vaginal suppositories the cure rates of 80-mg terconazole suppositories for three days were comparable to those of 100-mg miconazole nitrate suppositories for seven days. The clinical cure rates with 80-mg terconazole suppositories ranged from 90.0% to 92.2% and the microbiologic cure rates, from 80.4% to 85.0%. The 30- to 35-day microbiologic relapse rates of the 80-mg terconazole suppositories ranged from 20.0% to 28.1%. Terconazole cream and suppositories demonstrated an excellent safety profile in all the studies; no life-threatening side effects occurred with any of the regimens. The frequency of common side effects was similar with terconazole and miconazole nitrate formulations.

Chlamydia trachomatis genital infections in Tahiti

The rate of Chlamydia trachomatis infection was determined in three populations in Tahiti by means of a direct immunofluorescence test performed in specimens, tissue culture and detection of chlamydial antibody in serum specimens using a single-serotype indirect immunofluorescence test. Chlamydia trachomatis was recovered in 53% of 53 bar girls, 24% of 75 women attending a public maternity clinic for routine care, and 37% of 71 men attending a sexually transmitted disease clinic with acute or subacute urethritis. The presence of chlamydial antibody in a high proportion of the groups studied confirmed the high frequency of chlamydial infections (62.3%, 66.6% and 83.1% respectively). Neisseria gonorrhoeae infection was often associated with chlamydial infection in both bar girls and men with urethritis (11.4% and 18.3% respectively). With regard to clinical manifestations, 58.3% (7/12) of bar girls and 23.2% (10/43) women at the maternity clinic without clinical complaints were found to be Chlamydia trachomatis-positive. The presence of Chlamydia trachomatis in these asymptomatic persons highlights their important role in spread of this organism in Tahiti. The findings indicate that routine testing for Chlamydia trachomatis is warranted in patients attending the sexually transmitted disease and public maternity clinics in Tahiti.

Vulvovaginitis of goats due to a herpesvirus

Two concurrent outbreaks of genital disease in goats were associated with infection by a herpesvirus that was isolated from vulval and vaginal lesions of affected does. Serum neutralising antibody to the virus was present both in goats with the clinical disease and some unaffected goats. Of 19 goat herds examined only 4 had serum neutralising antibody positive goats with low (5%) to high (60%) incidence of infection. The virus isolate was characterised as a herpesvirus on its physico-chemical and morphological features. It contained DNA and was inactivated at low pH and by treatment with lipid solvents and trypsin. The virus particles were icosahedral, consisting of a nucleocapsid surrounded by an envelope membrane and measured approximately 150 nm in diameter. The virus was serologically related to a New Zealand isolate of caprine herpesvirus (NZ-CpHV), associated with similar genital disease, and was distinct from bovine herpes virus-1 (BHV-1) showing a one way neutralisation pattern.

Gonococcal vulvovaginitis among female children in Malaysia

In this retrospective review of 16 children with vulvovaginitis due to Neisseria gonorrhoeae, the authors attempt to estimate the incidence of this infection and to ascertain the routes of transmission. From January 1977 to December 1982, 422 cases of gonococcal vulvovaginitis in women of all age groups were encountered at the University Hospital, Kuala Lumpur, Malaysia. Of these, 406 cases (96.2%) occurred in adults, and 16 cases (3.8%) occurred in children younger than 12 years of age. Penicillinase-producing N. gonorrhoeae (PPNG) strains were isolated from five (31%) of the 16 girls; all five cases were subsequently treated with cefuroxime and probenecid. The rest responded to intramuscular procaine penicillin. Although all patients appeared to be cured, only ten of 11 (two with PPNG) had test-of-cure cultures performed after treatment. Although interviewing the parents revealed no history of sexual contact in these children, nine of the girls were linked to culture-positive adult(s).