Surgical implications of pseudomonas aeruginosa necrotizing fasciitis in a child with acute lymphoblastic leukemia

Necrotizing fasciitis caused by Pseudomonas aeruginosa is extremely rare. Only 4 cases were reported in the literature. The authors report the occurrence of P aeruginosa necrotizing fasciitis starting out as a vulval abscess in a girl before induction chemotherapy for acute lymphoblastic leukemia. To our knowledge, this is the second case described in association with leukemia. In this case, the outcome was favorable because of early surgical intervention, confirming the diagnosis. J Pediatr Surg 36:948-950.

Efficacy of maintenance therapy with topical boric acid in comparison with oral itraconazole in the treatment of recurrent vulvovaginal candidiasis

OBJECTIVE

Our purpose was to examine the efficacy of a topical long-term treatment with boric acid versus an oral long-term treatment (itraconazole) in the cure and prevention of recurrent vulvovaginal candidiasis.

STUDY DESIGN

A prospective, nonrandomized study of patients affected by recurrent vulvovaginal candidiasis was undertaken. In 3 years we recruited 22 consecutive patients who underwent therapy with itraconazole (group 1) or boric acid (group 2). Women were followed up for 1 year, with clinic and microbiologic controls after 1, 3, 6, and 12 months after the first visit.

RESULTS

During the treatment, the positive culture results (15.1% vs 12.1%) and the signs and symptoms (33.3% vs. 24.2%) were similar within the 2 groups, with no significant statistical difference. With the withdrawal, after 6 months relapses were common in the 2 groups (54.5%).

CONCLUSIONS

Boric acid seems to be a valid and promising therapy both in the cure of the vaginal infection and in the prevention of relapses of recurrent vulvovaginal candidiasis, but its efficacy ends with the suspension of the therapy.

Pure versus complicated vulvar vestibulitis: a randomized trial of fluconazole treatment

OBJECTIVE

To examine the effectiveness of a 6-month treatment consisting of a weekly oral dose of 150 mg fluconazole for women with vestibulitis, and to explore the causes of treatment failure.

METHODS

Forty women with vestibulitis were randomized to either of two treatment groups. One group received a 6-month low oxalate diet with calcium citrate complement, as a placebo, and the second group the same diet and calcium citrate with the addition of a weekly oral tablet of 150 mg fluconazole. The women were examined 3 months after completing treatment, for response to therapy.

RESULTS

The addition of intensive 6-month fluconazole treatment did not lead to an outcome better than that attained by maintaining a low oxalate diet with calcium citrate supplementation. The satisfactory response rate was 15 and 30%, respectively. The presence of 'complicated vestibulitis', candidiasis concomitant with vestibulitis, decreases the satisfactory response rate regardless of the type of treatment administered (odds ratio 19.9, 95% CI 1.6, 250).

CONCLUSION

Prolonged oral fluconazole is an ineffective treatment of vestibulitis, whether pure or complicated by concomitant vulvovaginal candidiasis. The coexistence of candidiasis and vestibulitis - complicated vestibulitis - might represent a subset of vestibulitis that is resistant to the currently available medical therapy.

Trichophytic granuloma of the vulva

Fungal infections causing deep tissue involvement are known as trichophytic granulomas. We describe an unusual case of trichophytic granuloma presenting in the vulva of a 39-year-old woman.

Vulvar symptoms in paediatric and adolescent patients

Vulvovaginal symptoms in children and young adolescents are not yet very well understood, nor is the actual incidence known. This study evaluates the character and possible infectious aetiology of vulvar symptoms of females aged up to 16 y. The signs, symptoms and bacteriological findings of 68 consecutive cases were studied. The study was conducted in the University Hospital of Tampere at a special gynaecological consultation clinic for children and adolescents. Sixty-eight patients were included in the study: 48 girls (71%) were prepubertal, at Tanner stage M1P1, 26 patients were 2-4-y-old and 15 were 5-7-y-old. The duration of symptoms was known for 46 patients: 41% had had symptoms for >1 mo and 20% for >6 mo. Forty-eight patients had abnormal clinical findings on examination and 16 (33%) of them had an infectious aetiology. Streptococcus pyogenes infection was identified in 11 (16%) patients, all of whom had symptoms. Candida was identified in 6 (9%) patients. No infectious aetiology was found among 26 patients who had symptoms and abnormal clinical findings. Vulvovaginal symptoms during childhood are more common among younger children (<7 y). In 67% of patients no infectious aetiology could be found. Samples for microbiological culture should be taken from symptomatic patients and symptomatic areas. Cultures of Candida and bacteria are necessary but usually sufficient. If a microbiological aetiology is established, treatment can be assigned accordingly. Patients with vulvar symptoms and findings but with an unclear aetiology need support and advice on proper hygiene and can intermittently use mild corticosteroids locally.

An infective aetiology for vulval lichen sclerosus re-addressed

Although there is evidence to support an autoimmune basis for lichen sclerosus, there have also been some studies which suggest an infective aetiology. These include reports of the presence of spirochaetal forms with Steiner silver stains and purplish coccoid forms with Fite stains. We have repeated these studies on vulval biopsies obtained from 16 patients with vulval lichen sclerosus. Using the Steiner silver method we found no evidence of spirochaetal forms in any of the specimens. With the Fite stain we observed purple-staining coccoid forms within the dermis of 13 of the 16 lichen sclerosus specimens. However, these coccoid forms also stained strongly positive with toluidine blue, suggesting they were mast cell granules rather than micro-organisms. We were therefore unable to demonstrate evidence for an infective aetiology in vulval lichen sclerosus, although this cannot yet be excluded. Further work is also needed to understand the significance of mast cells in lichen sclerosus.

Effect of antibiotic use on the prevalence of symptomatic vulvovaginal candidiasis

OBJECTIVE

The purpose of the study was to evaluate the influence of antibiotic use on the prevalence of symptomatic vulvovaginal candidiasis.

STUDY DESIGN

This is a case-control study of 684 women with symptomatic vulvovaginal candidiasis who were enrolled at a vaginitis clinic and 901 control subjects who attended a cytologic screening service.

RESULTS

The prevalence of antibiotic use in the month preceding the visit was 19.3% (132/684) among patients with Candida infection compared with 11.9% (107/901) among control subjects (P <.001). After adjustment by logistic regression for potential confounders (age, marital status, and contraceptive method used), the odds ratio for vulvovaginal candidiasis among patients who reported antibiotic use in the month preceding the visit was 1. 75 (95% confidence interval 1.33 to 2.32). No differences in risk were found by type of antibiotic used. The likelihood of vulvovaginal candidiasis was directly related to the duration of antibiotic use and was higher in patients who had a history of repeated episodes of Candida vaginal infection.

CONCLUSIONS

Antibiotic use is a short-term risk factor for symptomatic vulvovaginal candidiasis, either as a first episode or in the form of recurrence. Increasing duration of antibiotic use is directly related with an increased prevalence of Candida vaginal infection.

Vulvodynia. Theory and management

Vulvodynia, defined as vulval pain, soreness or burning as opposed to itching or pruritus, is a common and important problem. Although not a sexually transmitted disease, it often presents to physicians working in that field. The main groups of vulvodynia are those where the symptoms are the consequence of an active dermatosis or infection, and those where it is not attributable to such conditions. In the latter group, the patients fall into two main categories: those of dysesthetic vulvidynia, with constant unprovoked pain, and vulval vestibulitis, with pain provoked by attempted vaginal entry. The recent realization that dysesthetic vulvodynia and vulval vestibulitis may be regarded as pain syndromes is proving a fruitful concept as regards both theory and management of these troublesome conditions.

Vulvar disorders in prepubertal girls. A literature review

OBJECTIVE

To review and discuss vulvar disorders in prepubertal girls.

STUDY DESIGN

Literature review.

RESULTS

Bacterial and fungal vulvitis, dermatitis, inflammatory dermatoses, secondary drug reactions, viral infections and a variety of vulvar tumors can all present as primary vulvar problems in prepubertal girls. In addition, systemic diseases can present with vulvar involvement.

CONCLUSION

In order to facilitate optimal care of prepubertal girls with vulvar disorders, a comprehensive review of the literature is presented.

Postpartum and vulvar necrotizing fasciitis. Early clinical diagnosis and histopathologic correlation

OBJECTIVE

To review the clinical course and correlate histopathologic findings of obstetrics and gynecology patients with necrotizing fasciitis

STUDY DESIGN

Seven-teen patients with postpartum or vulvar necrotizing fasciitis were identified from 1981 to 1996. Medical records were retrospectively reviewed. Information was available for all patients until death or discharge from the hospital. Histopathologic material on 15 patients was available for review.

RESULTS

Five postpartum patients were diagnosed and surgically debrided one to nine days after cesarean delivery, with no mortality. Twelve patients with vulvar necrotizing fasciitis were diagnosed and surgically debrided <1-10 days after presentation to a physician, with three deaths (25%). On histopathologic review, all cases had prominent lobular and septal panniculitis. Thirteen cases had histologic evidence of fasciitis.

CONCLUSION

Early diagnosis and aggressive surgical debridement in patients with postpartum and vulvar necrotizing fasciitis may improve the outcome. Histopathologic findings are remarkably consistent and may help to confirm the diagnosis.

Risk assessment, symptoms, and signs as predictors of vulvovaginal and cervical infections in an urban US STD clinic: implications for use of STD algorithms

OBJECTIVE

To identify clinical epidemiological correlates of cervical and vaginal infections and assess alternative algorithms, including two new reproductive tract infection (RTI) algorithms, for syndromic management of these infections.

DESIGN, SETTING AND SUBJECTS

We prospectively studied clinical manifestations and risk correlates of cervical and vaginal infections in a randomly sampled group of 779 female patients seeking evaluation for a new problem at a Seattle STD clinic.

METHODS

One experienced clinician performed standardised history, physical examination, and microscopy. Reference laboratories performed microbiological tests. Three levels of retrospective evaluation of algorithms included risk assessment and symptom review (RAS) alone; addition of speculum and bimanual examinations; and further addition of microscopy.

RESULTS

(1) Chief complaint of abnormal vaginal discharge predicted a significantly lower rate of gonorrhoea (GC) or chlamydial infection (CT) than rates observed with no complaint of vaginal discharge. Only the elicited symptom of yellow vaginal discharge (not the more common symptoms of increased or malodorous vaginal discharge) predicted GC or CT. Chief complaint of abnormal vaginal discharge itself predicted trichomoniasis (TV) and bacterial vaginosis (BV), not cervical infection. Candida albicans was strongly associated with the chief complaint of vulvar pruritus, not with the chief complaint of abnormal vaginal discharge. (2) Applying these algorithms in STD clinics only to women with the chief complaint of abnormal vaginal discharge, rather than to all women, decreases sensitivity for GC or CT, without increasing positive predictive value (PPV). Criteria for inclusion of patients have more effect on the performance of these algorithms than do the levels of evaluation used. (3) A modified World Health Organisation (WHO) algorithm applied only to patients with symptoms of vaginal discharge, involving treatment of RAS positives for cervical infection, followed by treatment of vaginal infections and cervicitis based on examination of RAS negatives and positives, had a sensitivity of 50% and PPV of 33% for cervical infection, and very low sensitivity for BV, TV, and for vulvovaginal candidiasis (VVC). (4) An RTI algorithm derived from these data, and applied to all STD patients, involving RAS and examination of all RAS negatives, provided treatment to all cases of BV and TV associated with symptoms of vaginal discharge; treatment of all VVC associated with symptoms of vulvar pruritus; treatment for GC and GT to all RAS positives (using easily elicited risk factors) and to RAS negatives with signs of cervicitis or PID. This algorithm had a sensitivity of 87% and a PPV of 33% for GC or CT in this population, with its 24% prevalence of GC or CT. The sensitivity for BV, TV, and VVC greatly exceeded that of the modified WHO algorithm. (5) A modified RTI algorithm, involving examination rather than treatment of RAS positive women, no examination of RAS negatives, decreased the sensitivity for cervical infection to 55% but increased the PPV to 51%.

CONCLUSIONS

Syndromic management of vaginal discharge offers relief of symptoms, prevention of transmission of trichomonas, and perhaps prevention of complications of BV. The 51% PPV of the modified RTI algorithm probably would warrant treatment and partner notification for GC and CT in settings with similar rates of GC and CT where more specific tests are lacking. However, as the prevalence of GC or CT decreases, the ratio of uninfected to infected who receive treatment with these algorithms would increase greatly, making the algorithms potential victims of their own success.

Disseminated Histoplasma capsulatum infection presenting as genital ulcerations

BACKGROUND

Histoplasma capsulatum infection in adults is most often subclinical but can result in disseminated disease with weight loss, fever, hepatosplenomegaly, and oropharyngeal ulcerations. Genital ulceration as the presenting sign of the disease has been reported rarely.

CASE

A 63-year-old woman presented with multiple vaginal ulcerations due to chronic disseminated H capsulatum infection. Initial diagnosis was made by Papanicolaou and Giemsa-stained vulvar smears. Ketoconazole therapy resulted in clearing of the lesions in 5 weeks.

CONCLUSION

Chronic disseminated histoplasmosis is an insidious and potentially fatal disease that can present rarely as genital mucocutaneous ulcerations in women. Prompt presumptive diagnosis can be accomplished by examination of smears obtained by ulcer abrasion, permitting institution of appropriate therapy.

Labial masses following vaginoplasty in male transsexuals: the differential diagnosis

Following vaginoplasty and vulvoplasty for male-to-female transsexualism, a mass may evolve in one of the major labia in a minority of patients. From April of 1989 to April of 1994, we treated seven patients with such masses. The case reports presented illustrate some of the differential diagnoses of this long-term complication. More often than not, the swelling was caused by infection. The funiculus or even testicular rest in itself also may represent the mass. Intralabial urethral fistula appears to be the second cause of swelling, either with or without inflammation. As an exceptional cause we observed a swelling representing a cyst of prostatic origin. In all, the mass could be excised completely.

Pasteurella multocida--an uncommon cause of obstetric and gynaecological sepsis

Pasteurella multocida is a common cause of wound infection following animal-inflicted wounds, but is a rare cause of female genito-urinary sepsis. We present a case of vulval sepsis and a case of intrapartum septicaemia with this bacterium. These two cases indicate that Pasteurella multocida can occasionally colonise the female lower genital tract and this bacterium should be considered in the differential diagnosis of serious infection related to this site.

Management of human papilloma virus vulvo-perineal infection with systemic beta-interferon and thymostimulin in HIV-positive patients

OBJECTIVES

To evaluate the effect of a combined therapy based on beta-interferon and thymostimulin in HIV-seropositive women with florid vulvoperineal condylomatosis.

METHODS

Nineteen HIV-seropositive women affected by HPV florid vulvo-perineal infection were studied. Their ages ranged from 19 to 32 years (mean = 26); all were smokers; 11 (57.89%) were intravenous drug users with a mean period of drug addiction of 5 years. No patient was on AZT therapy. All patients underwent a combined medical therapy based on beta-interferon administration with doses of 3,000,000 IU i.m. daily for 7 days and subsequently on alternate days for 2 weeks associated with the administration of 70 mg i.m. of thymostimulin per day on alternate days for 30 days.

RESULTS

Seven (36.84%) patients showed complete recovery at the end of follow-up; 5 (26.31%) patients showed partial recovery and 7 (36.84%) did not respond to therapy.

CONCLUSION

A pro-host immunotherapy seems to be indicated in patients affected by immunodeficiency syndrome.

Demonstration of Epstein-Barr virus DNA in acetowhite lesions of the vulva

Acetowhite lesions in the vulva disclosing koilocytosis have been related to infection by human papilloma virus (HPV). Because of the clinical resemblance of these lesions to oral hairy leukoplakia (OHL), and EBV-manifestation, 23 women with acetowhite koilocytotic lesions in the vulva were examined. The PCR-technique was used to detect EBV DNA as well as HPV DNA in 17% of 23 patients examined. In a control group of 19 patients EBV DNA was detected in 11% and HPV DNA in 42% of cell samples from normal vulvar mucosa. EBV DNA has not previously been demonstrated in the vulvar mucosa, and this virus might be related to subclinical acetowhite lesions.

Vaginismus: an important factor in the evaluation and management of vulvar vestibulitis syndrome

Dyspareunia is a common complaint in general gynecological practice. Many patients with dyspareunia suffer from vulvar vestibulitis syndrome (VVS). This syndrome constitutes severe pain on vestibular contact or attempted vaginal entry, tenderness to pressure within the vulvar vestibule and physical findings of vulvar erythema of various degrees. As a last resort, and only when all conservative treatments have failed, surgery is attempted. It has been our observation that a considerable percentage of patients with VVS present with concomitant vaginismus. Furthermore, surgery is less successful in this subgroup of patients unless the vaginismus is first treated. This report describes the evaluation and treatment of 14 patients with VVS.

Multicentric papillomavirus infection of the female genital tract. A study of morphologic pattern, possible risk factors and viral prevalence

We have investigated 103 biopsy specimens obtained from 50 women (average 28.1 years, range 16-66) with multicentric condylomatosis of the genital tract, including the uterine cervix (48 samples), the vagina (23), and the vulva (32). Each patient had at least 2 biopsies. A positive in situ hybridization for a Human Papilloma Virus (HPV) cocktail was observed in samples from 38 patients: in these multiplicity of lesions regarded the cervix and vulva (22 cases), cervix and vagina (12), vulva and vagina (1), cervix, vulva and vagina (3). Viral types 6,11 were more prevalent in simple condylomata. Both low- and high grade lesions of cervix, vagina, and vulva showed prevalence of types 16, 18 and 31, 33, 35. Signaling for more than one probe cocktail was detected in 14 (13.6%) samples. Partner's condylomatosis was referred to by a sizeable minority of patients. It is concluded that the spectrum of HPV infection in the female genital tract reflects a multiplicity of factors, including involved viral type and site, immunitary reaction of the host, perpetration or reactivation of latent infections.

[Kerion of the vulva. Report of a case and review of the literature]

We report a case of a 43 year old woman who developed an extensive vulvar kerion caused by Trichophyton menthagrophytes that was initially mistaken for a bacterial infection. The peculiarity of this case lies in the fact that the kerion is rarely located in the vulva and it has not yet been described in the literature. On the contrary, cases have been found in the scalp, beard, eye-brow, etc. We discuss the etiopathogenetic aspects, criteria for differential diagnosis and therapy management of this rare clinical picture.

Evaluation of a monoclonal antibody-based enzyme immunoassay for early detection of herpes simplex virus genital infection

A monoclonal antibody-based enzyme immunoassay test for detection of herpes simplex virus (HSV) type-common antigen was evaluated in 40 women with vulvar lesion suspicious for genital HSV infection. The assay gave interpretable readings in 90% of the cases, with sensitivity and specificity of 100% and 92% respectively, a negative predictive value of 100%, and a positive predictive value of 75%. With a few limitations, the assay may be used for early diagnosis of genital HSV infection.