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Case 343

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The patient is a 55 y/o female, married, sexually active, G4P4A0, with a yellowish and slightly malodorous vaginal discharge for the last 5 months, associated with vaginal pruritus. Last menstrual period was one month ago. In use of an intrauterine device. On gynecological exam, there is vulvar erythema, discreetly atrophic and hyperemic vaginal mucosa, and an abundant yellowish vaginal discharge. Schiller’s test was performed (Image 1).

Based on the image and the clinical history, what is the most likely diagnosis?

a) Suppurative cervicitis

25%

b) Trichomoniasis

25%

c) Vulvovaginal candidiasis

25%

d) Bacterial vaginosis

25%
   

Image analysis

Image 1:Photography of gynaecologic speculum examination after Schiller’s test was performed, revealing lesions resulting from capillary dilation and punctate hemorrhages, characterizing macular cervicitis or “strawberry cervix” (yellow circles). The intrauterine device’s string can be noted externalizing from the cervical canal (white arrow).

Highlights

- Vaginal discharges must be distinguished from physiologic vaginal secretion, which is asymptomatic, low-volume, with little or no malodour, and variable with the menstrual cycle;

- Signs of vaginitis: abnormal vaginal discharge, malodour, pruritus, irritation, burning sensation and dyspareunia;

- The main causes of vaginitis are infectious: bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis;

- The diagnosis is based on clinical history, and additional testing includes vaginal pH, KOH test and microscopic examination;

- Etiologic definition is essential for defining the treatment.

References

- Rio SMP. Corrimento vaginal. In: Camargos AF, Melo VH, Carneiro MM, Reis FM. Ginecologia ambulatorial baseada em evidências científicas. 2 ed. Belo Horizonte: Coopmed; 2008. p. 591-606.

- Paladine HL, Desai UA. Vaginitis: diagnosis and treatment. Am Fam Physician. 2018; 97(5):321-329.

- Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Comissão Nacional de Incorporação de Tecnologia no SUS. Protocolo clínico e diretrizes terapêuticas infecções sexualmente transmissíveis – relatório de recomendação. Brasília: Ministério da Saúde, 2015.

- Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) international union against sexually transmitted infections (IUSTI) world health organisation (WHO) guideline on the management of vaginal discharge. International Journal of STD & AIDS. 2018;0(0):1-15.

Authors

Mateus Jorge Nardelli, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: mateus.nardelli[at]gmail.com

Supervisors

Rayana Rolla Campos, Volunteer Professor of the Gynaecology and Obstetrics department at Faculdade de Medicina da UFMG.

E-mail: rayanarc[at]gmail.com

Reviewers

Luana Almeida, Guilherme Carvalho, Daniela Manso, professor José Nelson Vieira and professor Viviane Santuari Parisotto Marino.

Translated by

Rafael Antonio Teixeira Malta, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: rafaelmalta148[at]gmail.com

Test question

a) Cytolytic vaginitis

25%

b) Bacterial vaginosis

25%

c) Trichomoniasis

25%

d) Chlamydial cervicitis

25%

e) Candidose

25%
   

Commentics

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