1. VAGINITIS
2. TOXIC SHOCK SYNDROME
3. SCABIES
4. PEDICULOSIS
5. VIBRIONIC ABORTION
6. PUERPERAL FEVER
7. LISTERIOSIS

Etiology

Bacterial Vaginosis (BV) is caused by Gardnerella vaginalis, Mycoplasma hominis and various anaerobic bacteria including Mobiluncus sp., and Prevotella sp. BV is the most common vaginal infection. The disease has been found in 12 to 25 percent of women in routine clinic populations, 10 to 26 percent of women in obstetrics clinics and 32 to 64 percent of women in clinics for sexually transmitted infections (STI’s).

Other organisms can cause vaginitis; Candida albicans (candidiasis) and Trichomonas vaginalis (trichomoniasis). These infections of the vagina are discussed in this section of the chapter as well.

Manifestations

Vaginal infections are often accompanied by vaginitis, which is an inflammation of the vagina characterized by discharge, irritation, and itching. The cause of vaginitis cannot be adequately determined solely on the basis of symptoms or a physical examination. Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis. A variety of effective drugs are available for treating vaginal infections and accompanying vaginitis.

BACTERIAL VAGINOSIS

Etiology

Bacterial Vaginosis (BV) is usually caused by Gardnerella vaginalis, Mycoplasma hominis and various anaerobic bacteria including Mobiluncus sp., and Prevotella sp.

Manifestations

Bacterial vaginosis is usually manifested as an unpleasant vaginal odor in varying degrees and an excessive white or gray vaginal discharge with a milk-like consistency. Women often report that the odor is particularly embarrassing after sexual intercourse. When semen mixes with vaginal secretions, it lowers the acidity level to make the odor particularly strong. Odor may also be more noticeable around the time of menses. Vaginal itching or burning is also sometimes present. Up to 40% of women with BV may experience no outward symptoms. BV has been associated with pelvic inflammatory disease, which can result in infertility, as well as increased risk of endometritis, cervicitis, pregnancy complications, and post-operative infections. Pregnant women with BV in the 23rd to 26th weeks of pregnancy were 40% more likely to deliver a low birth-weight baby (i.e., less than 5.5 lbs).

Epidemiology

Pathogenesis

Bacterial vaginosis is caused by an overgrowth of bacteria rather than yeast or other organisms. These are primarily anaerobic bacteria and an organism called Gardnerella vaginalis, all of which can be found in low numbers in the healthy vaginal microflora. In women with BV, the vaginal balance is disrupted so that these bacteria overgrow at the expense of the protective bacteria; Lactobacillus. Lactobacilli produce hydrogen peroxide to help maintain a healthy and normal balance of microorganisms in the vaginal mucosa. Women who have been diagnosed with BV have up to 1,000 times more anaerobic bacteria than women without the disease. Instead of the normal predominance of Lactobacillus bacteria, increased numbers of organisms such as Gardnerella vaginalis, Bacteroides, Mobiluncus, and Mycoplasma hominis are found in the vagina in women with BV. The cause of this imbalance in the microflora of the vaginal mucosa is not currently known. Some studies have suggested that douching may be one cause of BV.

Diagnosis

Three of four criteria should be positive to obtain a diagnosis of BV

Treatment and Prevention

Products like douches or deodorant sprays that mask vaginal odor should not be used to treat BV. Although they may temporarily eliminate odor, they will not cure the condition. It is important to tell the patient not to douche or use a feminine hygiene spray for a few days before their appointment. These products may actually hide important clues that can help in diagnosing BV, and may make the condition worse. If the patient has BV then it can be treated with the following:metronidazole or clindamycin

Mycotic Vulvovaginitis or Vulvovaginal Candidiasis

Etiology

The causative agent of this disease is a yeast called Candida albicans.

Manifestations

The vaginal discharge frequently appears as a thick, curd like discharge containing epithelial cells and masses of hyphae/pseudohypha. The patient usually has intense pruritus of the vulva and erythematous vagina and labia.

Epidemiology

Overgrowth with C albicans is the second most common cause of vaginitis.

Pathogenesis

When the delicate balance of organisms in the vagina is upset, the yeast can overgrow and cause vaginitis. When a woman takes certain antibiotics to treat a bacterial infection, the antibiotic may also kill the lactobacilli that produce hydrogen peroxide to protect against yeast overgrowth. Other factors that may upset the balance and lead to yeast infection include pregnancy, obesity, diabetes, birth control pills, steroids, and prolonged exposure to moisture, and poor feminine hygiene.

Diagnosis

Diagnosis is frequently made based on the character of the vaginal discharge (i.e., curd-like discharge) and on other patient signs and symptoms. Grams stains and KOH treatment of the discharge can be performed to look for yeast cells and pseudohyphae.

Treatment and Prevention

Intravaginal agents like butoconazole, clotrimazole, nystatin or terconazole can be given. An oral antifungal agent fluconazole can also be given to treat this disease.

Trichomoniasis

Etiology

The etiological agent is a flagellated protozoan Trichomonas vaginalis.  It is a pear shaped organism exhibiting a characteristic motility described as a wobbling and rotating motion, recognition of this on wet mounts is important in diagnosis.

Manifestations

In females proliferation of the organisms is associated with a low-grade inflammation manifested by: itching and burning, painful urination and a frothy, green, creamy discharge, which is described as being leukorrheic and very malodorous. Because of the ease of anatomic spread to the urethra, urethritis develops and is manifested chiefly by; dysuria and increased frequency and urgency. Many women with this infection may not have any symptoms.

In males symptoms can be associated with urethritis and prostatovesiculitis however men are usually asymptomatic. If symptoms exist they include: dysuria and increased frequency and urgency. Occasionally in severe cases there is exudate formation

Epidemiology

Pathogenesis

Low-grade inflammation is associated with the presence of high numbers of trichomonads. This parasite attaches to the cells that line the surface of the vagina and produce proteases and cytotoxic toxins that cause the host cells to round up and detach. This damage results in an immunological response from the host with many PMN’s arriving at the mucosal surface of the vagina and in the vaginal discharge. These high numbers of trichomonads become established oftentimes because of a disruption of the normal flora that has allowed them to overgrow. Immunity to infection does occur but it is only partially protective against subsequent T vaginalis infections.

Diagnosis

Clinical diagnosis depends upon recognition of the symptoms of dysuria, frothy, cream, malodorous discharges associated with punctate lesions and hyperemia of the vagina. The most practical method of specific diagnosis is microscopic examination for motile trichomonads in vaginal or urethral discharges. This vaginal discharge contains many PMN’s which usually are not present in the other causes of vaginitis.

Treatment and Prevention

Metronidazole is effective in treating this infection. Most men have asymptomatic T vaginalis infections and so can give back this parasite back to their female sexual partner. The use of male condoms can lower chances of transmission from an asymptomatic male to their female sexual partner. However, the best means of avoiding reinfection is to treat the male sexual partner with metronidazole.

A. Epidemiology

• Seen most commonly in women, coincident with the onset of menstruation.
• Predisposing factors include use of hyperabsorbable tampons.
• Localized infections with TSST-1 producing strains of S. aureus can also cause TSS. This disease can occur in men as well as women.
• The case fatality rate is approximately 3.3% and there are approximately 150 cases per year.

C. Manifestations

• Fever (> 40°C), vomiting, diarrhea, and myalgias
• Hypotension (< 90 mm Hg) due to hypovolemia
• Diffuse, "sunburn like" erythematous rash (mostly on trunk, less on extremities), which characteristically undergoes desquamation.
• Conjunctival and vaginal hyperemia
• Signs of uremia

Toxic shock syndrome should be considered in cases involving unexplained fever associated with an erythematous rash and diffuse organ involvement, especially in menstruating women. Diagnostic criteria include:

• Fever > 38.9°C
• < 90 mm Hg systolic pressure
• Rash with subsequent desquamation (especially palms and soles)
• Involvement of > 3 organ systems
• Gastrointestinal (vomiting and diarrhea)
• Muscular (severe myalgias)
• Mucous membranes (hyperemia)
• Renal insufficiency (BUN and creatine and pyuria)
• Liver (hepatitis with bilirubin, SGOT and SGPT 2x normal)
• Blood (thrombocytopenia)
• CNS (disorientation without focal neurologic signs)

• Aggressive fluid replacement
• Beta lactamase resistant antibiotics (oxacillin or nafcillin) I.V.

A. Etiology

S. pyogenes M types 1 and 3 producing streptococcal pyogenic exotoxin A (Spe A).

B. Epidemiology

• As the result of a minor trauma, the organisms enter the body.
• About 50-100 cases/year.
• Case Fatality rate = 30-70%.

D. Case definition

1. Isolation of group A streptococcus
        a. From sterile site.
        b. From non-sterile site.

2. Clinical signs of severity
        a. Hypotension
        b. Two or more clinical and laboratory abnormalities (see below)

Definite case = 1a and 2 (a and b)
Probable case = 1b and 2 (a and b)

Clinical and laboratory abnormalities

• Renal impairment
• Coagulopathy
• Liver abnormalities
• Acute respiratory distress syndrome
• Extensive tissue necrosis
• Erythematous rash

Aggressive fluid replacement, Beta lactam antibiotics or clindamycin

Miscellaneous others

Scabies - mite infestation (sarcoptes scabiei, excellent image from Jens G. Mattsson, MSc. Ph.D.)

• Causes itching (especially at night), mite burrows into skin.
• Dx
• Grossly or microscopically demonstrate mite, its eggs, larvae, or feces.
• India Ink placed on skin can be used to detect where the organisms burrow in the skin.
• Demonstrate lesion pruritic, erythematous, papular eruptions.
• Typical clinical presentation.
• Treatment
• Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8-14 hours.
• Lindane (1%) 1 oz. of lotion or 30 g of cream applied thinly to all areas of the body from the neck down and thoroughly washed off after 8 hours.
• Sulfur (6%) precipitated in ointment applied thinly to all areas nightly for 3 nights. Previous applications should be washed off before new applications are applied. Thoroughly wash off 24 hours after the last application.

• Caused by lice (pediculosis pubis, image 2)
• Dx
• Finding lice or nits attached to genital hairs (definitive Dx)
• Patient with a history of pubic lice presents with pruritic erythematous papules (presumptive Dx).
• Treatment
• Permethrin 1% creme rinse applied to affected areas and washed off after 10 minutes. OR
• Lindane 1% shampoo applied for 4 minutes to the affected area, and then thoroughly washed off. This regimen is not recommended for pregnant or lactating women or for children aged less than 2 years. OR
• Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes.

 

A. Etiology:

The disease is caused by the organism Listeria monocytogenes

• They are small Gram- to Gram variable rods; they are motile by means of peritrichous flagella and are said to exhibit a characteristic end-over-end tumbling motion at 22°C.
• Physiology
• They grow well and exhibit Beta-hemolysis; they are frequently best isolated on blood agar following cold enrichment techniques (4°C for 48 hours before plating). they exhibit a tumbling motility at room temperature.

• This organism can be isolated from soil, water, vegetation, and a variety of mammals, birds, insects, fish, and other animals.
• Listeriosis is transmitted via the placenta to the fetus and is ingested in contaminated foods (e.g. contaminated milk, soft cheese, undercooked meat, unwashed raw vegetables, and cabbage).
• Most healthy adults have no symptoms of infections. 1 to 5% of adults are healthy asymptomatic human carriers.
• Peak attack rates occur at ages less than 1 year and between the ages of 55- 64. When disease is manifested it is in the very young, elderly, pregnant women, and people with defective cell-mediated immunity.
• There are 12.4 cases of invasive human disease per 100,000 live births and 7.4 cases per million population.
• The incidence of listeriosis in AIDS patients is 100 times greater.
• 4th most common cause of community-acquired meningitis
• The mortality rate (20-30%) of symptomatic listerosis is higher that almost all other foodborne diseases.

• Early onset disease or granulomatosis infantiseptica: prenatal listeria septicemia
• Results from a low grade uterine infection of the mother; the infection spreads to the fetus and causes severe disease.
• Results in abortion, premature delivery, stillbirth or death within a few days.
• severe cardiovascular distress
• vomiting
• diarrhea
• maculopapular skin lesions on legs and trunk
• severe meningitis resulting in coma and death
• generally the mother is totally asymptomatic during pregnancy.
• high mortality rate unless treated.
• Post natal infection in both age groups results in a severe meningitis or meningoencephalitis with septicemia that has a 70% mortality rate associated with it.
• Adults:
• asymptomatic or mild flu-like symptoms
• meningitis
• bacteremia

• Although L. monocytogenes is ubiquitous, and is transmitted via the placenta to the fetus and is ingested in contaminated foods (e.g. contaminated milk, soft cheese, undercooked meat, unwashed raw vegetables, and cabbage).
• Meningeal localization is the most common clinical form of listeriosis; it is pathologically similar to other forms of pyogenic meningitis.
• All virulent strains produce a toxin called listeriolysin O.
• It exists in humans as a intracellular pathogen that can grow in macrophages and epithelial cells.

• Diagnosis depends upon isolation of the organism L. monocytogenes.
• Alert the laboratory if you suspect it because the isolation may be a slow, drawn out affair.
• Serodiagnosis is complicated because of low levels of natural agglutinins.

• It has a 90% fatality rate if untreated.
• Infected neonates die with or without treatment, particularly if infected for some time in utero.

A combination of penicillin G and gentamicin.

High risk people should avoid eating raw or partially cooked foods of animal origin, soft cheese, and unwashed raw vegetables.

Vibrionic abortion (vibriosis) is an infectious disease caused by the organism Vibrio fetus.

A. Epidemiology

• Vibriosis is primarily a venereal disease of cattle, sheep and goats.
• Man usually acquires the disease from direct contact with infected livestock, although the portal of entry is poorly defined (probably orally).
• In cases involving abortion, it is thought that an asymptomatic male transmits the disease to a pregnant sex partner and the organism transcends the placenta to infect the fetus.

• Fever is the most common manifestation in adults, although it may be complicated by endocarditis, thrombophlebitis, septic arthritis or osteomyelitis.
• In infants it usually presents as a fulminating, lethal meningoencephalitis.

• Vibriosis should be suspected in cases involving obscure febrile conditions associated with thrombophlebitis or abortion and/or premature delivery in pregnant women.
• The diagnosis is confirmed by microscopic demonstration of the comma-shaped bacteria in Gram strains of clinical isolates, followed by agglutination tests with specific anti-vibrio antibodies.

A. Etiology

Both Group A and Group B streps are responsible.

B. Pathogenesis

In the mother the streptococci invade the endometrium and lymphatics to result in bacteremia.

C. Manifestations include:

• High irregular fever, chills
• Tachycardia
• Leukocytosis
• Foul smelling vaginal discharge

It may take up to 60 days to become manifest in the infant and then it is usually as a meningitis.

It is a disease of great historical significance but it is much less common due to greater sterility precautions during the birth process.

D. Treat with ampicillin.