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

A recent Gallup survey found that very few women have a thorough understanding of vaginitis. While 95 percent of women surveyed had heard about yeast infections only 36 percent had ever heard of a more common vaginal infection called bacterial vaginosis (BV).

Bacterial Vaginosis (BV) due to Gardnerella vaginalis, Mycoplasma hominis and various anaerobic bacteria including Mobiluncus sp., and Bacteroides 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 diseases (STDs).

Vaginal infections are often accompanied by vaginitis, which is an inflammation of the vagina characterized by discharge, irritation, and/or 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.

A. Etiology
Bacterial Vaginosis (BV) due to Gardnerella vaginalis, Mycoplasma hominis and various anaerobic bacteria including Mobiluncus sp., and Bacteroides sp.

B. Epidemiology
Bacterial vaginosis (BV) is the most common cause of vaginitis symptoms among women of childbearing age. BV--previously called nonspecific vaginitis or Gardnerella-associated vaginitis-- can be transmitted through sexual activity, although the organisms responsible also have been found in young women who are not sexually active.

Bacterial vaginosis is caused by an overgrowth of bacteria rather than yeast or other organisms. These are primarily anaerobic bacteria (requiring no oxygen) and an organism called Gardnerella, all of which can be found in low numbers in the healthy vagina. In women with BV, the vaginal balance is disrupted so that these bacteria overgrow at the expense of protective bacteria known as lactobacilli. Lactobacilli excrete hydrogen peroxide to help maintain a healthy and normal balance of microorganisms in the vagina. Women who have been diagnosed with BV have been found to 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.

A few studies have also correlated BV with increased douching, an increased number of sexual partners and use of intrauterine devices. While sexual activity may increase the likelihood of developing BV, the condition has also been found in sexually inexperienced and monogamous women.

C. Manifestations

1. 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 noticable around the time of menses.
2. Vaginal itching or burning are also sometimes present.
3. Up to 40 percent of women with BV may experience no outward symptoms
4. 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 percent more likely to deliver a low birth-weight baby (less than 5.5 lbs).

Three of the four criteria should be positive
• thin homogeneous discharge.
• pH of discharge >4.5.
• Clue cells in saline wet mount or Gm stain of vaginal discharge.
• Mixture of vaginal discharge and 10% KOH liberates an "amine-like" or "fishy" odor.

antibiotic therapy: metronidazole or clindamycin for 7 days.

BARBARA A. MAJERONI, M.D., 1998. Bacterial Vaginosis: An Update. American Family Physician. March 15, 1998. http://www.aafp.org/afp/980315ap/majeroni.html

1. Epidemiology

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

When the delicate balance of organisms in the vagina is upset, the yeast may overgrow and cause vaginitis. For example, 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, prolonged exposure to moisture and poor feminine hygiene.

• A thick, curd like vaginal discharge (epithelial cells and masses of hyphae/pseudohypha)
• intense pruritus of the vulva
• erythematous vagina and labia

• evaluation of symptoms and clinical setting
• Gram stains of exudates (image 1 and 2)

• Nystatin for 2 weeks OR
• Miconazole nitrate 2% vaginal cream, one applicator full, intravaginally at bedtime for 7 days OR
• Clotrimazole, 1 vaginal suppository daily for 7 days

A. Etiology

The etiological agent is a flagellated protozoan Trichomonas vaginalis.

1. Morphology
• 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.

• T. vaginalis is a common parasite of both males and females and the incidence is in part related to hygiene.
• Intercourse is the usual method of transmission, especially via asymptomatic males.
• In rare instances it  may be passed on by wet towels, washcloths and bathing suits
• The infection often persists because the parasite rarely causes symptoms in men, so that reinfection of women by untreated men is common.
• Some women can be infected for months to years as the infection is passed back and forth between the woman and her sexual partner. For this reason, both sexual partners must be treated at the same time, even if they are in a monogamous relationship.

• Vaginitis and urethritis in females
• Disruption of normal flora organisms in vagina may alter pH (>4.5) and other factors which allow T. vaginalis to overgrow.
• Proliferation of the organisms is associated with a low grade inflammation manifested by:
• Itching and burning
• Painful urination
• A frothy, green, creamy discharge, that is described as being leukorrheic and very malodorous.
• Because of the ease of anatomic spread to the urethra, urethritis develops; again it is manifested chiefly by
• Dysuria
• Frequency and urgency
• many women with this infection may not have any symptoms
• Urethritis and prostatovesiculitis in males is usually asymptomatic but may be manifested by:
• Dysuria
• Urgency and frequency
• Occasionally in severe cases there is exudate formation

• Low grade inflammation is associated with the presence of high numbers of trichomonads.
• These high numbers of trichomonads become established because something has disrupted the normal flora and allowed them to overgrow.

• Clinical diagnosis depends upon recognition of the symptoms of dysuria, frothy, cream, malodorous discharges associated with punctate lesions and hyperemia of the vagina - highly suggestive.
• The most practical method of specific diagnosis is microscopic examination for motile trichomonads in vaginal or urethral discharges.

• Oral metronidazole, single dose -- supplement with vaginal insert for 10 days in women.
• Don't treat pregnant females with this until they deliver because of potential harmful effects on the developing fetus.

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.