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| __NOTOC__ | | __NOTOC__ |
| Candida Vulvovaginitis
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| ==Historical Perspective==
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| B. Lagenbeck in 1839 in Germany was the first to demonstrate that a yeast-like fungus existed in the human oral infection "thrush." He also found that a fungus was able to cause thrush.<ref name="pmid18509848">{{cite journal |vauthors=Barnett JA |title=A history of research on yeasts 12: medical yeasts part 1, Candida albicans |journal=Yeast |volume=25 |issue=6 |pages=385–417 |year=2008 |pmid=18509848 |doi=10.1002/yea.1595 |url=}}</ref>
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| The genera ''Candida'', species ''albicans'' was described by botanist Christine Marie Berkhout. She described the fungus in her doctoral thesis, at the University of Utrecht in 1923. Over the years the classification of the genera and species has evolved. Obsolete names for this genus include ''Mycotorula'' and ''Torulopsis''. The species has also been known in the past as ''Monilia albicans'' and ''Oidium albicans''. The current classification is ''nomen conservandum'', which means the name is authorized for use by the [http://www.bgbm.org/iapt/nomenclature/code/SaintLouis/0000St.Luistitle.htm International Botanical Congress (IBC)].
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| The full current taxonomic classification is available at ''[[Candida albicans]]''.
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| The genus ''Candida'' includes about 150 different species. However, only a few of those are known to cause human infections. ''C. albicans'' is the most significant pathogenic (=disease-causing) species. Other ''Candida'' species causing diseases in humans include ''C. tropicalis'', ''C. glabrata'', ''C. krusei'', ''C. parapsilosis'', ''C. dubliniensis'', and ''C. lusitaniae''.
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| ==Classification==
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| ===Candida Vulvovaginitis===
| | {{Roseola}} |
| [[Candida]] [[vulvovaginitis]] can be classified based on the duration, as well as the strain of [[Candida]] causing the infection.
| | {{CMG}}:{{AE}}{{DAMI}} |
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| ====Duration====
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| [[Candida]] [[vulvovaginitis]] can be divided based on the duration of the infection into:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid7995997">{{cite journal |vauthors=Vazquez JA, Sobel JD, Demitriou R, Vaishampayan J, Lynch M, Zervos MJ |title=Karyotyping of Candida albicans isolates obtained longitudinally in women with recurrent vulvovaginal candidiasis |journal=J. Infect. Dis. |volume=170 |issue=6 |pages=1566–9 |year=1994 |pmid=7995997 |doi= |url=}}</ref>
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| *Acute, uncomplicated: these are usually sporadic cases of [[Candida]] [[vulvovaginitis]], which respond to topical anti-fungal therapy and have a high cure rate
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| *Acute, complicated: symptoms are more severe than uncomplicated infections and typically require a combination of oral and topical anti-fungal treatment
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| *Recurrent: defined as 4 or more cases of [[Candida]] [[vulvovaginitis]] per year, usually caused by the same strain of [[Candida]]. Treatment also requires a combination of oral and topical anti-fungal agents
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| ====Microbiology==== | | ==[[Roseola overview|Overview]]== |
| [[Candida]] [[vulvovaginitis]] can also be divided based on the strain of [[Candida]] causing the infection:<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid15709796">{{cite journal |vauthors=Buscemi L, Arechavala A, Negroni R |title=[Study of acute vulvovaginitis in sexually active adult women, with special reference to candidosis, in patients of the Francisco J. Muñiz Infectious Diseases Hospital] |journal=Rev Iberoam Micol |volume=21 |issue=4 |pages=177–81 |year=2004 |pmid=15709796 |doi= |url=}}</ref><ref name="pmid12932875">{{cite journal |vauthors=Corsello S, Spinillo A, Osnengo G, Penna C, Guaschino S, Beltrame A, Blasi N, Festa A |title=An epidemiological survey of vulvovaginal candidiasis in Italy |journal=Eur. J. Obstet. Gynecol. Reprod. Biol. |volume=110 |issue=1 |pages=66–72 |year=2003 |pmid=12932875 |doi= |url=}}</ref> | |
| *''[[C. albicans]]'': comprises the majority of cases of [[Candida]] [[vulvovaginitis]]
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| *''C. glabrata'': it is the second most common causative pathogen
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| *''C. tropicalis''
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| *''C. krusei''
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| *''C. parapsilosis''
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| ==Pathophysiology== | | ==[[Roseola historical perspective|Historical Perspective]]== |
| ===Pathogenesis===
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| *All strains of ''[[C. albicans]]'' possess a yeast surface mannoprotein. This allows the various strains to adhere to both the exfoliated and buccal epithelial cells of the vagina.<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref>
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| *Several virulence factors of [[Candida]] are implicated in [[vulvovaginitis]]. These include proteolytic enzymes, toxins and phospholipase. Proteolytic enzymes destroy the proteins that normally impair fungal invasion, allowing for [[Candida]] to colonize the vagina.<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref>
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| *The understanding of the transition from asymptomatic vaginal colonization with [[Candida]] to symptomatic [[vulvovaginitis]] is not clear.<ref name="pmid3895958">{{cite journal |vauthors=Sobel JD |title=Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis |journal=Am. J. Obstet. Gynecol. |volume=152 |issue=7 Pt 2 |pages=924–35 |year=1985 |pmid=3895958 |doi= |url=}}</ref><ref name="pmid2688924">{{cite journal |vauthors=Sobel JD |title=Pathogenesis of Candida vulvovaginitis |journal=Curr Top Med Mycol |volume=3 |issue= |pages=86–108 |year=1989 |pmid=2688924 |doi= |url=}}</ref>
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| ===Genetics=== | | ==[[Roseola classification|Classification]]== |
| Genetic factors could be involved in the pathophysiology of [[Candida]] [[vulvovaginitis]]. Supporting evidence is that many cases were found to be more common in African-American women, run in families, as well as being associated with ABO-Lewis non-secretor phenotype, a rare blood group. In addition, women with [[Candida]] [[vulvovaginitis]] were found to have decreased concentrations of [[mannose binding lectin]] (MBL), hence, the variant (MBL) gene is thought to be a contributing factor in the development of [[Candida]] [[vulvovaginitis]].<ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref><ref name="pmid16256117">{{cite journal |vauthors=Liu F, Liao Q, Liu Z |title=Mannose-binding lectin and vulvovaginal candidiasis |journal=Int J Gynaecol Obstet |volume=92 |issue=1 |pages=43–7 |year=2006 |pmid=16256117 |doi=10.1016/j.ijgo.2005.08.024 |url=}}</ref><ref name="pmid18715406">{{cite journal |vauthors=Donders GG, Babula O, Bellen G, Linhares IM, Witkin SS |title=Mannose-binding lectin gene polymorphism and resistance to therapy in women with recurrent vulvovaginal candidiasis |journal=BJOG |volume=115 |issue=10 |pages=1225–31 |year=2008 |pmid=18715406 |doi=10.1111/j.1471-0528.2008.01830.x |url=}}</ref>
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| ===Gross Pathology=== | | ==[[Roseola pathophysiology|Pathophysiology]]== |
| <gallery>
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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| Image:speculum_vagina.jpg|left|thumb|350px|This photograph is a speculum examination of the vagina with Candida infection and the typical thick, curdy vaginal discharge.
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| Image:Renal candidiasis 001.jpg|left|thumb|350px|This autopsy photograph of the kidneys demonstrates the multifocal punctate lesions visible on the serosal surface (arrows). Don't confuse these small yellow punctate lesions with the fat that is adherent to the renal capsule.
| | ==[[Roseola causes|Causes]]== |
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| Image:Renal candidiasis 002.jpeg|left|thumb|350px|This photograph of the cut surface of these kidneys shows that these multifocal punctate lesions are primarily in the cortex (arrows).
| | ==[[Roseola differential diagnosis|Differentiating Any Disease from other Diseases]]== |
| <br clear="left"/>
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| </gallery>
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| ===Microscopic Pathology=== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
| <gallery>
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| Image:Calbicans.jpg|left|thumb|350px|This is a a microscopic image of Candida albicans, grown on cornmeal agar medium.
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| Image:Renal candidiasis 003.jpeg|left|thumb|350px|This is a low-power photomicrograph of lymph node with three prominent areas of Candida colonies (arrows). Even at this low magnification, the purple-staining yeast and pseudohyphae can be easily seen. This section was stained with Periodic Acid-Schiff Hematoxylin (PASH), which stains the cell wall of fungi to make them more easily visible.
| | ==[[Roseola risk factors|Risk Factors]]== |
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| Image:Renal candidiasis 004.jpeg|left|thumb|350px|This is a low-power photomicrograph of one of the Candida colonies from this lymph node. The chains of yeast which are termed "pseudohyphae" are apparent at this magnification.
| | ==[[Roseola screening|Screening]]== |
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| Image:Renal candidiasis 005.jpeg|left|thumb|350px|This higher-power photomicrograph shows the yeasts and pseudohyphae in this focus of Candida organisms.
| | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Image:Renal candidiasis 006.jpeg|left|thumb|350px|This high-power photomicrograph shows the yeasts (1) and pseudohyphae (2).
| | ==Diagnosis== |
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| | [[Roseola history and symptoms|History and Symptoms]] | [[Roseola physical examination|Physical Examination]] | [[Roseola laboratory findings|Laboratory Findings]] | [[Roseola electrocardiogram|Electrocardiogram]] | [[Roseola chest x ray|Chest X Ray]] | [[Roseola CT|CT]] | [[Roseola MRI|MRI]] | [[Roseola echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Roseola other imaging findings|Other Imaging Findings]] | [[Roseola other diagnostic studies|Other Diagnostic Studies]] |
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| </gallery>
| | ==Treatment== |
| | [[Roseola medical therapy|Medical Therapy]] | [[Roseola surgery|Surgery]] | [[Roseola primary prevention|Primary Prevention]] | [[Roseola secondary prevention|Secondary Prevention]] | [[Roseola cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Roseola future or investigational therapies|Future or Investigational Therapies]] |
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| ===Associated Conditions=== | | ==Case Studies== |
| *[[Candida]] [[vulvovaginitis]] may be associated with other pathogens that cause [[vulvovaginitis]]. These include ''Trichomonas vaginalis'' and ''Gardnerella vaginalis''. The association may be a mixed infection, where 2 or more pathogens are symptomatic, or a co-infection, in which there are 2 or more pathogens but some are not symptomatic.<ref name="pmid23354954">{{cite journal |vauthors=Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE |title=Mixed vaginitis-more than coinfection and with therapeutic implications |journal=Curr Infect Dis Rep |volume=15 |issue=2 |pages=104–8 |year=2013 |pmid=23354954 |doi=10.1007/s11908-013-0325-5 |url=}}</ref><ref name="pmid15026404">{{cite journal |vauthors=Anderson MR, Klink K, Cohrssen A |title=Evaluation of vaginal complaints |journal=JAMA |volume=291 |issue=11 |pages=1368–79 |year=2004 |pmid=15026404 |doi=10.1001/jama.291.11.1368 |url=}}</ref>
| | [[Roseola case study one|Case #1]] |
| ==Epidemiology and Demographics==
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| Epidemiological studies on [[Candida]] [[vulvovaginitis]] are hard to perform, because of several factors:<ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
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| <br>1. [[Candida]] [[vulvovaginitis]] is not a reportable disease<br>
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| 2. The diagnosis of [[Candida]] [[vulvovaginitis]] is based on clinical presentation, as well as positive laboratory findings. Relying on a positive culture alone would likely overestimate the prevalence of [[Candida]] [[vulvovaginitis]]<br>
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| 3. The use of over-the-counter (OTC) topical anti-fungals makes epidemiological studies harder to perform
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| ==Risk Factors==
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| The following risk factors have been implicated in the development of [[Candida]] [[vulvovaginitis]]:
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| *Previous infection with [[Candida]] [[vulvovaginitis]]<ref name="pmid2305918">{{cite journal |vauthors=Foxman B |title=The epidemiology of vulvovaginal candidiasis: risk factors |journal=Am J Public Health |volume=80 |issue=3 |pages=329–31 |year=1990 |pmid=2305918 |pmc=1404680 |doi= |url=}}</ref>
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| *Previous infection with ''Neisseria gonorrhea''<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref>
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| *Nuillparity<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
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| *Luteal phase of the menstrual cycle<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
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| *Recent [[antibiotic]] use<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref><ref name="pmid12825971">{{cite journal |vauthors=Wilton L, Kollarova M, Heeley E, Shakir S |title=Relative risk of vaginal candidiasis after use of antibiotics compared with antidepressants in women: postmarketing surveillance data in England |journal=Drug Saf |volume=26 |issue=8 |pages=589–97 |year=2003 |pmid=12825971 |doi= |url=}}</ref>
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| *[[Pregnancy]]<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
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| *[[Diabetes Mellitus]]<ref name="pmid11835694">{{cite journal |vauthors=de Leon EM, Jacober SJ, Sobel JD, Foxman B |title=Prevalence and risk factors for vaginal Candida colonization in women with type 1 and type 2 diabetes |journal=BMC Infect. Dis. |volume=2 |issue= |pages=1 |year=2002 |pmid=11835694 |pmc=65518 |doi= |url=}}</ref><ref name="pmid12433331">{{cite journal |vauthors=Donders GG |title=Lower Genital Tract Infections in Diabetic Women |journal=Curr Infect Dis Rep |volume=4 |issue=6 |pages=536–539 |year=2002 |pmid=12433331 |doi= |url=}}</ref>
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| *[[Obesity]]
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| *[[Immunosuppression]], such as [[HIV]] or [[glucocorticoid]] use<ref name="pmid12636961">{{cite journal |vauthors=Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, Sobel JD |title=Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity |journal=Obstet Gynecol |volume=101 |issue=3 |pages=548–56 |year=2003 |pmid=12636961 |doi= |url=}}</ref>
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| *Condom use<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref>
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| ==History and symptoms==
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| Symptoms of [[Candida]] [[vulvovaginitis]] include the following:<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid9500475">{{cite journal |vauthors=Sobel JD, Faro S, Force RW, Foxman B, Ledger WJ, Nyirjesy PR, Reed BD, Summers PR |title=Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations |journal=Am. J. Obstet. Gynecol. |volume=178 |issue=2 |pages=203–11 |year=1998 |pmid=9500475 |doi= |url=}}</ref>
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| *[[Vulvar]] itching or burning
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| *Pain on urination ([[dysuria]])
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| *Pain on sexual intercourse ([[dyspareunia)]]
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| *Change in the amount of color of vaginal discharge: [[Candida]] [[vulvovaginitis]] is typically characterized by a thick, white "cottage cheese-like" vaginal discharge
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| *[[Vulvovaginal]] soreness
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| ==Physical Examination==
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| [[Candida]] [[vulvovaginitis]] requires a careful examination of the external genitalia, the vaginal sidewalls, as well as the cervix. Signs include:<ref name="pmid9794664">{{cite journal |vauthors=Eckert LO, Hawes SE, Stevens CE, Koutsky LA, Eschenbach DA, Holmes KK |title=Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm |journal=Obstet Gynecol |volume=92 |issue=5 |pages=757–65 |year=1998 |pmid=9794664 |doi= |url=}}</ref><ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref>
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| *Vulvar edema or erythema
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| *Fissures and excoriations of the external genitalia, and/or
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| *Thick, white vaginal discharge.
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| ==Laboratory Findings==
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| The following laboratory tests are done in the diagnosis of [[Candida]] [[vulvovaginitis]]:<ref name="pmid16990387">{{cite journal |vauthors=Eckert LO |title=Clinical practice. Acute vulvovaginitis |journal=N. Engl. J. Med. |volume=355 |issue=12 |pages=1244–52 |year=2006 |pmid=16990387 |doi=10.1056/NEJMcp053720 |url=}}</ref><ref name="pmid22519657">{{cite journal |vauthors=Mendling W, Brasch J |title=Guideline vulvovaginal candidosis (2010) of the German Society for Gynecology and Obstetrics, the Working Group for Infections and Infectimmunology in Gynecology and Obstetrics, the German Society of Dermatology, the Board of German Dermatologists and the German Speaking Mycological Society |journal=Mycoses |volume=55 Suppl 3 |issue= |pages=1–13 |year=2012 |pmid=22519657 |doi=10.1111/j.1439-0507.2012.02185.x |url=}}</ref><ref name="pmid17560449">{{cite journal |vauthors=Sobel JD |title=Vulvovaginal candidosis |journal=Lancet |volume=369 |issue=9577 |pages=1961–71 |year=2007 |pmid=17560449 |doi=10.1016/S0140-6736(07)60917-9 |url=}}</ref>
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| *[[Vaginal]] pH: in [[Candida]] [[vulvovaginitis]], [[vaginal]] pH is normal (ranges from 4.0-4.5)
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| *Microscopy/ wet mount: visualizes [[Candida]] [[hyphae]] or [[spores]]
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| *Culture: culture for diagnosing [[Candida]] [[vulvovaginitis]] is not routinely done. However, it should be done in a symptomatic woman with a negative microscopy and a normal vaginal pH. Sabouraud agar, Nickerson's medium or Microstix-candida culture media may be used
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