Differentiation Between Women with Vulvovaginal Symptoms Who Are Positive Or Negative for Candida Species by Culture
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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by PubMed Central Infect Dis Obstet Gynecol 2001;9:221–225 Differentiation between women with vulvovaginal symptoms who are positive or negative for Candida species by culture Iara M. Linhares 1,2, Steven S. Witkin 2, Shirlei D. Miranda 1, Angela M. Fonseca 1, Jose A. Pinotti 1 and William J. Ledger 2 1Department of Gynecology, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil 2Division of Immunology and Infectious Diseases, Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY Objective: Toinvestigatewhether clinical criteria coulddifferentiate between women with vulvovaginitiswho were culture positive or negative for vaginal Candida species. Methods: Vulvovaginalspecimens were obtainedfrom 501 women with avaginal dischargeand/ orpruritis. Clinical information andwet mountmicroscopy findings were obtained.All specimenswere sentto a central laboratory for species identification. Results: Apositiveculture for Candida specieswas obtainedfrom 364 (72.7%) ofthe specimens. C. albicans was identified in86.4% ofthe positivecultures, followed by C. glabrata in 4.5%, C.parapsilosis in 3.9%, C.tropicalis in 2.7%and other Candida speciesin 1.4%. Women with apositive Candida culturehad anincreased utilization of oral contraceptives(26.1% vs.16.8%, p = 0.02) andantibiotics (8.2% vs.0.7%, p = 0.001), andwere more likely to bepregnant (9.1% vs.3.6%, p = 0.04) than the culture-negativewomen. Dyspareuniawas more frequentin women without Candida (38.0% vs.28.3%, p = 0.03) while vaginal erythema ( p = 0.01) was more common in women with a positive Candida culture. Conclusions: Although quantitativedifferences were observed, the presenceof vaginal Candida vulvovaginitis cannot be definitively identified by clinical criteria. Key words: V ULVOVAGINITIS ; CANDIDA SPECIES; DIFFERENTIAL DIAGNOSIS Itis difficultto obtain accurate information regard- vaginal discharge, itching,pain or burning as a ingthe prevalence andincidence of vulvovaginitis ‘yeast’infection. In three studies, more thanhalf of associated witha Candida species infection. thewomen with a supposedvaginal yeast infection Althoughup to75% of womenwill acknowledge were misdiagnosed 2–4. having hada vaginal Candida infectionduring their Conversely, inmany womena truevaginal lifetime1,this diagnosis is suspect. Theskyrocket- Candida infectionmay remain unrecognized. ingsales ofover-the-counter medications for Detectionof avaginal Candida infectionby micro- Candida vaginitis, at arate many times thatof the scopicexamination ofavaginal specimen diluted numberof infected women, highlights the preva- inpotassium hydroxideis relatively insensitive, lentoverdiagnosis ofthis disorder.Many women, especially fornon-albicansspecies 3,5.False-positive andunfortunately also many clinicians, label any microscopicexaminations are also possible 5 and are Supported by Janssen-Cilag, Sao Paulo, Brazil Correspondenceto: StevenS. Witkin, Ph.D., Departmentof Obstetrics and Gynecology, Weill Medical Collegeof Cornell University, 515 East 71st Street, New York, NY 10021, USA. Email: [email protected] Clinical Study 221 Vulvovaginal symptoms and Candida infection Linhares et al. probablymore commonthan generally suspected. independentsamples. The c2 test was usedto Itis also possible tohave Candida vulvovaginitis comparequalitative variables betweenboth witha false-negative Candida culture.At least 3000 groups.Findings were consideredsignificant at organisms/ml are necessary toobtain a positive p < 0.05. culture6. Inan attempt to more accuratelycharacterize symptomatic womenwith a positive Candida RESULTS species vaginal culture,and to differentiate them Candida was detectedby culturein 364 (72.7%) of fromwomen with vaginal symptoms dueto other thesubjects. The distribution of individual Candida causes, astudywas initiated inthree cities inBrazil. species canbe seen inTable 1. C. albicans was iden- tified in86.4% of thepositive cultures, followedby C. glabrata (4.5%), C.parapsilosis (3.9%) and MATERIALS AND METHODS C.tropicalis (2.7%). Apresumedidentification of Candida was made bymicroscopic examination Thisstudy was approvedby the Clinical and in87.1% of womenwith a positive cultureand in Ethical Committee ofHospital das Clinicas, Uni- 5.1%of thosewith a negative culture. Trichomonas versity ofSaoPaulo, and informed written consent vaginalis was present in2.9% and 1.4% of women was obtainedfrom all subjects.The study popula- witha negative andpositive Candida culture, tionconsisted of 501consecutive reproductive age respectively. Clue cells were observed in16.8% of womencomplaining of avaginal discharge and/or womenwith a negative cultureand in 9.1% of vulvovaginal pruritis, seen as private patients inthe womenwith apositive Candida culture (p = 0.01). Brazilian cities ofSao Paulo, Rio Grande de Sul Forall analyses, thepatients were dividedinto andSalvador. Exclusioncriteria includedthe use twogroups based on thepresence orabsence ofa ofimmunosuppressive medications, vaginal medi- positive Candida culture.Demographics of women cationsor oral antifungalagents withinthe last inboth groupsare shownin Table 2. Ahigherper- 30 days. centageof blackwomen, but not ofwhitewomen Clinical anddemographic data were collectedat orthose of other races, were presentin the eachcenter by a single participatingphysician. culture-negative group(16.8%) thanin the Signs andsymptoms uponphysical examination Candida culture-positive group (8.3%) ( p = 0.01). were standardizedas muchas possible betweenthe Therelationship between predisposing factors differentsites byproviding common diagnostic anda positive ornegative Candida culture is criteria forerythema, edema, dischargeand detailed inTable 3. Pregnancy(9.1% vs. 3.6%, dysuria. Definitionswere similar tothose utilized p =0.04), oralcontraceptive usage (26.1% vs. by Eckert and colleagues 7. 16.8%, p =0.02) andcurrent antibiotic use (8.2% Specimens were obtainedby scraping the vs. 0.7%, p =0.001) were eachassociated with vaginal walls witha cottonswab and immediately detectionof a positive Candida culture.Con- transferringthe contents to a glass slide. Adropof versely, apositive HIV serology(7.3% vs. 3.3%, saline was addedand diagnosis of Candida was basedon the observed presence ofmycelium Table 1 Candida species identified by culture (branchedhyphal elements) orblastospores (the Candida species Percentage women positive unicellularyeast form). Asecondspecimen was placedin transport medium andshipped to a albicans 86.4 centralclinical laboratory.Specimens were glabrata 4.5 culturedon Sabouraud agar containingchloram- parapsilosis 3.9 phenicol. Candida species were identifiedby tropicalis 2.7 theautomated Amphotericin B (ATB) express krusei 0.9 method. guilliermondii 0.6 famata 0.3 Comparisons betweenwomen with positive or pulcherrima 0.3 negative Candida culturesfor quantitative variables susitanii 0.3 were analyzedby the Student’ s t-test for 222 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Vulvovaginal symptoms and Candida infection Linhares et al. Table 2 Demographics ofwomen with vulvovaginitis Table 4 Signsand symptoms ofwomen with vulvo- and a positive or negative culture for Candida vaginitis positive and negative for Candida by culture Candida No Candida Candida No Candida (n = 364) (n = 137) Vulvar pruritis 83.2% 82.5% Race Vulvar burning 61.8% 66.4% White 79.0% 73.7% Vaginal discharge 85.7% 87.6% Black 8.3% 16.8%* Dyspareunia 28.3% 38.0%* Oriental 5.0% 1.5% Dysuria 19.8% 21.9% Other 7.7% 8.0% >1 previous episode 44.5% 53.3% Age (years) 32.2 (10.1) † 33.8 (10.8) † Length of symptoms (days) 18.6 ± 8.6 15.0 ± 12.0 Sexually active 93.1% 84.7% > 1 Sexual partner 7.5% 3.1% *p = 0.03 vs. women with Candida *p = 0.01 vs. black women with Candida; †standard deviation Table 5 Clinicalfindings in women with vulvovaginitis and positive or negative for Candida by culture Table 3 Predisposingfactors associated with Candida Candida No Candida species culture-positive and -negative vulvovaginitis Vulvar edema 10.7% 9.5% Candida No Candida Vulvar erythema 16.5% 16.3% Diabetes 2.8% 4.4%. Vaginal fissures 18.4% 16.1% Pregnancy 9.1%* 3.6%. Vaginal erythema 86.8%* 59.2% Oral contraception 26.1%** 16.8% . Leukorrhea 84.9% 88.6% IUD usage 6.6% 11.0% . Excoriation 9.9% 8.8% Corticosteroid usage 2.2% 2.2%. Cervical ectopy 11.5% 14.6% Antibiotic usage 8.2%*** 0.7%. Vesicles 2.2% 2.2% HIV seropositive 3.3% 7.3%† Pustules 2.2% 2.2% Prior STD 9.7% 17.5%†† *p = 0.01 vs. women without Candida *p = 0.04, **p = 0.02, *** p = 0.001 vs. women without Candida; †p = 0.05, ††p = 0.01 vs. women with Candida DISCUSSION p =0.05) andprior history of a sexually trans- Althoughsome quantitativedifferences inthe mitted disease (17.5% vs. 9.7%, p = 0.01) were frequencyof patient symptoms, clinical findings associated witha negative Candida culture.The andpredisposing factors were identifiedbetween HIV-seropositive womenwere at theearliest groupsof women who were culture-positive or stages of their disease. culture-negative for Candida species, noneof Therelationship between patient-reported theevaluated criteria were pathognomonicfor signs andsymptoms and Candida culturefindings is Candida inthe vagina. Similar findingshave been shownin Table 4. Therewas considerableoverlap reportedpreviously byothers 2,6–8.Ina large study betweenthe twogroups in complaints of avaginal ofwomen attending a sexually transmitted disease discharge, vulvar pruritis andburning,