MMIC BLOG 1 - Case 6

Preliminary Information

Name: Ong Fei Fei
Sex: Female
Age: 37
Clinical Diagnosis: Urinary Tract Infection (UTI)
Symptoms: Fever, pain during urination, virginal discharge
Anitbiotic Treatment: none
Specimen: Vaginal discharge


Introduction

[UTI]

• More common in female than male
• Infection occurs less frequently in men because the urethra is much longer and the distance between the anus and urethral meatus is greater than in women
• Prostatic secretions also confer a degree of antibacterial activity
• A single episode of UTI in women is usually uncomplicated
• UTI infection is limited to the bladder - the responsible organisms are usually gram negative coliforms
• Ascending infection from the bladder can cause acute pyelonephritis which typically presents with loin pain, fever and chills, costovertebral angle tenderness, nausea and vomiting
• A woman with UTI symptoms without significant bacteriuria finding on culture = acute uretheral syndrome (in 30% cases; 70% bacterial infections)
• Patients with acute uretheral syndrome can be either with pyuria on urinalysis (70%) or without (30%)
• Those with pyuria have true microbial infection usually with chlamydia; those without pyuria have no known microbial cause and the dysuria (a burning sensation in the urethra during voiding) and frequency may be related to irritation from mechanical trauma
• Mostly caused by Commensal colonic gram-negative aerobic bacteria (> 75%)E.g. E. coli strains (with specific attachment factors for transitional epithelium of the bladder and ureters), other enterobacteria, especially Klebsiella, Proteus mirabilis, and Pseudomonas aeruginosa.
• Enterococci (group D streptococci) and coagulase-negative staphylococci (eg, Staphylococcus saprophyticus) are the most frequently implicated gram-positive organisms.
• Infection Localization - Vaginitis is often distinguished by the presence of vaginal discharge, vaginal odor, and dyspareunia

[Vaginal Discharge]

• It is a secretion produced from glands in the vaginal and the cervical lining
• All women have a little discharge starting approximately a year before puberty and ending after the menopause
• A normal physiological discharge is usually clear, creamy or very slightly yellow
• Abnormalcy when there is suddenly a great amount of discharge or the color is brownish, reddish or greenish or it becomes smelly.
• Pathogens implicated are bacterial, fungal and protozoan
• May be associated with Sexually Transmitted Disease (STDs); due to hypoestrogenism
  
  

Etiology

Trichomonas Vaginalis

• Transmission: STD
• Symptoms: Frothy green/yellow discharge, pruritus, urinary symptoms. May be asymptomatic (50%)
• Protozoa found only in tropozoite stage, with 4 flagella
• May be seen in urine
• Offensive odour
• Vagina may be inflamed (Complain of Vaginal/Vulval pruritis)
• May have cervical erosions
  

Candida Albicans

• A type of fungal (yeast) infection
• Transmission: Increased with pregnancy, Diabetes Mellitus & antibiotics.
• Symptoms: Discharge is white, resembles milk curds; Severe itching, dysuria, dyspareunia.

Bacterial Vaginosis (anaerobic/non-specific)

(Rarely presented with dysuria or dyspareunia)

1. Gardnerella vaginalis
Transmission: unknown; may be STD
Symptoms: Thin, watery, yellow-gray discharge with "fishy" odor

2. Mobiluncus species

3. Gonorrhoea
Transmission: STD (More easily transmitted from an infected man to womon ~90%)
Symptoms: Purulent vaginal discharge, dysuria, urinary frequency, inflammation, vulvar swelling and the cervix may be eroded. Most women are asymptomatic.

4. Chlamydia trachomatis (C. trachomatis, C. psittaci, C. pneumoniae)
Transmission: commonly STD
Symptoms (mild): May have thin/purulent discharge, urinary burning and frequency, lower abdominal pain and friable cervix. Women usually asymptomatic.


Possible Interpretation
Vaginal Discharge - suggests Vaginitis or urethritis (e.g. Sexually transmitted Disease (STD), candidiasis) due to hypoestrogenism: e.g. T. vaginalis or N. gonorrhoeae.


Investigation required

• Urinalysis - for screening; inexpensive, easy to perform
• Urine culture - for accurate diagnosis of infection to determine complications, such as antimicrobial susceptibility of infecting bacteria
• Vaginal and urethral discharge - wet-mount preparation to detect Trichomonas vaginalis and Candida species
• Gramstaining - detect Neisseria gonorrhoeae

References:

http://www.escriber.com/ > TrendsInUGSH > Features
http://www.cfps.org.sg/ > sfp > 23 > 232> articles > e232136.html
http://cks.library.nhs.uk/ > uti_lower_women > in_depth > goals_and_outcome_measures
http://www.merck.com/ > mmpe > sec17 > ch231 > ch231b.html
http://www.aafp.org/ > afp > 20020415 > 1589.pdf

Posted by: Pei Shan, TG02