HPI
•
A 23 year-old female comes to your office
complaining of vaginal discharge, itching, and
burning with urination for several days. The
symptoms had worsened during her menstrual
period. She has had a similar infection in the
past, but she doesn't remember what it was.
She only remembers that she took 4 pills for it
in the office and it went away.
HPI cont'd


Medical Hx: none
Social Hx: College student studying biology. Sexually
active with one new male partner for the last 2 months.
Does not smoke. Drinks 2-3 beers on weekends with
friends.

Meds: none

Family Hx: father with HTN
What physical exam will be most helpful for
diagnosis?
Physical Exam



Vital Signs: all normal
Speculum exam shows
frothy, green,
malodorous discharge.
Cervix has small, red,
punctuate hemorrhages.
ROS: normal other than
in HPI
Cervix on exam
What is your differential diagnosis?
Image from pediatrics.georgetown.edu, “Week 28, Case 1,” retrieved 12/28/2012
http://pediatrics.georgetown.edu/residents/visualdiagnosis/week28
Differential Diagnosis
•
Trichomoniasis
•
Chlamydia
•
Gonorrhea
•
Bacterial Vaginosis
What is your next step? Any tests you want to
order/perform?
Lab Results
•
•
Wet mount shows
many PMNs and motile
organisms. No clue
cells are seen.
There are other options
for diagnosis: culture or
rapid antigen tests.
However, if
trichomonads are seen
on wet mount, these
are unnecessary.
PMNs
Trichomonads
Image from pediatrics.georgetown.edu, “Week 28, Case 1,” retrieved 12/28/2012
http://pediatrics.georgetown.edu/residents/visualdiagnosis/week28
Trichomoniasis
•
Caused by flagellated protozoan
trichomonas vaginalis.
•
Sexually transmitted. Can have
asymptomatic carrier phase,
increasing transmission from
partners who do not know they
have the disease.
•
High prevalence of co-infection
with other sexually transmitted
diseases
Image from UpToDate, “Trichomonas vaginalis,” retrieved 12/28/2012
Treatment
•
Metronidazole or tinidazole, 2 grams orally x1
•
Longer courses of treatment are available, but
they do not improve cure rates. Instead, they
decrease compliance.
Is there anything else you want to do?
You need to treat her partner!
•
Because the disease is sexually transmitted,
you need to treat your patient's partner as
well! He may have an asymptomatic infection
and cause re-exposure to the disease even
after she is treated.
•
Patients should avoid sexual contact for
approximately one week to avoid re-infection.
What if your patient is 22-weeks pregnant?
Trichomoniasis in Pregnancy
•
Trichomoniasis is believed to be associated
with preterm delivery and infection in pregnant
women. However, it is currently not
recommended to treat asymptomatic infection
in pregnancy, as this does not reduce these
risks.
•
Also, if she were near term, she could possibly
transmit the infection to her newborn at
delivery.
•
Treatment in pregnancy is metronidazole.
Summary
•
Trichomoniasis is a common sexually-transmitted
infection caused by the protozoan trichomonas vaginalis.
•
Characteristic symptoms include green, frothy,
malodorous discharge, pruritis, and dysuria. Physical
exam may show a “strawberry cervix.”
•
Wet mount will show many neutrophils, motile
trichomonads. It will not usually show clue cells
(associated with bacterial vaginosis).
•
Treatment is with metronidazole. All sexual partners
should also be treated, and sexual contact should be
avoided for 7 days following treatment to prevent reinfection.