Natalia Novikova

Facts and myths on recurrent vulvovaginal candidosis-a review on epidemiology, clinical manifestations, diagnosis, pathogenesis and therapy.

Approximately three-quarters of all women will experience an episode of vulvovaginal candidosis at least once in their life and 5-10% of them will have more than one attack. Women suffering from three to four attacks within 12 months will be diagnosed with recurrent vulvovaginal candidosis (RVVC). This review covers the large number of proposed aetiological factors for RVVC. The diagnosis of the condition made by conventional means by health providers is often false and is also often misdiagnosed by the affected woman herself. The review covers various methods of diagnosing RVVC and the current knowledge on potential pathogenetic mechanisms proposed for genital candida infections. Treatment of RVVC, including local and systemic antimicrobial therapy and behaviour modification to decrease the risk of recurrences, are discussed. Recent knowledge on drug resistance in candida is also included.

Colonisation of extragenital sites by Candida in women with recurrent vulvovaginal candiosis

Objectives To study colonisation of extragenital sites by Candida in women with a history of recurrent vulvovaginal candidosis and to determine the association of such colonisation with clothing and sexual practice.

Can the diagnosis of recurrent vulvovaginal candidosis be improved by use of vaginal lavage samples and cultures on chromogenic agar

OBJECTIVE: To investigate if introital and vaginal flushing samples inoculated on chromogenic agar could increase the recovery rate and rapid identification of Candida and non-albicans species, as compared to culture of posterior vaginal fornix samples on Sabouraud agar and speciation of isolates by biochemical tests. METHODS: Samples from the introitus and the posterior vaginal fornix and vaginal lavage samples were collected from 91 women with a history suggestive of recurrent vulvovaginal candidosis (RVVC), and with a suspected new attack of the condition. The specimens were cultured on Sabouraud and CHROMagar. Speciation of yeast isolates was made on the chromogenic agar by API 32C kits and by an atomized system (Vitek). RESULTS: Forty-six (51%) women were positive for Candida from one or more of the samples. The introital cultures were positive in 43 (47%) women, both on Sabouraud and chromogenic agar. From the posterior vaginal fomix, 42 (46%) women were positive on the Sabouraud and 43 (47%) on chromogenic agar cultures, while the vaginal lavage cultures yielded Candida on those two media in 40 (44%) and 41 (45%) cases, respectively. Candida albicans was the most frequent species recovered, from 40 (87%) cases, followed by C. krusei in 4 (9%), C. glabrata in 2 (4%), and C. parapsilosis in one case. There was only one woman who had a mixed yeast infection, by C. albicans and C. krusei. There was only one discrepancy in the speciation as demonstrated by mean of chromogenic agar and API 32C kit. CONCLUSIONS: Neither cultures of introital nor of vaginal lavage samples increases the detection rate of Candida in RVVC cases as compared to cultures of posterior vaginal fornix samples. Use of chromogenic agar is a convenient and reliable means to detect colonization by Candida and differentiate between C. albicans and non-albicans species.

Detection of candida by polymerase chain reaction vs microscopy and culture in women diagnosed as recurrent vulvovaginal cases

The objectives were to compare the outcome of polymerase chain reaction (PCR), culture and microscopy of introital and vaginal samples for detection of candida in women with a history of recurrent vulvovaginal candidosis (RVVC). One hundred and three women with a history of RVVC, i.e. with at least four episodes of the condition in the previous year and who consulted with complaints consistent with a new episode, were studied. Introital and vaginal swabs were cultured on Sabouraud and CHROMagar®. Isolated strains were identified on the chromogenic agar and by API 32C kits and by Vitek® automatized identification system (BioMérieux, France). PCR for detection of Candida spp. was performed on vaginal lavage fluid. There was a complete agreement in the recovery rate when using the two agar media. However, complete concordance was not obtained between culture and PCR. In 32 (43.8%) of 73 women both PCR and culture were positive, and in 17 (23.3%) both were negative. In 15 (20.5%), only cultures proved positive, while in another 13 (17.8%) patients only the PCR was positive. Four of the PCR-negative became PCR-positive on retesting after dilution of the sample to try to reduce any potential putative PCR inhibitors. In the 47 PCR-positive women, 26 (55.3%) of the introital smears and 31 (65.9%) posterior vaginal smears showed candida morphotypes. In the 25 PCR-negative women, the corresponding figures were 9 (36.0%) and 17 (68.0%), respectively. The PCR test identified Candida albicans in 21 (87.5%) instances, but failed to do so in three (12.5%) cases in which the metabolic/assimilation tests were positive for this species. The corresponding figures for non-albicans Candida spp. were four (57%) and three (43%), respectively. The study of women with RVVC did not show any uniform agreement between the different diagnostic methods used to identify candida in genital samples or for speciation of yeast isolates. Thus reliance only on microscopy, culture or PCR may lead to inaccurate results.

Microscopy of stained smears of vaginal secretion in the diagnosis of recurrent vulvovaginal candidosis.

This study was undertaken to determine the value of stained smears from the vaginal introitus and the posterior vaginal fornix for detection of candida morphotypes in the diagnosis of recurrent vulvovaginal candidosis (RVVC) in cases with an assumed novel attack of the condition, and to compare the value of microscopy of such smears in relation to candida culture, vaginal pH-determinations and leucocyte esterase tests (LE). One hundred and thirteen women with a history and a current assumed attack of RVVC were studied by means of culture of samples from the vaginal introitus and posterior vaginal fornix on Sabouraud and CHROMagar. Microscopy of methylene blue- and Gram-stained smears from these sites was performed. The pH of vaginal secretion and the LE activity in vaginal flushing fluid was measured. Candida morphotypes were found significantly more often in the smears from candida culture-positive than culture-negative women. There was no difference in this respect between the findings in the methylene blue- and Gram-stained smears. Differences were found in candida morphotypes among Candida albicans and non-albicans-positive cases, as blastoconidia were detected only in the latter cases. The leukocyte esterase activity score was higher in the candida-positive than in candida-negative cases. The study showed that microscopy of fixed, stained genital smears can play a role in attempts to distinguish cases infected and not infected by candida among patients consulting with an assumed novel attack of RVVC. Study of methylene blue-stained smears is recommended as they represent an easier means than Gram-stained smears to diagnose genital candida infections in assumed RVVC cases.

Characterization of women with a history of recurrent vulvovaginal candidosis

Background.  To characterize history, signs, and symptoms in women with a history of recurrent vulvovaginal candidosis (RVVC) and who had consulted with symptoms generally associated with the condition.

Leukocyte esterase activity in vaginal fluid of pregnant and non-pregnant women with vaginitis/vaginosis and in controls

Objectives: To determine the leukocyte esterase (LE) activity in vaginal lavage fluid of women with acute and recurrent vulvovaginal candidosis (VVC and RVVC respectively), bacterial vaginosis (BV), and in pregnant and non-pregnant women without evidence of the three conditions. Also to compare the result of LE tests in women consulting at different weeks in the cycle and trimesters of pregnancy.The LE activity was correlated to vaginal pH, number of inflammatory cells in stained vaginal smears, type of predominating vaginal bacteria and presence of yeast morphotypes. Methods: One hundred and thirteen women with a history of RVVC, i.e. with at least four attacks of the condition during the previous year and who had consulted with an assumed new attack of the condition, were studied. Furthermore, we studied 16 women with VVC, 15 women with BV, and 27 women attending for control of cytological abnormalities, who all presented without evidence of either vaginitis or vaginosis. Finally, 73 pregnant women were investigated. The LE activity in vaginal fluid during different weeks in the cycle of 53 of the women was measured. Results: In the non-pregnant women, an increased LE activity was found in 96, 88, 73 and 56% of those with RVVC, VVC and BV and in the non-VVC/BV cases, respectively. In 73% of pregnant women in the second trimester, and 76% of those in the third, the LE test was positive. In all groups of non-pregnant women tested, the LE activity correlated with the number of leukocytes in vaginal smears, but it did not in those who were pregnant. There was no correlation between LE activity and week in cycle. The vaginal pH showed no correlation to LE activity in any of the groups studied. Conclusions: The use of commercial LE dipsticks has a limited value in the differential diagnosis of RVVC, VVCand BV. There is no correlation between the LE activity in vaginal secretion on one hand and vaginal pH, week in the menstrual cycle and trimester in pregnancy on the other. Women with BV often have signs of inflammation as evidenced by a positive LE test and inflammatory cells in genital smears.

Chlamydia trachomatis infections – a major concern for reproductive health. Where do we stand regarding epidemiology, pathogenesis, diagnosis and therapy?

The current article deals with the problem of distinguishing between relapse and reinfection of genital chlamydial infections due to the chronic character of such infections. The problem of detecting and treating chlamydial pelvic inflammatory disease is considered. Factors that may affect the clinical presentation of such infections, such as hormonal therapy, are also highlighted. Observations on novel manifestations of Chlamydia trachomatis infections, such as spontaneous abortion, prematurity and intrauterine infections as well as a statistical correlation of a certain serovar to cervical cancer, are described. The representivity of the data on infections with C. trachomatis monitored in national surveillance programs is questioned. The paper also elaborates on which type of sample, sample site and detection method may be optimal for the diagnosis of such infections in women. Whether to screen at clinics and self-sampling at home of specimens from an index case and a sexual partner to be mailed to a laboratory for testing is discussed. Whether or not females are more susceptible to genital chlamydial infections and their sequelae than males is also discussed. The effectiveness of recommended antibiotic regimens is considered, e.g. in relation to the recent detection of the existence of strains of C. trachomatis that show heterotypic resistance to drugs commonly used for their treatment.

DIFFERENTIATION OF ASSUMED RECURRENT VULVOVAGINAL CANDIDOSIS BEING OR NOT BEING CONFIRMED BY CULTURE

Background: Among women assumed to suffer from recurrent vulvovaginal candidosis (RWC), culture studies do not confirm the presence of Cundida organism in more than half of all such cases. Objectives: To investigate if careful history taking, incl. the pattern of previous R W C episodes, iatrogenic measures, such as the prescriptions or recommendations of therapy as well as outcomes of the therapies, presence of any of the many endogenous etiological factors proposed for R W C and of some behavior factors, could differen t iat e Cundidu cult ure-posi tive and cult ure-nega t ive cases presenting with symptoms suggestive of R W C . Material and Methods: Eighty-three women with a history consistent with R W C were interviewed regarding 32 parameters, incl. exploration of the majority of factors that have been proposed to relate to R W C . Cultures of Cundidu were made from vaginal introitus and posterior fornix. 136 women without history of any genital infection were interviewed with the same questions. Results: Only in a few cases either in those 43 with and in the 40 without a proven Cundidu infection any of all factors considered to be able to trigger R W C , could be traced. The most common data believed to be related to the debut of vulvovaginal candidosis in Cundidu culturepositive patients were antibiotic treatment, followed by sexual intercourse, pregnancy, period of warm or humid weather, stress, wear of tight clothes in that order. The corresponding data in the Cundida-negative were antibiotic therapy, sexual intercourse, hygiene procedure, pregnancy, intake of a lot of sweets and wear of tight clothes. Conclusions: R W C is a condition that is often misdiagnosed (and thereby also often mistreated). Any factors suggested to trigger the condition in both Candidu culture-positive and culture-negative cases can generally not be detected. Even careful history taking has a limit power to differentiate those cases being Cundidu culture-positive and culture-negative. A score system (including history taking, clinical investigation and niicrobiological tests, such as cultures, PCR assays and vaginal smear microscopy) is needed to improve the accuracy of the diagnosis of R W C . CORRELATION OF MICROSCOPY, CULTURE, VAGINAL PH AND LEUCOCYTE ESTERASE ACTIVITY IN RECURRENT VAGINAL CANDIDOSIS

CORRELATION OF MICROSCOPY, CULTURE, VAGINAL PH AND LEUCOCYTE ESTERASE ACTIVITY IN RECURRENT VAGINAL CANDIDOSIS

Background: Among women assumed to suffer from recurrent vulvovaginal candidosis (RWC), culture studies do not confirm the presence of Cundida organism in more than half of all such cases. Objectives: To investigate if careful history taking, incl. the pattern of previous R W C episodes, iatrogenic measures, such as the prescriptions or recommendations of therapy as well as outcomes of the therapies, presence of any of the many endogenous etiological factors proposed for R W C and of some behavior factors, could differen t iat e Cundidu cult ure-posi tive and cult ure-nega t ive cases presenting with symptoms suggestive of R W C . Material and Methods: Eighty-three women with a history consistent with R W C were interviewed regarding 32 parameters, incl. exploration of the majority of factors that have been proposed to relate to R W C . Cultures of Cundidu were made from vaginal introitus and posterior fornix. 136 women without history of any genital infection were interviewed with the same questions. Results: Only in a few cases either in those 43 with and in the 40 without a proven Cundidu infection any of all factors considered to be able to trigger R W C , could be traced. The most common data believed to be related to the debut of vulvovaginal candidosis in Cundidu culturepositive patients were antibiotic treatment, followed by sexual intercourse, pregnancy, period of warm or humid weather, stress, wear of tight clothes in that order. The corresponding data in the Cundida-negative were antibiotic therapy, sexual intercourse, hygiene procedure, pregnancy, intake of a lot of sweets and wear of tight clothes. Conclusions: R W C is a condition that is often misdiagnosed (and thereby also often mistreated). Any factors suggested to trigger the condition in both Candidu culture-positive and culture-negative cases can generally not be detected. Even careful history taking has a limit power to differentiate those cases being Cundidu culture-positive and culture-negative. A score system (including history taking, clinical investigation and niicrobiological tests, such as cultures, PCR assays and vaginal smear microscopy) is needed to improve the accuracy of the diagnosis of R W C . CORRELATION OF MICROSCOPY, CULTURE, VAGINAL PH AND LEUCOCYTE ESTERASE ACTIVITY IN RECURRENT VAGINAL CANDIDOSIS