Clinical Case Study Presentation
CLINICAL PRESENTATION “TRICHOMONIASIS”.
STUDENTS: CECILIA CRUZ
MARTA CELLEZ
MSN-5600L
PRESENTATION:
Chief complaint: “ I have vaginal discharge”.
HPI: Ms. L.B is a 26 years old Afro-American female patient, complaining of malodorous, yellow-greenish vaginal discharge since 5 days ago. Symptoms are accompanied for vulvovaginal pruritus, genital irritation with dysuria and pain during intercourse.
Usually practice unprotected sex, the last was 2 weeks ago with an occasional couple .
TRICHOMONIASIS-EPIDEMIOLOGY:
The most common Sexual Transmitted Disease(STD) caused by Trichomonas Vaginalis(TV), an anaerobic protozoan parasite.
Affect more than 120 million of women in the word.
It affects women during the reproductive years frequently between the ages of 25 and 49.
Women more symptomatic and with higher prevalence (1.2 to 4.4 times more than men).
Racial disparities with more prevalence in Afro-American(Kissinger,2015)
TRICHOMONIASIS-ETIOLOGY
Trichomonas vaginalis,(TV) :anaerobian, pear-shaped, flagellated protozoan common isolated in vagina, urethra and Skene’s glands.
TV grows in vaginal PH between 5-6, better around 7.
Transmitted among humans, its only known host, primarily by sexual intercourse.
The incubation period is 5 to 28 days.
In men, frequently asymptomatic; and urethritis, epididymitis, and prostatitis can occur.
Infections involve inflammatory processes, which may facilitate vaginal infection with HIV (Kissinger,2015).
TRICHOMONIASIS-RISK FACTORS:
Multiple sexual partners
Unprotected intercourse
Other STDs
Untreated partner with previous infection
Use of douching or feminine powders
(Domino,Baldor,Golding,&Stephens,2017).
Others: lower socioeconomic status, smoking, trading sex, single marital status.(Riley et al.,2016)
ASSOCIATED CONDITIONS:
Bacterial vaginosis
Cervicitis
Herpes Virus infections that links with cervical neoplasia.
Candidiasis
Chlamydia
Gonorrhea
Syphilis
Herpes simple 1-2
Higher susceptibility to bacterial vaginosis.
Increased appearance of HIV target cells
Impair the mechanical barrier to HIV via punctate mucosal hemorrhages.
(Bouchemal, Bories, & Loiseau, 2017)
Urethritis
HISTORY:
Family medical Hx: Mother: Diabetes.
Current medications: None.
PMHx: Chlamydia 4 months ago.
Allergy: NKA.
Gyn/Obstetric Hx: Pregnancy :2 Delivery: 0 Spontaneous Abortions :2
LMP: 7/23/2019 Last PAP smear:2013
Contraceptive Hx: no used
Social History: Current smoker, 1 pack daily.
Alcohol: no. Marital status: divorced.
Educational level: High school/Unemployment.
Sexual activity: 4 couples in the last 6 months, unprotected
sex the last occurred 2 weeks ago with an occasional
couple.
Surgical Hx/hospitalization: none
PHYSICAL EXAM:
Weight: 130 lbs. Height:5’4’’ BMI:22.3 Temp: 98.4F Pain scale: 0/10 BP:118/70 HR:87x’ RR:18x’ O2 Sat room air:99%
General: female patient, pleasant, no appearance of acute distress
HEENT: head normocephalic. Eyes: Pupils equal, round, reactive to light. Nose central, no deviation. Ears: normal implant, no pain or drainage. Tympanic membranes no budge. Oropharynx: mucosa pink, no oral lesions.
Neurologic: Ax3. Reflex present and symmetric. Sensory normal. Cranial nerves intact
Skin: normal; No change in color, moist and warm to touch, no lesions.
PHYSICAL EXAM:
Cardiovascular: S1, S2 with regular rate and rhythm, no gallop or murmur. Capillary refill <2 sec
Lungs: Clear to auscultation, no rales, wheezing or rhonchi, no abnormal breath pattern, no cough
Abdomen: flat, BS present in 4 quadrants, normal sonority on percussion, soft, non- tenderness, no visceromegaly on palpation.
Musculoskeletal: no pain of joints, no stiffness, ROM without limitation.
GYNECOLOGIC EXAM:
External genitalia: vulva noticed with redness, irritation, no glands swelling or lesion.
Speculum exam: Vagina: walls redness, yellow-greenish malodorous discharge, cervix central, with multiple petechias( strawberry cervix). Sample taken from vagina for lab microbiologic study/ PAP smear done.
Bimanual exam: uterus AV, normal size, mild pain on movement, annexes no palpable.
DIFERENTIAL DIAGNOSIS:
In women: other vaginitis:
Bacterial Vaginosis.
Vaginal Candidiasis.
Chlamydia (Chlamydial Genitourinary Infections).
Gonorrhea infection
Pelvic Inflammatory Disease(Domino et al.,2017)
Cervicitis
Cystitis, nonbacterial
Other urethritis (Kissinger,2015)
TESTS:
Wet mount microscopy: direct visualization of motile protozoa from vaginal, cervical or urethral samples , common method, inexpensive, high specificity if reading < first hour of collection.
Culture: takes 4 to 7 days to grow, sensitivity >95%. specificity>99%.
Nucleic Acid Amplification test (NAAT): gold standard for diagnosis, sensitivity and specificity-95-99%.
FDA approved for vaginal , endocervical and female urine specimen
Antigen detection: ELISA and direct fluorescent antibodies test. High sensitivity 70-80%
PAP smear: not effective TV screening test given sensitivity as low as 60%
TREATMENT:
First Line:
Metronidazole 2 gr PO one dose (FDA Pregnancy risk-category
B- cure rate 84-98%)
or Tinidazole 2 gr PO one dose (FDA Pregnancy risk category
C- cure rate 92-100%)
2nd Line:
Metronidazole 500 mg PO BID per 7 days.
--only if symptoms persist after first treatment
--Fist line in HIV patient
For infection persistent dose can be increased to 2 gr PO per 7 days.
Intravaginal Metronidazole gel is not effective
Pregnancy: Metronidazole is effective but may increase the risk
of preterm and low-birth-weight babies.
TREATMENT-PATIENT EDUCATION:
Advise patient to notify sexual partner to be treated.
Discuss STD prevention and use of condom to prevent recurrence.
Abstain for sexual intercourse during treatment, and use condom if abstention is not possible.
Avoid alcohol use during treatment and 24 hours after last dose of metronidazole or 48-72 hrs. of last dose of Tinidazole.(Domino et al, 2017)
Others: refrain from douching, wear cotton underwear and loose clothing to reduce symptoms of irritation.
TRICHOMONIASIS-PROGNOSIS:
Condition has excellent prognosis. Generally eliminated the infection after first dose of antibiotic.
In pregnancy: associated to low weight birth, premature rupture of membranes and preterm birth.
Other complications if untreated patients: endometritis, infection of adnexa, Skene and Bartholin glands. In men, it can cause epididymitis, prostatitis, and decreased sperm cell motility(Domino et al.,2017)
REFERENCES:
Bouchemal, K., Bories, C., & Loiseau, P. M. (2017). Strategies for prevention and treatment of
trichomonas vaginalis infections. Clinical Microbiology Reviews, 30(3), 811-825.
doi:10.1128/cmr.00109-16
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
Kissinger, P. (2015). Trichomonas vaginalis: a review of epidemiologic, clinical and treatment
issues. BMC Infectious Diseases, 15(1). doi:10.1186/s12879-015-1055-0
Riley, E. D., Cohen, J., Dilworth, S. E., Grimes, B., Marquez, C., Chin-Hong, P., & Philip, S. S. (2016).
Trichomonas vaginalis infection among homeless and unstably housed adult women living in a
resource-rich urban environment: Table 1. Sexually Transmitted Infections, 92(4), 305- 308.
doi:10.1136/sextrans-2015-052143