Morning Report

Dec 19, 2012

Avoiding the naughty list

 HPI: 19 yo female, c/o itching down there x 4 days.

Sometimes painful (sharp) with itching. Itches w/ sitting more than standing. Tried to keep underwear dry, normal showers. No douching, no OTC meds tried. Denies recent addition of lotions, fragrances or detergents. No fevers, normal appetite, no CMT

 SHx: Attends Horizonte high school and lives at home with boyfriend and boyfriends family.
Is sexually active, with same partner x 2 years. She is a teen mom and has an IUD for contraception.

PMH: Teen Mom, C-section, UTI during pregnancy

FHx: No chronic illnesses

All: none
Meds: Mirena IUD, Claritin PRN

 Physical Exam:
HEENT NCAT, EOMI, PERRL CV RRR, S1/S2 no murmur, pulses 2+ Chest CTAB, no adventitious sounds Abd moderately obese, no pain with palpation (deep or superficial), (+) BS GU external vagina with normal appearance, no sores or skin changes; vaginal canal with moderate amount of discharge, no erythema or conspicuous changes on cervix.
Manual exam with mild discomfort to vagina, but no cervical motion tenderness or pain with palpation over ovaries, bil

Differential Dx

Differential Dx
She is recommended to get Micoconazole topical cream OTC and use as instructed She returns to clinic one week later, with no improvement in symptoms. What further tests should you do?

Trichomonas Vaginalis
T vaginalis is a flagellated protozoan that is the size of a leukocyte. It requires adherence to host cells for survival. The incubation period averages 1 week but ranges from 5 to 28 days. T vaginalis infection is the most common curable sexually transmitted infection (STI) in the United States and globally and commonly coexists with other conditions, particularly with Neisseria gonorrhoeae and Chlamydia trachomatis infections and bacterial vaginosis.

Trichomonas Vaginalis
Asymptomatic in up to 90% of infected men and 85% of infected women Clinical manifestations in symptomatic pubertal or postpubertal female patients consist of a diffuse vaginal discharge, odor, and vulvovaginal pruritus and irritation. Dysuria and, less often, lower abdominal pain can occur. The cervix can appear inflamed and sometimes is covered with numerous punctate cervical hemorrhages and swollen papillae, referred to as strawberry cervix.

Clinical manifestations in symptomatic men include urethritis and, more rarely, epididymitis or prostatitis.
Reinfection is common, and resistance to treatment is rare but possible. T vaginalis infection can increase both the acquisition and transmission of human immunodeficiency virus (HIV).

Trichomonas Vaginalis

Diagnostics
Microscopy has 60% to 70% sensitivity for diagnosis of T vaginalis in vaginal secretions of a symptomatic female but is less sensitive if she is asymptomatic. The presence of symptoms and the identification of the organism are related directly to the number of organisms.

Treatment
Metronidazole (2 g, orally, in a single dose)
results in cure rates of approximately 90% to 95%.
Tinidazole (2

g, orally, in a single dose)

appears to be similar or even superior to metronidazole.

Both drugs are approved for this indication in adults and adolescents, and metronidazole also is approved in children

E.P.T.
Sexual partners should be treated concurrently, even if asymptomatic, because reinfection is a major factor in treatment failures.
The Pharmacy Privacy Act is amended to provide an option for physicians to use expedited partner therapy and "excludes from the definition of unprofessional conduct and unlawful conduct under the Division of Occupational and Professional Licensing, issuing a prescription for an antibiotic to an unnamed partner of a person who has any one of certain designated sexually transmitted disease." Utah Code Ann. 58-1-501.3 Health Department may authorize physician to write standing order prescriptions without patient name or date for treatment of STDs to be filled out and delivered to patient by nurse. Utah Code Ann. 58-17b-620.

Per AAPs Red Book

STIs are a major problem
An estimated 25% of adolescents will acquire an STI before 18 years of age. adolescents; Although an STI in an infant or child early in life can be the result of vertical transmission or autoinoculation, certain STIs (eg, gonorrhea, syphilis, chlamydia, herpes simplex virus [HSV] type 2]) are pathognomonic of sexual abuse if acquired after the neonatal period. Whenever sexual abuse is suspected, appropriate social service and law enforcement agencies must be involved to ensure the child's or adolescent's protection and to provide appropriate counseling.

References
http://www.cdc.gov/std/ept/legal/utah.htmL American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases Teen Mom Clinic, Salt Lake Valley Health Dept.