Bacterial vaginitis is an uncommon, but by no means rare, cause of vaginitis. Distinct from bacterial vaginosis, bacterial vaginitis can occur with group B Streptococcus with no apparent risk factors, and as a result of secondary infection with any of several bacteria, most often in a setting of a foreign body, atrophic vaginitis, or an erosive disease such as lichen planus (41-43).
Table 13 Erythrasma
Diagnosis Symptoms appearance Differential diagnosis Therapy
Erythrasma None Pink-tan, lightly Tinea cruris, psoriasis, Erythromycin 500 mg scaling plaques eczema, candidiasis b.i.d. or topical on proximal, erythromycin medial thighs solution b.i.d. until clear
Bacterial vaginitis can occur in any age group, but group B Streptococcal infection is found primarily in the well-estrogenized vagina, and alpha hemolytic Streptococcus is seen most often in prepubertal girls, sometimes in association with perianal streptococcal dermatitis. Bacterial vaginitis is most often characterized by irritation, burning, and dyspareunia, although some patients describe itching. Women often report a yellow vaginal discharge, but odor is not prominent. Vestibular and vaginal erythema is usual, and a yellow or yellow/green vaginal discharge is present (Fig. 15). The vaginal pH is high, and a microscopic examination of a wet mount shows a high proportion of immature epithelial cells and a striking increase in neutrophils. Lactobacilli are generally absent. In the event of a group B Streptococcal infection, chains of cocci are often evident (Fig. 16).
The differential diagnosis includes atrophic vaginitis, the postpartum vagina, desquamative inflammatory vaginitis, trichomoniasis, and any disease causing vaginal erosions, such as erosive lichen planus and even a vaginal HSV infection. The use of a caustic chemical in the vagina, such as fluorouracil, can produce similar findings.
The diagnosis is made by the setting, a culture, and response to therapy. In the event of a secondarily infected underlying process, such as a foreign body, atrophic vaginitis, or erosive lichen planus, the response to therapy may be incomplete and short-lived until the underlying process is identified and corrected. Group B Streptococcus is more often a colonizer than a pathogen (42,43). However, in the setting of vaginal inflammation and symptoms, this organism can produce an inflammatory vaginitis.
The therapy of bacterial vaginitis consists of an oral or intravaginal antibiotic directed toward the causative organism as well as the correction of any underlying predisposing conditions. A bacterial culture should reveal the organism and its susceptibilities to antibiotics. In the case of group B Streptococcus, the patient can be treated with intravaginal clindamycin nightly for several weeks or with a penicillin
Figure 15 (See color insert) In uncommon cases, bacterial vaginitis can occur, extending to infect the skin and producing red, scaling, or exudative skin.
(penicillin V potassium, amoxicillin, or ampicillin) orally. Patients should be reevaluated while on medication for response of symptoms and vaginal inflammation to therapy. Nearly immediate relapse is extremely common. More prolonged therapy, sometimes several months, may be required. A positive culture is frequently seen in asymptomatic patients, with or without vaginal discharge.
For those patients whose cultures show other organisms, most often S. aureus or alpha hemolytic Streptococcus, an underlying process should be sought and treated in addition to antimicrobial therapy. The vagina should be examined for a foreign body (most often toilet paper or a retained tampon) and the vagina, oral mucosa, and vulva should be evaluated for signs of erosive disease such as lichen pla-nus. A history normally makes the diagnosis of an accompanying atrophic vaginitis or postpartum vagina. Sometimes, an evaluation of the vagina after treatment of the bacterial infection better reveals any concomitant abnormalities (Table 14).
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