Vaginal Discharge Reveals Branching Hyphae Consistent With Candida

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The first test performed on a woman with menstrual cycle irregularities should be a pregnancy test.

A history of anovulatory cycles does not confer absolute protection against pregnancy. Ovulation may occur intermittently and irregularly. If the woman does not want to become pregnant, she should be counseled on contraceptive options.

REFERENCES

Albers JR. Hull SK. Wesley RM. Abnormal uterine bleeding. Am Fam Physician

2004:69:1915-1926. 1931 -1932. Carr BR. Bradshaw KD. Disorders of the ovary and female reproductive tract. In: Kasper DL. Braunwald E. Fauci AS. et al (eds). Harrison's principles of internal medicine. 16th ed. New York: McGraw-Hill, 2(X)5. Accessed online at: www. accessmedicine.com/resourceTOC.aspx?resourceID=4

A 30-year-old woman presents to your office with the chief complaint of a "yeast infection that I can't seem to shake." She also has noticed that she has been urinating more frequently, but thinks that it is related to her yeast infection. Over the last several years she has noticed that she has gained more than 40 lb. She has tried numerous diets, most recently a low-carbohydrate, high-fat diet. The patient's only other pertinent history is that she was told to watch her diet during pregnancy because of excessive weight gain. Her baby had to be delivered by cesarean because he weighed more than 9 lb. Her family history is not known, as she was adopted. On physical examination, her blood pressure is 138/88 mm Hg. her pulse is 72 beats/min, and her respiratory rate is 16 breaths/min. Her height is 65 inches and her weight is 190 lb (body mass index [BMI] = 31.6). Her physical examination reveals darkened skin that appears to be thickened on the back of her neck and moist, reddened skin beneath her breasts. Her pelvic examination reveals a thick, white, vaginal discharge. A wet preparation from the vaginal discharge reveals branching hyphae consistent with Candida. A urine dipstick is performed that is negative for leukocyte esterase, nitrites, protein, and glucose.

♦ What is the most likely primary diagnosis for this patient?

♦ What physical findings does she have that are suggestive of the diagnosis and have implications for management?

^ What diagnostic studies should be ordered at this time?

ANSWERS TO CASE 51: Diabetes Mellitus

Summary: A 30-year-old obese woman presents with a difficult-to-treat yeast infection and polyuria. She has gained 40 lb in spite of her effort to lose weight. She has a history of significant weight gain and having been told to "watch her diet" during a pregnancy. On examination she is found to have a BMI of 31.6, acanthosis nigricans, candidal vaginitis .but a negative urine dip.

^ Most likely diagnosis: Type 2 diabetes mellitus

♦ Significant physical findings: Obesity, acanthosis nigricans, blood pressure that is elevated for a diabetic (goal is <135/85 mm Hg), candidal vaginitis, and possibly candidal skin infection under her breasts

^ Diagnostic studies: Blood glucose measurement (random sugar can be checked in the office with a fingerstick sample); follow-up testing should include electrolytes, blood urea nitrogen (BUN), creatinine, fasting lipids, urine microalbuminxreatinine ratio, and hemoglobin A|c.

Analysis

Objectives

1. Know the diagnostic criteria for diabetes mellitus. including, signs and symptoms, physical findings, and diagnostic studies.

2. Know the pathophysiologic and epidemiologic differences between type I and type 2 diabetes mellitus.

3. Learn the treatment options for diabetic patients.

4. Be aware of the acute emergencies that can occur to diabetics and how to manage them.

Considerations

Diabetes mellitus is one of the most common medical problems encountered in medical practice. There are an estimated 17 million diabetics in the United States and the number is increasing both in the United States and worldwide. Diabetes affects all ethnic groups, but there is a disproportionate burden of disease in African-Americans. Native Americans, and Hispanics. The global epidemic of obesity has led to a dramatic increase in the number of type 2 diabetics presenting with disease in their teens and 20s.

The complications of diabetes are myriad. Diabetics are 6-10 times more likely than nondiabetics to be hospitalized for cardiovascular disease and 15 times more likely to be hospitalized for peripheral vascular diseases. It is the leading cause of blindness in working-age adults in the United States, most of which is preventable. It is also the leading cause for end-stage renal disease and nontraumatic amputations. In 1997. the direct and indirect cost related to diabetes mellitus was estimated to be S98 billion dollars.

Other complications that may be less well known to patients but that are attributable to diabetes include neuropathic, gastrointestinal, and immunologic changes. Peripheral neuropathy, leading to reduced sensation or pain, can lead to the development of ulcerations, infections, or injuries of the extremities. Gastroparesis can be a difficult-to-manage problem that makes diabetes more difficult to manage by impairing the patient's ability to eat properly. Immunologic changes make diabetics more prone to opportunistic infections, such as fungal skin or genitourinary infections.

Impaired glucose tolerance or frank diabetes may be present for years prior to the diagnosis of type 2 diabetes. In the case presented, the history of excessive weight gain during pregnancy with a large baby and cautions on watching her diet may be a sign of a history of gestational diabetes. Women with gestational diabetes have an increased risk of developing nongestational diabetes.

As in the case presented, difficult-to-treat or recurrent fungal infections may be the initial presentation that leads to the diagnosis of diabetes. This patient has both vaginal and skin infections. Although, in this case, the diagnosis is diabetes, other immune deficiency states must be considered when recurrent fungal infections are found. In the appropriate setting. HIV or other immunosuppressive conditions must be considered.

The symptom of polyuria should also lead to an increased suspicion for diabetes. High serum glucose levels function as an osmotic diuretic, resulting in frequent urination. This is often associated with polydipsia, a state of extreme thirst. Patients with type 1 diabetes also may present with polyphagia. Their lack of insulin prevents their food intake from being appropriately metabolized, resulting in a state of hunger for which they will frequently eat but not feel sated.

The absence of glucose in the urine dipstick does not exclude the diagnosis and should not delay a blood glucose measurement. Glucosuria occurs when the blood glucose level is greater than a renal "threshold" level, above which the glucose will spill into the urine. The lack of glucosuria only shows that the blood sugar level is not above this threshold level. Overt signs of insulin resistance (acanthosis nigricans, elevated blood pressure, obesity) also make the diagnosis of type 2 diabetes more likely.

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