Objective: The objectives of this study were to assess the efficacy of medical management for vulvar vestibulitis and to examine several historical variables and determine their predictive values as to which treatments will be most successful.
Methods: Seventy-four patients diagnosed with vulvar vestibulitis were evaluated. Each patient was treated using a sequence of consecutive medical therapies for vulvar vestibulitis. These therapies were topical aqueous 4% lidocaine with intercourse, topical corticosteroid therapy, oral amitriptyline, topical low-dose 5-fluorouracil (5-FU) cream, intralesional alpha-interferon, and a low-oxalate diet in combination with oral calcium citrate. The patients were followed over 3–30 months and their responses to therapy were assessed. In addition, a statistical analysis was performed to determine the positive predictive values of certain historical variables and specific treatment successes.
Results: Forty-nine patients reported positive responses to one of the initiated therapies. More specifically, 18.1% of the patients who used lidocaine, 33.8% who used topical corticosteroids, 57.1% who used amitriptyline, 16.7% who used 5-FU, none who received interferon, and 50% who tried a low-oxalate diet had positive responses to therapy. No historical variables were predictive of which therapies would have the most successful outcome.
Conclusions: Medical management is effective in alleviating the symptoms of vulvar vestibulitis. Various aspects of a patient's history are not helpful in selecting the therapy that will be most effective.
Background: Disseminated cytomegalovirus (CMV) infection is relatively uncommon, occurring primarily in immunocompromised hosts and neonates. Patients with acquired immunodeficiency syndrome (AIDS) are the most common hosts, with symptoms secondary to lung and eye involvement. There have been no reports of symptomatic CMV infection of the pelvis in women.
Case report: This case is the first described of acute symptomatic CMV infection of the genital tract in a woman with AIDS. Her presenting symptoms were the result of acute CMV oophoritis. In addition, CMV was found in the endometrium and endosalpinx (an infected structure heretofore unreported).
Conclusion: The increasing prevalence and incidence of AIDS in women should make us aware of the possibility of opportunistic, symptomatic CMV pelvic infection.
Background: A concomitant infection with human immunodeficiency virus (HIV) may alter the natural history of other infections. Several reports indicate that syphilis may behave more aggressively when HIV infection is present.
Case: A woman presented with a rash involving her hands and feet and progressive loss of the vision in her right eye. Her serologic tests for syphilis and HIV infection were positive. A diagnosis of neurosyphilis was confirmed by an analysis of cerebrospinal fluid (CSF). She was treated with high-dose intravenous (IV) penicillin. Her skin lesions resolved, but her vision did not improve.
Conclusion: The incidence of HIV infection among women is rising. A patient with HIV and syphilis may develop neurosyphilis in a much shorter time than a patient without HIV infection.
Endomyometritis following parturition is a major cause of maternal morbidity. It is most common following cesarean delivery, especially in certain high-risk patient populations. The infection is usually caused by bacteria in the cervicovaginal tract that are inoculated into the uterus during labor and delivery. Both anaerobes and aerobes are thought to be involved in the disease process. A prompt diagnosis based on clinical suspicion, a thorough physical examination, and adjunctive laboratory measures is necessary to insure effective therapy and prompt resolution of the infection. The treatment consists of supportive care and broad-spectrum antibiotic coverage either with single extended-spectrum drugs or with combinations of antimicrobials. In cases appropriately treated, recovery without sequelae is the rule.
Background: Pasteurella multocida is a commensal organism found in the saliva and oropharynx of domestic animals. It causes a variety of human infections ranging from cellulitis to bacteremia and sepsis. The severity of infection is somewhat related to the immunocompetency of the infected host. An immunocompromised host is more likely to suffer a disseminated infection as a result of contact with this organism than an immunocompetent host. This case report and review of the literature are presented to further evaluate the types of infections caused by this organism in oncology patients.
Case: A 54-year-old woman with epithelial ovarian cancer and a chemotherapy-induced nadir of her WBC count developed P. multocida bacteremia after she incurred a scratch from her pet cat. She was treated with ceftazidime and then penicillin G with prompt resolution of the bacteremia.
Conclusion: This paper summarizes an infectious complication that is likely to become more common as chemotherapy-induced neutropenia and pet ownership in the elderly become common coincidences. As such, oncologists and infectious disease physicians should keep this organism in mind when selecting antibiotics to treat the febrile, nadiring cancer patient who has known pet contact.
Objective: Lactoferrin is a glycoprotein released from the secondary granules of activated neutrophils in the setting of infection. The purpose of this study was to determine if amniotic-fluid (AF) lactoferrin levels are elevated in preterm labor (PTL) patients with subclinical intraamniotic infection (IAI).
Methods: AF samples were obtained from 186 pregnant patients with
the following characteristics: group 1 - term, no labor; group 2 - preterm, no labor; group 3 - PTL with IAI; group 4 - PTL without IAI. Lactoferrin levels were measured with an enzyme-linked immunosorbent assay (ELISA).
Results: AF lactoferrin levels were elevated in normal gestation after 31 weeks (P < 0.0001). Lactoferrin levels were also higher in infected PTL patients compared with noninfected PTL patients at gestations ≤31 weeks (P = 0.005). An AF lactoferrin level of >2.5 μg/ml is highly suggestive of infection in PTL patients at <32 weeks, with an overall sensitivity of 82% and a specificity of 83%, when infection is defined as a positive AF culture or positive placental histology.
Conclusions: AF lactoferrin levels increase after 31 weeks in normal gestations, but lactoferrin levels >2.5 μg/ml in PTL patients before this gestational age are highly suggestive of IAI. AF lactoferrin levels may be a useful clinical tool for selecting those PTL patients who might benefit from antimicrobial therapy, closer observation, or early delivery.
Objective: The intent of this study was to determine the efficacy and tolerance of single-dose oral azithromycin in the treatment of pregnant women with endocervical chlamydial carriage.
Methods: A retrospective review of clinic records over a two-year period identified pregnant patients treated with a single 1-g dose of azithromycin for chlamydial carriage. The side effects and subsequent chlamydial carriage (test of cure) were noted.
Results: A total of 146 pregnant women treated with azithromycin was reviewed. A cure rate of
96% was found. Side effects were reported in 5%.
Conclusions: A single 1-g oral dose of azithromycin is effective for the treatment of chlamydia and is well tolerated in pregnant women.
Objective: We undertook the present study to attempt to apply clinical indicators predictive of cervical infection in nongravid populations with either Neisseria gonorrhoeae or Chlamydia trachomatis to our pregnant population and to determine the significance of the clinical diagnosis of “cervicitis.”
Methods: A retrospective chart review of all pregnant women with a final diagnosis of cervicitis who were seen in the Medical College of Virginia obstetrical emergency room was performed during the period of September 1991 to December 1992.
Results: Given the diagnosis of cervicitis in our emergency department, we found that the clinical examination predicted cervical infection with N. gonorrhoeae or C. trachomatis in only 20% of the pregnant women. Gravidas with chlamydial infections were younger (20.1 ± 3.7 years) compared with gravidas not infected (23.2 ± 5.4 years) (P < 0.0001). They were also more likely to have a diagnosis of lower urinary-tract infection [relative risk (RR) 2.89, 95% confidence interval (CI) 1.42–5.85].
Conclusions: The clinical indicators of cervical infection with C. trachomatis and N. gonorrhoeae were unreliable.
Objective: Our goal was to determine the in vitro susceptibility of Ureaplasma urealyticum and Mycoplasma hominis isolates to several antibiotics in Argentina.
Methods: Ninety-four strains of U. urealyticum and 18 strains of M. hominis isolated from cervical and urethral specimens were studied. Broth microdilution and agar dilution tests for minocycline, tetracycline, erythromycin, ciprofloxacin, and ofloxacin were performed.
Results: Both methods proved to be reliable and reproducible for U. urealyticum and M. hominis, with no major differences in results. The U. urealyticurn strains were inhibited by erythromycin at MICs ranging from ≤0.5 to >8 μ/ml. Ofloxacin showed the highest activity against this latter organism. No differences between tetracycline and minocycline MICs were observed with U. urealyticum. Two M. hominis strains displaying high MICs both to tetracycline and to minocycline were detected.
Conclusions: The emerging resistance of mycoplasmas to certain antibiotics emphasizes the need to undertake further surveillance studies on the clinical isolates of such organisms.
Lyme disease is the most commonly transmitted vector-borne disease in the United States, with many regions of the country at risk. Like other spirochete-borne infections, Lyme disease progresses in stages, making diagnosis in the early stages of the illness and prompt treatment important for cure. An early diagnosis is made difficult by the less-than-ideal serologic tests and the varied clinical presentations of the disease. Although Lyme disease has been reported in pregnancy, the transmission rate to the fetus and potential harmful effects are largely unknown. This review discusses the diagnosis, clinical course, and treatment of Lyme disease with an emphasis on the pregnant patient.
Objective: Numerous published reports have linked various disease states and pregnancy-related conditions with meteorologic factors such as weather, humidity, and temperature. The purpose of this study was to determine if temperature and dew point affect the incidence of pyelonephritis during pregnancy.
Methods: A retrospective chart review of a 4-year period from 1989 to 1992 was performed. The records of women who were diagnosed with pyelonephritis during pregnancy were abstracted for the dates of admission. The climatic records of the Tampa Bay area of Florida were obtained from the National Weather Service.
Results: The average, minimum, or maximum daily temperature or average daily dew point during the month of admission had no significant effect on the rate of pyelonephritis during pregnancy in the Tampa Bay area.
Conclusions: The rate of pyelonephritis during pregnancy per number of deliveries in the Tampa Bay area was not affected by the average, minimum, or maximum daily temperature or average daily dew point.
Background: Despite increased immigration to the United States from endemic areas, the diagnosis
of microfilariasis in this country remains infrequent. This disease may occasionally present as a breast mass, in the absence of other clinical findings.
Case: We report an unusual case of Wuchereria bancrofti diagnosed in a pregnant woman by breast fine-needle aspiration (FNA) and discuss the clinical implications of filariasis in pregnancy.
Conclusion: FNA is safe and reliable in pregnancy. Infants of mothers with breast filariasis should be monitored.
Objective: The purpose of this study was to compare erythromycin and azithromycin in the treatment
of chlamydial cervicitis during pregnancy with regard to efficacy, side effects, and compliance.
Methods: In a prospective manner, 48 pregnant patients with cervical chlamydial infections diagnosed by routine screening tests were randomly assigned to receive either erythromycin, 500 mg q.i.d. for 7 days (N = 24), or azithromycin, 1 g as a one-time dose (N = 24). All sexual partners were given prescriptions for doxycycline, 100 mg b.i.d. for 7 days. The treatment efficacy was assessed by follow-up chlamydia testing 3 weeks after the therapy was completed. The side effects, intolerance to therapy, and overall compliance were evaluated by means of a standardized posttreatment questionnaire.
Results: There was no significant difference in cure rates noted between the erythromycin group and the azithromycin group (77% vs. 91%, respectively; P = 0.24). Gastrointestinal side effects were reported more frequently among patients treated with erythromycin compared with patients treated with azithromycin (45% vs. 17%, respectively; P = 0.004). The patients who received erythromycin reported intolerance to therapy secondary to side effects more frequently than patients who received azithromycin (23% vs. 4%, respectively; P = 0.07). Furthermore, the patients in the azithromycin group were more likely to complete their course of therapy as prescribed than the patients in the erythromycin group (100% vs. 61%, respectively; P = 0.002).
Conclusions: Azithromycin is efficacious and well tolerated for the treatment of chlamydial cervicitis in pregnancy. Erythromycin, though efficacious, is poorly tolerated, as demonstrated by the number of patients reporting significant side effects during the course of therapy. Since the cost of azithromycin is comparable to that of generic erythromycin, the present study supports the use of azithromycin as an alternative to erythromycin for the treatment of chlamydial cervicitis in pregnancy.
Background: Hepatitis C virus (HCV) is now recognized as the cause of 90% of non-A, non-B (NANB) hepatitis. This virus is responsible for a large percentage of chronic persistent and chronic active hepatitis in the United States. Parenteral and sexual transmission are well described, so a significant population of pregnant patients is at risk. Vertical transmission of the virus to the fetus is dependent upon the level of maternal viremia.
Case: The cases described in the following report demonstrate that fulminant disease may present in pregnancy. They also demonstrate the cofactors promoting the severity of illness, methods of diagnosis, potential treatment, and outcome of the infection.
Conclusion: HCV may be encountered in pregnancy. Although most acute-phase illness will be self limiting, some patients will manifest liver failure during gestation. Because vertical transmission to the fetus is possible, the pediatrician should be informed of the maternal disease. Chronic hepatitis is almost the rule rather than the exception, so patients require close postpartum follow-up. Interferon, which may alter the course of the chronic disease, has been used on rare occasions in pregnancy.
Background: In the late 1960s, the first isolates of Aeromonas were recovered from human specimens. Presently, there is sufficient evidence to suggest that the different isolates of the genus Aeromonas are human pathogens. The most frequent site of infection is the digestive tract, although extraintestinal infection also occurs. In those cases involving septicemia, most infections occur in individuals with underlying diseases. This report presents the case of a pregnant woman with no underlying disease or signs of immunodeficiency who developed A. hydrophila septicemia at 24 weeks gestation.
Case: A 20-year-old pregnant woman was admitted with a history of 10 days of fever, chills, and diaphoresis. Three days before her hospitalization, she noted jaundice and choluria. Her liver was enlarged and her liver function tests were abnormal, with a moderate elevation of serum aminotransferases and direct serum bilirubin and a high serum alkaline phosphatase. Her blood and bone-marrow cultures revealed A. hydropkila. She was treated with parenteral ceftriaxone. She experienced a complete remission of her symptoms and laboratory abnormalities after therapy. The remainder of the pregnancy was normal. At 39.2 weeks gestation, she delivered a healthy male infant.
Conclusion: An association was noted between pregnancy and
A. hydrophila septicemia in a woman without immunodeficiency or underlying disease, possibly indicating another infectious complication in pregnancy.
Objective: The objectives of this study were to ascertain the acceptance rate of human immunodeficiency virus type 1 (HIV-1) testing in a high-prevalence area and to describe the sociodemographic
and clinical characteristics of seropositive women diagnosed in the prenatal setting.
Methods: A retrospective review was carried out of the prenatal HIV-1 counseling and testing program at University Hospital, Newark, NJ (1989-1990).
Results: Sixty-seven percent (741/1,114) of the women offered HIV-1 counseling services accepted testing and 40 (40/741:5.3%) new cases were identified. Heterosexual contact was the primary exposure (17:52%) of these women, of whom 13 (73%) had negative syphilis serologies. Sixty-four percent were asymptomatic. The mean absolute CD4 lymphocyte count in seropositive women was 514 ± 305 cells/mm3
. Severe immunosuppression was seen in 7/32 (22%) patients. Seventy-three percent (24/33) depended on public-assistance programs for their health-care services.
Conclusions: A voluntary HIV-1 counseling and testing program is well accepted in the prenatal setting. It can provide early identification of asymptomatic seropositive women and infants at risk and lead to early intervention and therapy.
Objective: The purpose of this study was to determine if granulocyte colony-stimulating factor
(G-CSF) is normally present in amniotic fluid and then to determine if amniotic-fluid G-CSF levels
are affected by labor and intrauterine infection.
Methods: Amniotic fluid was collected from 35 patients in 4 groups: no labor, early labor, late labor, and labor plus chorioamnionitis. G-CSF levels were measured by enzyme-linked immunosorbent
Results: The mean amniotic-fluid G-CSF concentrations prior to labor were lower than during labor (0.49 ± 0.25 ng/ml for prior to labor vs. 1.83 ± 1.0 ng/ml for labor, P < 0.001). With chorioamnionitis, the mean levels were elevated compared with normal labor (25.0 ± 4.8 ng/ml for chorioamnionitis vs. 1.83 ± 1.0 ng/ml for normal labor, P < 0.0001). In early and late labor, G-CSF was higher than prior to labor (0.49 ± 0.25 ng/ml for no labor vs. 1.48 ± 1.0 ng/ml for early labor, P < 0.02, vs. 2.2 ± 0.8 ng/ml for late labor, P < 0.0005). The mean concentrations in early and late labor were not different.
Conclusions: G-CSF is present in amniotic fluid and increased with labor. When labor is complicated by chorioamnionitis, G-CSF is significantly elevated.
Chlamydia trachomatis (CT) infections of the female genital tract, although frequently asymptomatic, are a major cause of fallopian-tube occlusion and infertility. Early stage pregnancy loss may also be due to an unsuspected and undetected CT infection. In vitro and in vivo studies have demonstrated that this organism can persist in the female genital tract in a form undetectable by culture. The mechanism of tubal damage as well as the rejection of an embryo may involve an initial immune sensitization to the CT 60 kD heat shock protein (HSP), followed by a reactivation of HSP-sensitized lymphocytes in response to the human HSP and the subsequent release of inflammatory cytokines. The periodic induction of human HSP expression by various microorganisms or by noninfectious mechanisms in the fallopian tubes of women sensitized to the CT HSP may eventually result in tubal scarring and occlusion. Similarly, an immune response to human HSP
expression during the early stages of pregnancy may interfere with the immune regulatory mechanisms required for the maintenance of a semiallogeneic embryo.
Background: Although cytomegalovirus (CMV) is an uncommon cause of viral hepatitis during pregnancy, a definitive diagnosis is important because of the potential for congenital CMV. In the case reported here, a diagnosis of hepatitis caused by CMV was made after the more common viral pathogens had been ruled out.
Case: A 17-year-old, 12-week pregnant patient was evaluated for fever and right upper quadrant tenderness. A serologic evaluation revealed elevated liver function levels and a positive maternal serology for CMV IgM. A diagnosis of hepatitis caused by CMV was made after the more common viral pathogens and drug-induced hepatitis had been ruled out. She was counseled about the potential effects of CMV on her fetus.
Conclusion: A step-wise approach to the diagnosis of viral hepatitis during pregnancy is needed to determine the etiology because a potential teratogenic virus may be involved.