TITLE: CYTOLYTIC VAGINOSIS - DIAGNOSTIC CHALLENGE
KEY WORDS: cytolytic vaginosis, candidiasis, vulvovaginitis
ABSTRACT
INTRODUCTION: Vaginal discharge is a common finding in medical practice as one in ten women will report the symptom over the period of twelve months. Candidiasis, trichomoniasis and bacterial vaginosis are the three pathologies most frequently found. Different entities may present the same symptoms, such as candidiasis and cytolytic vaginosis (CV): vaginal itching associated with a white discharge. Therefore attending physicians must face a challenge of correctly diagnosing in order to institute the most effective therapeutic approach.
METHODOLOGY: As a literary review on the differential diagnosis between cytolytic vaginosis and candidiasis, considering the etiology, clinical presentation, laboratory and clinical diagnoses of cytolytic vaginosis. The descriptors '' cytolytic vaginosis'', ''candidiasis'' and ''vulvovaginitis'' were included in the Pubmed, Scielo, Lilacs and Google Scholar databases, delimiting the publication period between 2000 and 2020. 1.275 articles were found in Portuguese, Spanish and English. After excluding 36 duplicates, 777 articles were analyzed, 45 were chosen, and finally, 8 articles were selected to support this essay.
RESULTS : Eighty species of Lactobacillus were found in normal vaginal flora. The most frequent in the Brazilian population are Lactobacillus crispatus , which coexists with other species of microorganisms such as Gardnerella vaginalis , Trichomonas vaginalis and Candida albicans. The balance between these agents is influenced by the hormonal status, as well as the individual's immune response, use of contraceptives, sexual activity and trauma. Lactobacilli are gram-positive bacteria responsible for maintaining vaginal pH between 3.8- 4.5 through the transformation of glycogen into lactic acid. The acid environment prevents overgrowth of pathogens. An exaggerated increase in Lactobacilli can be found in an individual with VC. Theories indicate hormonal influence as responsible for this modification. Cytolysis occurs in the middlayer epithelium by increasing the production of lactic acid and consequently decreasing the pH. Patients will then present itching, dysuria and whitish, lumpy, odorless and “milky” discharge. Clinically similar to candidiasis, microscopic examination is necessary, which demonstrates: numerous pleomorphic Lactobacilli , few leukocytes and no bacteria. If colonization by candidiasis, there will be filamentary structures (hyphae and pseudo-hyphae ) along with multiple microorganisms and normal Lactobacilli .
CONCLUSION : Cytolytic vaginosis is an underdiagnosed pathology and often misdiagnosed with candidiasis in clinical practice, resulting in ineffective and prolonged treatment. Besides causing iatrogenesis, medical error lead to aggravating the patient's symptoms and cause unnecessary health system expenses. Considering the diagnostic challenge, it is necessary to educate physicians about the value of microscopic analysis and morphological differences between VC and candidiasis.
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