azole-resistant Candida glabrata

Case report-Subjects-Three cases are described oflong-standing vaginal candidosis due to Candida glabrata. These had failed to respond to local and systemic antifungals. In each case the infecting strain appeared resistant to a range of azole drugs in vitro. Clinical course-Case one-This patient recovered following prolonged treatment with oral itraconazole in combination with oral and vaginal nystatin. Case two. Yeasts were eradicated from this patient following cyclical treatment with oral dydrogesterone; prolonged vaginal treatment with nystatin may have helped. Case three. This patient did not respond to a prolonged course of oral itraconazole in combination with vaginal and oral nystatin, oral medroxyprogesterone or intravaginal boric acid. Eradication of C glabrata was finally achieved by local application of 1% gentian violet. Shortly after eradication of the C glabrata infection, both Case two and Case three developed infections with other Candida species responsive to azole antifungals. (Genitourin Med 1993;69:112-114) Department of Genitourinary Medicine, Birmingham General Hospital D J White Regional Mycology Laboratory, Department of Microbiology, Bristol Royal Infirmary E M Johnson D W Warnock Correspondence to: Dr D J White, Department of Genitourinary Medicine, The General Hospital, Steelhouse Lane, Birmingham B4 6NH, UK Accepted for publication 5 January 1993 Introduction Although Candida albicans is the usual cause of vulvovaginal candidosis, other members of the genus are sometimes involved. The second most common yeast recovered from the genital tract of women with vaginitis is Candida glabrata (formerly Torulopsis glabrata) which accounts for about 5% of vaginal infections.' Infections with this organism are apt to be mild and it is not often associated with florid clinical signs. Most women with vulvovaginal candidosis respond well to local or oral antifungal treatment. In some, however, the infection is recurrent, while others have persistent symptoms that fail to respond to treatment. Azole drug resistance has seldom been implicated as the cause of treatment failure in women with persistent vaginitis. However, recent reports indicate that even short-term treatment can lead to the rapid development of drug resistance in patients with C glabrata infection.2 This paper describes three cases of persistent vaginal candidosis, unresponsive to azole drug treatment. In each case, laboratory testing of the C glabrata isolates showed that the organisms were resistant to a range of azole antifungal drugs. Case histories All three women were otherwise well. A range of investigations including full blood count, random blood sugars, T-cell subsets and lymphocyte proliferations including those to whole C albicans antigen were normal. Case 1 A 38 year old woman presented with a 3 year history of persistent vaginal discharge, pruritus, external dysuria and marked superficial dyspareunia. Her symptoms worsened before menstruation. Numerous vaginal swabs had yielded heavy growths of yeast. She had been treated with nystatin and with topical and oral azole antifungals without response. Midstream urine specimens had yielded significant growths of coliforms, but her dysuria had not responded to the antibiotics prescribed. On examination, she was found to have a thick white vaginal discharge with minimal vulvovaginitis. Large numbers of yeasts were seen in a vaginal smear and a heavy growth of a Candida sp. was obtained in culture. Treatment with fluconazole (150 mg once weekly) was commenced, but four weeks later her symptoms and signs were unchanged. Yeasts were seen on microscopy of a high vaginal swab which subsequently yielded a heavy growth of Candida glabrata. Oral fluconazole was discontinued and treatment with oral itraconazole commenced (200 mg twice daily for one day followed by 200 mg twice daily three times weekly). Three weeks later her symptoms were much improved, although she still complained of marked vulval irritation. No evidence of vaginal yeasts was found on either microscopy or culture. Treatment with itraconazole (200 mg twice daily for one day per week) was continued for a further four weeks. In addition, oral nystatin (100 000 units four times daily) and nystatin pessaries (500 000 units nightly) were prescribed. Her vulval symptoms settled after four months. All antifungals were then discontinued. Case 2 A 31 year old woman presented with a 2 year history of recurrent vaginal discharge, marked superficial dyspareunia and mild vulval irritation. Numerous vaginal swabs had yielded heavy growths of yeast. Her symptoms had not responded to a range of intravaginal imidazole antifungals, but a transient improve12 group.bmj.com on August 14, 2017 Published by http://sti.bmj.com/ Downloaded from