Case No. 10 Chen, I- Ling( Claire)

GTZ, 57 y/o female, came in because of vaginal pruitus. She also experience weight loss, polyphagia, polyuria, nocturia and polydipsia. FBS showed 250 mg/dl.

Diagnosis -Vulvovaginal candidiasis (Yeast infection) secondary to Diabetes Mellitus -Polyphagia, polydipsia, polyuria -Etiologies -Treatment-resistant Candida species other than Candida albicans -Frequent antibiotic therapy -Contraceptive use -Compromise of the immune system -Sexual activity -Hyperglycemia

Diabetes and Vulvovaginal Candidiasis Diabetes mellitus is often considered a predisposing factor for recurrent vulvovaginal candidiasis Primarily because of hyperglycemia induced alterations, including decreased random motion of neutrophils, chemotaxis, phagocytosis, and microbial killing. Hyperglycemia enhances the ability of C. albicans to bind to vaginal epithelial cells.

Plan of Management 1. Non-pharmacologic Proper glucose control is important in the management of vulvovaginitis in diabetic women. –Most study data indicate that overall yeast carriage and infection rates increase in diabetes patients Patients should also be advised to keep the vulvar area clean and dry Exercise

2. Pharmacologic Selection of therapy should be based on factors such as causative organisms, safety and side effects, the potential for drug interactions, and patient preferences.

Miconazole (Topical Agent) Mechanism of action –Azoles Inhibit biosynthesis of ergosterol or other sterols, damaging the fungal cell membrane Inhibit biosynthesis of triglycerides and phospholipids by fungi. Inhibit oxidative and peroxidative enzyme activity Pharmacokinetics –Small amounts absorbed systemically following intravaginal administration and topical administration.

ADVERSE EFFECTS : Occasional local irritation and hypersensitivity reaction include mild burning sensation, erythema and itching, headache, hives and skin rash may occur. Treatment should be discontinued if these are severe. Abdominal or stomach cramps or pain.

Ketoconazole (Oral Agent) Mechanism of Action –Ketoconazole interferes with sterol synthesis, damaging the cell membrane and increasing its permeability –This leads to a loss of essential intracellularr elements and inhibition of cell growth Pharmacokinetics –Ketoconazole is absorbed variably and distributed widely. –Undergoes extensive liver metabolism and is excreted through the bile and feces.

Adverse effects –Anaphylaxis –Joint pain –Chills –Fever –Ringing in the ears –Impotence –photophobia

Drug interactions –With drugs that decrease gastric acidity may decrease absorption of ketoconazole and reduce its antimycotic effects –With phenytoin may alter metabolism and increase blood levels of both drugs –Use with other liver toxic drugs my increase the risk of liver disease

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