CASE REPORT

CONDYLOMA ACUMINATA ACCOMPANYING CANDIDIASIS VULVOVAGINALIS

Henky Yoga Prasetya, Wiwiek Dewiyanti, Alwi Mappiasse Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACT
Condyloma acuminata (CA) is a macular lesions, papules, and stemmed the genital or anal mucosa, caused by infection with Human papillomavirus (HPV). Condyloma acuminata often simultaneously with sexually transmitted infections (STI). Reported one case, a woman 16 years, with clinical manifestations of papules verrucous with uneven surface of the vagina, accompanied by watery white vaginal discharge, odorless, and itching, also appeared erythematous around the vaginal area. Examination acetowhite gave positive results in accordance with condyloma acuminata. Examination by Amsel criteria negative, KOH examination gave positive results when fungal spores are found on microscopic examination, this is in accordance with vulvovaginal candidiasis. Treatment with electrocauterizaation, and fluconazole 50 mg 1x1 for 7 days. Keywords: condyloma acuminata, vulvovaginal candidiasis, a woman 16 years

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Henky Yoga Prasetya

Condyloma Acuminata Accompanying Candidiasis Vulvovaginalis

INTRODUCTION Condyloma acuminata (anogenital warts / genital warts) is a sexually transmitted disease such as benign proliferation of the skin and mucosa caused by infection with Human Papilloma Virus (HPV) of various subtypes, frequent HPV types 6 and HPV type 11. (1-5) Condyloma acuminata can strike all the nations where the frequencies between men and women are equal. (2, 3) It is estimated that 30% to 50% of sexually active adults are infected by HPV. (6) Most commonly occurs at the age of 16-25 years. (7, 8) Several epidemiological factors associated with increased HPV infection, among others: the young woman who did especially aktivas first sex at an early age, smokers, women who are pregnant or taking oral contraceptives. (9-12) Patients with condyloma acuminata often have other genital infections include candidiasis, and non-specific genital infection. (9) Though the condyloma accuminata may result from exposure to the virus during sexual activity, but HPV can also be transmitted through autoinoculation of finger warts, may also indirectly through contaminated objects. (13) Transmission of HPV can also go through perinatal transmission in neonates. (2, 10) Clinical picture was originally a very small papules form of a pin and a papilomatosa typically increase in size and grow cauliflower structure which can eventually cover the entire external genitalia. (3, 9) Predilection for female vulva and surrounding area, vaginal introitus, sometimes on porsio uteri. (2) Investigations CA include acetic acid test and histopathological examination. (1, 7) Vulvovaginal candidiasis investigation is the examination of KOH. (9, 14) Diagnosis CA disease is established 22

based on the clinical picture, acetic acid test examination (acetowhite) positive and histopathologic. Diagnosis of candidiasis vulvovaginalis with the discovery of spores on KOH 10 - 20% examination . (9, 14-16) The main goal of treatment is to eliminate CA lesions. (1) Many treatment options for CA, among others, can use topical therapy (podophyllin, podophyllotoxin, trichloroacetic acid, imiquimod, 5fluorouracil), surgery (power surgery, scalpel surgery, frozen surgery, laser surgery) and systemic therapy (interferon, isoprinosine). (7, 9, 13, 17, 18) Reported one case of a woman of 16 years with CA accompanied by vulvovaginalis candidiasis. CASE REPORT A woman, aged 16 years came to Dermatovenereology clinic Dr. Wahidin Sudirohusodo hospital with complaint appears bumps in pubic since 2 months ago. Initially small bump, then gradually getting bigger. The complaint was accompanied by vaginal discharge, itching, odorless since 1 month ago after patients frequently wash her genital with vaginal douching. No complaints of dispareunia, dysuria. History of sexual intercourse with her boyfriend 5 months ago. No prior treatment history. On physical examination found a good general condition, composmentis, sufficient nutrition. Vital signs within normal limits. On physical examination, dermatovenerology status: location labium major regio inferior and superior dextra with effloresense verrucous papules, diameter papules 1.5 cm and 0.5 cm, painful, no enlarged inguinal lymph, erythematous vaginal mucous and white watery vaginal discharge. (Figure 1)

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Other investigations such as acetowhite test positive, KOH examination showed fungal spores (Figure 2). Complete blood routine and urine routine in normal limit, nonreactive VDRL, and histopathological examination was also performed.

Based on history, clinical manifestation and laboratorium investigations the diagnosis is CA and candidiasis vulvovaginalis. Treatment given to patient include electrocauterization, amoxicillin 3 x 500mg, fluconazole 150 mg single dose. One week later, CA lesions have dried up, no new lesions, itching reduced, white watery discharge (figure 3). Histopathological result supports condyloma acuminata (figure 4) . Then treatment was continued fluconazole 50 mg once a day for 7 days, mupirocin cream, and sefadroxil 2 x 500 mg.

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Henky Yoga Prasetya

Condyloma Acuminata Accompanying Candidiasis Vulvovaginalis

DISCUSSION Diagnosis in this case is established based on history, clinical examination and laboratorium investigation showed condyloma acuminata and candidiasis vulvovaginalis. From history was obtained a lump in genital growing since two months with white vaginal discharge, and growing bump. This is consistent with literature that CA lesions appeared after incubation periode 1-8 months with an average 3 months, the lesions can be solitary or multiple lesions develop into 110 mm diameter with a typical clinical picture of the lesion in the form of papilliferus mass and irregular surfaces. (7, 9, 13) In women with vaginal discharge growing disease faster. (2) Venereology status showed white watery fluor albus , erythematous vaginal mucous. In accordance with literature described that candidiasis vulvovaginalis provide symptoms such as watery discharge, mild itching, odorless. Vaginal discharge often seen in vaginal mucous. (9, 14) Patients history was obtained itching in vagianl area, white homogenous vaginal discharge, erythematous vaginal mucous, and 10% KOH examination showed spores . In accordance with literature that candidiasis vulvovaginalis provide pruritus symptoms and vaginal mucous appeared red, white fluor albus, no smell and vaginal wall usually erythematous, and in 10-20% KOH exa24

mination seemed spores. (9, 14, 15) Condyloma acuminata frequent co-infections with candida and other anaero-bic bacteria. Results of research conduc-ted in the division of sexually transmitted diseases outpatient unit RSU Soetomo obtained was 21.7% in patients with CA and candidiasis vulvovaginalis. (9) Investigations conducted acetic acid test positive. Corresponding acetate literature that tests performed by applying 3-5% acetic acid in distilled water, there will be changes in lesions suspected condyloma and provide color changes to white (acetowhite). (3, 9) Histopathological examination showed hyperplasia epidermal, hyperkeratosis, acanthosis, slight coilositosis, papilomatous, upper dermis contained a mild mononuclear inflammation infiltrat, where appropriate literature of CA histopathology seen as hyperkeratosis, hypergranulosis, and coilositosis in stratum spinosum and irregular acanthosis that extends to the middle. Mononuclear infiltrates were slightly visible on dermis. Dominant picture CA histopathology form acanthosis and papillomatosis, parakeratosis horny layer also experienced but not too thick. (1, 3) In the investigation found 10% KOH examination and obtained spores on a microscope, showing the vulvovaginalis candidiasis. Appropriate literature that predisposing factor vulvovaginalis candidiasis among which endogenous

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and exogenous factors include among others: sexual contact frequently and do vaginal douche. This patient do vaginal douching frequently and sexual intercourse with her partner. Presumably the mechanism through an allergic reaction resulting in increased susceptibility to candida. Mechanisms of sexual contact can cause candidiasis vulvovaginalis allegedly caused by abrasion vagina and allergic to semen. (9, 14) Every CA patient is necessary to check possibility of sexually transmitted diseases such as gonorrhea, syphilis and others. (9) VDRL non-reactive in this case. Management CA should consider patient preference, availability of facilities, and the experience of health workers. (17) There is no single treatment is ideal for all patients with condyloma acuminata. Factors that influence the choice of treatment include: size, number, anatomic location and morphology of the lesion, the patient desires, the cost of treatment, convenience, adverse effects, and the experience of health workers. (17) Therapeutic modalities is used electrocauterization. The main goal of treatment using electrocauterization surgical due to lesions more than 1 cm and because so far it is still considered to be an effective methode for CA treatment . (2, 7) Treatment for candidiasis vulvovaginalis fluconazole 150 mg single dose, then 50 mg once a day for 7 days. Literature mentioned that vulvovaginalis candidiasis therapy using azole class more effective than nystatin. (9, 14) Patients were educated to control during therapy and CA in women have a higher incidence of developing into dysplasia of vulva, vagina or cervix. ( 7, 9, 13) For candidiasis vulvovaginalis when giving the right treatment it gives a good prognosis and do not cause complications and should also 25

avoid predisposing factors to prevent recurrence. (9, 14) REFERENCES

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Condyloma Acuminata Accompanying Candidiasis Vulvovaginalis

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