Under conditions closely mimicking vaginal fluid, Lactobacillus jensenii strain 62B produces a bacteriocin-like inhibitory substance that targets and eliminates Gardnerella species.

Within the vaginal ecosystem, lactobacilli and Gardnerella spp. likely interact and influence each other's growth, yet the details of this interaction are not clearly defined. Using medium simulating vaginal fluid and a two-chamber co-culturing system to prevent cell-to-cell contact between the bacteria, we examined the possibility that Lactobacillus jensenii 62B (Lj 62B) and/or G. piotii (Gp) JCP8151B produce extracellular factors through which they influence each other's viability. By 24 h post-inoculation (hpi) in the co-culture system and under conditions similar to the vaginal environment - pH 5.0, 37 °C, and 5% CO2, Lj 62B viability was not affected but Gp JCP8151B had been eliminated. Cell-free supernatant harvested from Lj 62B cultures (Lj-CFS) at 20 hpi, but not 16 hpi, also eliminated Gp JCP8151B growth. Neither lactic acid nor H2O2 production by Lj 62B was responsible for this effect. The Lj-CFS did not affect viability of three species of lactobacilli or eight species of Gram-positive and Gram-negative uropathogens but eliminated viability of eight different strains of Gardnerella spp. Activity of the inhibitory factor within Lj-CFS was abolished by protease treatment and reduced by heat treatment suggesting it is most likely a bacteriocin-like protein; fractionation revealed that the factor has a molecular weight within the 10-30 kDa range. These results suggest that, in medium mimicking vaginal fluid and growth conditions similar to the vaginal environment, Lj 62B produces a potential bacteriocin-like inhibitory substance (Lj-BLIS) that clearly targets Gardnerella spp. strains. Once fully characterized, Lj-BLIS may be a potential treatment for Gardnerella-related BV that does not alter the vaginal microflora.

Pubic Candida Folliculitis, A Case Report in a Patient With Recurrent Vaginal Candidiasis.

Objective: Folliculitis is a skin infection and inflammation that develops in the hair follicles. While most cases of folliculitis are caused by bacterial infections, here is a case of folliculitis caused by the Candida fungi in an immunocompetent host. Case report: A 23-year-old non-diabetic immunocompetent female with recurrent vaginal candidiasis developed clusters of erythematous, pruritic papules in the pubic area. Upon evaluation, the clusters were determined to be folliculitis. Risk factors for folliculitis included shaving of the pubic area, hot tub use, and wearing of tight, restrictive clothing. Cultures and skin samples of the folliculitis demonstrated Candida albicans. The patient was subsequently and successfully treated with clotrimazole solution and cream. There was no recurrence of the folliculitis upon her 3-month follow-up appointment. Conclusion: Candida folliculitis is a rare condition in non-diabetic patients. The patient's history, risk factors and immune status assessment, and physical examination with proper diagnostic testing, are crucial steps in attaining the correct diagnosis.

Glycogen availability and pH variation in a medium simulating vaginal fluid influence the growth of vaginal Lactobacillus species and Gardnerella vaginalis.

BACKGROUND: Glycogen metabolism by Lactobacillus spp. that dominate the healthy vaginal microbiome contributes to a low vaginal pH (3.5-4.5). During bacterial vaginosis (BV), strict and facultative anaerobes including Gardnerella vaginalis become predominant, leading to an increase in the vaginal pH (> 4.5). BV enhances the risk of obstetrical complications, acquisition of sexually transmitted infections, and cervical cancer. Factors critical for the maintenance of the healthy vaginal microbiome or the transition to the BV microbiome are not well defined. Vaginal pH may affect glycogen metabolism by the vaginal microflora, thus influencing the shift in the vaginal microbiome. RESULTS: The medium simulating vaginal fluid (MSVF) supported growth of L. jensenii 62G, L. gasseri 63 AM, and L. crispatus JV-V01, and G. vaginalis JCP8151A at specific initial pH conditions for 30 d. L. jensenii at all three starting pH levels (pH 4.0, 4.5, and 5.0), G. vaginalis at pH 4.5 and 5.0, and L. gasseri at pH 5.0 exhibited the long-term stationary phase when grown in MSVF. L. gasseri at pH 4.5 and L. crispatus at pH 5.0 displayed an extended lag phase over 30 d suggesting inefficient glycogen metabolism. Glycogen was essential for the growth of L. jensenii, L. crispatus, and G. vaginalis; only L. gasseri was able to survive in MSVF without glycogen, and only at pH 5.0, where it used glucose. All four species were able to survive for 15 d in MSVF with half the glycogen content but only at specific starting pH levels - pH 4.5 and 5.0 for L. jensenii, L. gasseri, and G. vaginalis and pH 5.0 for L. crispatus. CONCLUSIONS: These results suggest that variations in the vaginal pH critically influence the colonization of the vaginal tract by lactobacilli and G. vaginalis JCP8151A by affecting their ability to metabolize glycogen. Further, we found that L. jensenii 62G is capable of glycogen metabolism over a broader pH range (4.0-5.0) while L. crispatus JV-V01 glycogen utilization is pH sensitive (only functional at pH 5.0). Finally, our results showed that G. vaginalis JCP8151A can colonize the vaginal tract for an extended period as long as the pH remains at 4.5 or above.

Obstetric vascular Doppler velocimetry: clinical applications and overuses.

A safe and non-intrusive assessment of fetal health is not only crucial in low-risk gestations, but it is also the standard of care in high-risk pregnancies. Therefore, measuring blood flow across different vessels with non-invasive ultrasound methods has been accurately and painstakingly studied and published. Amongst these state-of-the-art techniques, umbilical artery (blood flow) Doppler velocimetry (UADV) has allowed for fetal well-being follow-ups and assess uteroplacental function, which obtains a more complete and clearer picture; particularly in regard to complicated pregnancies. Additionally, there are other modalities with diverse clinical applications that have emerged, including their clinical and research utilization in conditions such as fetal growth restriction (FGR), preeclampsia, fetal anemia, monochorionic twins vascular blood flow mismatch such as is in twin-to-twin transfusion syndrome, twin anemia polycythemia sequence, and twin reverse arterial perfusion sequence. Nevertheless, their applications regarding various other maternal-fetal diagnoses in the same way as premature births and/or multiple gestation surveillance have not been reported to hold strong clinical evidence. With that in regard, the purpose of this unique study was to give update of the multiple clinical applications of this very important obstetrical tool. Additionally, to review the pathophysiology as well as revisit their reported significant valid uses and occasional overuses. We also delved into quality control measures as related to the application of Doppler in obstetrics. Lastly, it is essential to look through and reflect on the future developments of this valuable, non-invasive, high-risk marvelous modern device.

Challenging Vaginal Discharge, Lactobacillosis and Cytolytic Vaginitis.

In women's health, clinicians are often faced with diagnosing and administering treatment to patients who present with an increased vaginal discharge without much other information to work with. It's only once a patient's background is reviewed and lab work is completed that two common reasons behind vaginal discharge with similar symptoms, Lactobacillosis and Cytolytic Vaginitis, can be differentiated and a proper diagnosis can be reached. Now, we understand that Lactobacillosis and Cytolytic Vaginitis are symptomatically confused by patients as well as inexperienced clinicians. Lactobacillosis involves the presence of abnormal, extremely long Lactobacilli, a keystone species for vaginal health, while Cytolytic Vaginitis mainly involves, increased Lactobacilli, pH between 3.5 and 4.5, presence of cytolysis, and a lowered white blood cell count. Both present with similar discharge, leading to their conflation. A microscopic examination of the discharge using a wet mount with normal saline can provide 80% diagnostic sensitivity until further testing can be completed.

Lactobacilli and Cytokine Modifications during Menopause and Their Relation to Vulvar and Vulvovaginal Disorders.

OBJECTIVES: Female sexual and reproductive health is heavily influenced by the levels and ratios of Lactobacilli species and vaginal cytokines. Menopause marks a profound body change as it shifts to a natural and permanent non-reproductive state. Vulvovaginal diseases encompass a broad variety of sexual health conditions. Furthermore, both menopause and vulvovaginal diseases affect vaginal Lactobacilli and cytokine levels. Thus, this study aimed to investigate the correlation between menopause, vulvovaginal diseases, and vaginal Lactobacilli and cytokine levels. METHODS: Vaginal swab samples were collected as part of a prospective data bank creation to study vaginal conditions as approved by the Institutional Review Board of Texas Tech University Health Sciences Center, Lubbock, USA. This study utilized 38 samples in this database, which were assigned to the pre-menopausal with no vulvovaginal conditions (n = 20) and post-menopausal with vulvovaginal conditions (n = 18) groups. A real-time polymerase chain reaction was conducted to determine the relative concentration of Lactobacilli species, while cytokine analysis was performed using multiplex enzyme-linked immunosorbent assay immunoassay. The standardized mean difference, multivariate analysis of variance, and permutational unequal variance t test were used for the statistical analysis. RESULTS: Cytokines, interleukin (IL)-6, macrophage inflammatory protein-1α, IL-8, and Lactobacillus iners expression were significantly elevated in the control group compared to the study group (P = 0.03 for the cytokines, P = 0.0194 for Lactobacilli). CONCLUSIONS: The levels of vaginal cytokine and Lactobacillus profile were significantly different between the pre-menopausal and post-menopausal groups.

Preterm Complete Uterine Rupture With En Caul Expulsion.

Spontaneous uterine rupture is a catastrophic obstetric complication for both the mother and fetus. We highlight a case of a 32-year-old G2P1A0L1 Hispanic female at 36 weeks gestation who presented to the labor and delivery unit with minimal prenatal care, complaining of abdominal pains and vaginal bleeding. An abdominopelvic ultrasound confirmed an empty uterus and fetal demise in the abdominal cavity, leading to an exploratory laparotomy to evacuate the fetus. At surgery, a preterm sized fetus "en caul" with intact amnions was floating in the abdominal cavity and a hemostatic, complete rupture of the anterior uterine wall was discovered. Uterus was repaired and the patient recovered postoperatively without complications. Despite the best evidence suggesting that a history of low-transverse Cesarean section poses a low risk for spontaneous uterine rupture, this complication should always be considered and patients should be counseled regardless of the low risk should they desire a cesarean section.

A post-operative reaction to povidone­iodine in a postpartum woman: A case report.

Introduction: High infection rates after cesarean section are a major concern in the United States. A majority of antiseptics have irritant properties if they are not used as specified in companies' guidelines. Allergic contact dermatitis caused by povidone­iodine is infrequent and is misdiagnosed by clinicians who fail to differentiate allergy from irritation. This case report describes an allergic reaction to povidone­iodine after cesarean section. Case Presentation: A 28-year-old underwent a repeat low transverse cesarean-section at 39 weeks of gestation. The patient informed the medical team that she had no known allergies and no significant past medical history. The new hospital protocol included cleaning the skin over the planned incision site multiple times with povidone­iodine 7.5% scrub followed by povidone­iodine 10% paint. The surrounding skin was prepped with chlorhexidine. The patient complained of an allergic reaction on her skin the night after the procedure, with severe itching, and stated that it got progressively worse. The patient was started on an oral regimen of steroids and hydroxyzine. The itching slowly improved and at discharge the patient was continued on hydroxyzine and steroids were discontinued. By the patient's six-week postpartum visit, skin hypopigmentation had completely resolved. Conclusion: This case illustrates a reaction to povidone­iodine after cesarean section. This allergic reaction could not be attributed to any other portions of the procedure.

Vulvar Neurodermatitis in a Postmenopausal African-American Patient: A Case Report.

Lichen simplex chronicus commonly presents as a distressing vaginal lesion caused by severe, cyclical itch-scratch behavior. Lichen simplex chronicus is diagnosed by obtaining a detailed medical history, performing a physical exam, and recording of self-reported symptoms. Lichen simplex chronicus can be treated by corticosteroids, immunomodulators, antiepileptics, antihistamines, antidepressants, and phototherapy. Our case describes a 55-year-old female patient who presented to a clinic with recurrent vaginal itching, combined with compulsive scratching behavior that disrupted daily functioning. Physical examination revealed hypertrophic nodules located on the labia minora with scaling and hyperpigmentation. And the patient was diagnosed with lichen simplex chronicus. Empirical treatment with behavioral modifications and clobetasol propionate cream with an occlusive dressing produced significant improvements in symptoms at a six-month follow-up. Lichen simplex chronicus can have unusual presentations and; therefore, must be carefully differentiated from infectious and malignant skin lesions.

The Vaginal Microbiome: II. Vaginal Dysbiotic Conditions.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "dysbiosis," "bacterial vaginosis," "cytolytic vaginosis," "desquamative inflammatory vaginitis," and "aerobic vaginitis." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The second article in this series focuses on vaginal dysbiotic conditions. Dysbiosis is a term describing imbalances in bacterial communities. Given that lactobacillus-dominated microbiota are thought to be the most optimal, vaginal dysbiosis is usually considered as lactobacilli-depleted VMB. Bacterial vaginosis (BV), the most common vaginal dysbiotic condition, is a polymicrobial disorder, considered the leading cause for vaginal discharge in women worldwide. In addition, we review the VMB in other vaginal conditions associated with lactobacilli depletion: desquamative inflammatory vaginitis and aerobic vaginitis. We also discuss the controversial diagnosis of cytolytic vaginosis, related with lactobacilli overgrowth. CONCLUSIONS: Bacterial vaginosis displays complex microbiology. The heterogeneity and diversity within the genus Gardnerella may impact the progression of BV. Bacterial biofilms may contribute to the etiology and persistence of BV, and various bacteria may affect its clinical presentation and pathogenicity. Lack of lactobacilli is not always accompanied by an overgrowth of anaerobes.

The Vaginal Microbiome: I. Research Development, Lexicon, Defining "Normal" and the Dynamics Throughout Women's Lives.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome, written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the current findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A database search of PubMed was performed, using the search terms "vaginal microbiome" (VMB) with "research," "normal," "neonate," "puberty," "adolescent," "menopause," and "ethnicities," as well as "human microbiome project." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: In the last 2 decades, many studies applying molecular techniques were performed, intending to characterize the vaginal microbiota. These studies advanced our understanding of how vaginal health is defined. The first article in this series focuses on the advancement of VMB research, technical definitions, the definition of "normal" VMB, and the dynamics of VMB throughout women's lives. CONCLUSIONS: Understanding how microorganisms inhabiting the vagina interact with each other and with the host is important for a more complete understanding of vaginal health. The clinical application of microbial community sequencing is in its beginning, and its interpretation regarding practical clinical aspects is yet to be determined.

The Vaginal Microbiome: III. The Vaginal Microbiome in Various Urogenital Disorders.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "Candida," "vaginitis," "urinary microbiome," "recurrent urinary tract infections," "sexually transmitted infections," "human immunodeficiency virus," "human papillomavirus," "nonspecific vaginitis," "vulvodynia," and "vulvovaginal symptoms." Full article texts were reviewed. Reference lists were screened for additional articles. The third article in this series describes VMB in various urogenital disorders. RESULTS: Variable patterns of the VMB are found in patients with vulvovaginal candidiasis, challenging the idea of a protective role of lactobacilli. Highly similar strains of health-associated commensal bacteria are shared in both the bladder and vagina of the same individual and may provide protection against urinary tract infections. Dysbiotic VMB increases the risk of urinary tract infection. Loss of vaginal lactic acid-producing bacteria combined with elevated pH, increase the risk for sexually transmitted infections, although the exact protective mechanisms of the VMB against sexually transmitted infections are still unknown. CONCLUSIONS: The VMB may constitute a biological barrier to pathogenic microorganisms. When the predominance of lactobacilli community is disrupted, there is an increased risk for the acquisition of various vaginal pathogents. Longitudinal studies are needed to describe the association between the host, bacterial, and fungal components of the VMB.

The Vaginal Microbiome: IV. The Role of Vaginal Microbiome in Reproduction and in Gynecologic Cancers.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "reproduction," "infertility," "fertility," "miscarriages," "pregnancy" "cervical cancer," "endometrial cancer," and "ovarian cancer." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The fourth article of this series focuses on 2 distinct areas: the role of VMB in various aspects of human reproduction and, in sharp contrast, the association between the VMB and gynecologic malignancies. Several of the negative pregnancy outcomes have been associated with an altered VMB. Dysbiosis is remarkably linked with poor pregnancy outcomes from preconception to delivery. The associations between the microbiome and gynecologic cancers are described. CONCLUSIONS: The development of the microbiome research, enabled by molecular-based techniques, has dramatically increased the detection of microorganisms and the understanding of bacterial communities that are relevant to maternal-fetal medicine in health and disease, as well as in gynecological malignancies. Proving causation in cancer is difficult because of the complex interactive nature of potential causative factors. Certain elements of the microbiota have been shown to provoke inflammatory reactions, whereas others produce anti-inflammatory reactions; this balance might be impaired with a change in microbial variety.

The Vaginal Microbiome: V. Therapeutic Modalities of Vaginal Microbiome Engineering and Research Challenges.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "treatment," "diagnosis," and "research." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The currently available approaches for treating vaginitis or attempting to modulate the VMB are often insufficient. It has traditionally relied on the use of antibiotics, antiseptics, and antifungals. The fifth and last article of this series discusses the new and/or alternative therapeutic modalities. It addresses the role of probiotics, prebiotics and symbiotics, activated charcoal, biofilm disrupting agents, acidifying agents, phage therapy, and the concept of vaginal microbiome transplant. The challenges facing the research of VMB, including the clinical impact of microbiome manipulation, classification, and new diagnostic approaches are discussed. CONCLUSIONS: Microbiome research has grown dramatically in recent years, motivated by innovations in technology and decrease in analysis costs. This research has yielded huge insight into the nature of microbial communities, their interactions, and effects with their hosts and other microbes. Further understanding of the bacterial, fungal, phage, and viral microbiomes in combination with host genetics, immunologic status, and environmental factors is needed to better understand and provide personalized medical diagnostics and interventions to improve women's health.

A rare case report: Cutaneous Candida tropicalis infection disguised as a sacral decubitus rash in an immunocompetent individual.

Candida infection is seen in patients with weak or disrupted host responses. Cutaneous candidiasis typically affects the intertriginous areas and presents with a red plaque surrounded by satellite lesions. Diagnosis of cutaneous candidiasis is made by visual inspection followed by potassium hydroxide normal saline microscopic preparation (wet mount) and polymerase chain reaction identification or culture of fungal organism. The following case describes a 38-year-old patient with limited mobility who presented with a peri sacral lesion that was first assumed to be a decubitus ulcer by nursing facility staff, but proved to be a cutaneous infection by Candida tropicalis, a less common Candida species. The unusual location as well as the characteristic C. tropicalis micro- and macroscopic appearance are described which ultimately led to the diagnosis of a cutaneous fungal infection in an otherwise immunocompetent individual that was resolved with fluconazole therapy. Our case report emphasizes the need for early diagnosis of cutaneous lesions in patients with limited mobility in consideration that not all Candida species thrive in similar environments and can present in unusual locations of the human body. Although rare, C. tropicalis could be found in this vulnerable population.

Cytokine profiles and Lactobacillus species presence in pre-menopausal subjects with genital Mycoplasma genitalium or Ureaplasma urealyticum colonization.

BACKGROUND AND PURPOSE: Lactobacilli play a vital role in protecting the vagina against pathogens. Cytokines are vital components of defense against infections in women. The genital mycoplasmas, Mycoplasma genitalium and Ureaplasma urealyticum, are associated with various infectious diseases in adults and infants. The objective of our study is to identify differences in cytokine profile and Lactobacillus species dominance between a study group of non-pregnant pre-menopausal women with genital M. genitalium or U. urealyticum colonization and a control group of non-pregnant pre-menopausal women without genital M. genitalium or U. urealyticum colonization. METHODS: A real-time polymerase chain reaction was performed to measure Lactobacillus species in vaginal swab samples. Cytokine analysis was performed using multiplex immunoassay techniques. Analysis of variance confirmed a significant difference in cytokine profiles between patient groups, with t-tests identifying the most significantly different cytokines. Categorical data analysis identified significant patterns of relative Lactobacillus species dominance in the study group. RESULTS: Lactobacillus iners was the predominant Lactobacillus species in the control group (p = 0.005). There were no dominant Lactobacillus species observed in the study group. Vascular endothelial growth factor A (p = 0.002), interleukin-8 (p = 0.001), and interleukin-1ß (p = 0.049) were expressed significantly higher in the study group, whereas interleukin-1 receptor antagonist (p < 0.001), interleukin-10 (p = 0.001), interleukin-12 (p = 0.002), and interferon-γ (p = 0.022) were expressed higher in the control group. Association matrices for cytokines were significantly different between two groups (p < 0.001), with mostly negative associations in the control group and mostly positive associations in the study group. CONCLUSION: Cytokine levels, their associations, and the patterns of Lactobacillus species dominance are observed to significantly diverge on the basis of M. genitalium and U. urealyticum colonization among non-pregnant pre-menopausal women.

Vulvar lesion mimicking vitiligo: A case report.

BACKGROUND: Post-inflammatory hypopigmentation (PIH) is an acquired partial or total loss of pigment that occurs as a result of cutaneous inflammation. Clinically, post-inflammatory hypopigmentation is recognized by a discoloration of the skin; however, proper diagnosis requires a skin biopsy. Although post-inflammatory hypopigmentation is similar in appearance to vitiligo, histopathological evaluation highlights the key differences in the presence of melanocytes and melanophages. CASE PRESENTATION: A 28-year-old woman presented with discoloration in the vulvovaginal area. Physical examination was within normal limits; however, a genital exam revealed a large, intensely white discoloration in an hourglass pattern involving the clitoris, labia majora, and perianal area. Pigmentation was observed at the base of the hair follicles, which is not consistent with vitiligo. The patient consented to a skin biopsy, which was performed without complication. The biopsy showed mild chronic vulvitis and pigment incontinence due to post-inflammatory hypopigmentation. The patient was prescribed a high-potency topical steroid and a significant reduction in lesion area was observed at 3-month follow-up. DISCUSSION: Proper diagnosis via clinical examination and skin biopsy is essential in the treatment of pigment deficiencies. In cases of post-inflammatory hypopigmentation, the initial cause of inflammation must first be identified in order to provide an effective treatment regimen. When facing uncommon dermatological conditions such as post-inflammatory hypopigmentation, proper histopathological diagnosis, course of treatment, and follow-up are important in order to achieve patient satisfaction.

Carbon dioxide (CO2) laser ablation treatment of a peri-urethral genital wart: A case report.

BACKGROUND: Visible genital warts are caused by the nearly 100 recognized strains of human papillomavirus (HPV). HPV infections caused by high-risk strains are associated with significant morbidity and mortality rates. Genital warts are diagnosed by visual inspection and treated by three major methods: topical agents, systemic agents, and surgical therapies. CO2 laser ablation is the best treatment option for warts that present as refractory, thick, extensive lesions. CO2 ablation offers benefits such as a painless procedure, increased clearance rate, lesser side-effects and decreased pain. CASE PRESENTATION: An 18-year old patient was referred to the obstetric/gynecology clinic and presented with severe urinary complications. She complained of dysuria, frequency, vaginal irritation, and spraying while voiding. Physical exam was within normal limits; however, genital examination revealed a 3 cm fungating mass corresponding to a large genital wart at the urethral meatus and peri-urethral area. Due to her progressing symptomatology, CO2 laser ablation therapy was advised. DISCUSSION: HPV directly impacts the public health system, affecting 1% of the US population with an estimated 10-20% prevalence rate. Treatment options such as CO2 laser ablation offers complete removal for most patients with limited side-effects. Accurate follow-up is necessary to monitor proper recovery. CONCLUSION: CO2 laser ablation is considered an effective form of therapy in cases where immediate removal is desired and surgical excision is not recommended. CO2 laser ablation provides high clearance rates and minimal instances of recurrence, as well as superior aesthetic outcome.

Vaginal Lactobacillus species and inflammatory biomarkers in pregnancy.

BACKGROUND: The aim of this study was to identify vaginal Lactobacillus spp. and quantify vaginal inflammatory cytokines in primigravida vs. multigravida women and pregnant vs. non-pregnant women. METHODS: Vaginal swabs were obtained from four groups of patients. A real-time PCR was carried out to identify the Lactobacillus spp. Multiplex immunoassays were performed to quantify a total of 27 cytokines using the Bio-Plex MAGPIX multiplex reader and MesoQuick Plex SQ 120 (Meso Scale Diagnostics LLC, Rockville, MD, USA). Inferential statistics using hypothesis tests were applied to detect differences in cytokine levels. RESULTS: Significant differences in cytokines and chemokines exist among the four populations of women studied. IP-10 is significantly higher in multigravida women as compared to primigravida women. IFN-γ, MCP-1, MIP-1ß, IL-2 and IL-10 are significantly higher in non-pregnant women compared to pregnant women. L. iners was the most abundant species in multigravida, pregnant and non-pregnant patients, while L. crispatus was the most abundant species in primigravida patients. Significant differences in the levels of MIP-1ß, TNF-α, PDGF-BB, VEGF-A, IL-12, and IL-10 exist between women identified with Lactobacillus species and women not identified with Lactobacillus species. CONCLUSIONS: There were significant differences regarding cytokines, chemokines, and Lactobacillus spp. among four groups of studied patients. With these results, we increase our understanding of the role that vaginal cytokines and Lactobacillus species have during pregnancy, with the goal that this novel research will be useful for examining vaginal biomarkers in obstetrical conditions.