Case Study: Severe Vulvovaginal Candidiasis Secondary to Clindamycin Therapy for a Suspected Dental Abscess

Case at a Glance

A 37-year-old female developed severe, treatment-refractory vulvovaginal candidiasis shortly after starting a course of Clindamycin for a suspected dental abscess. The distress from the side effect led her to consider premature discontinuation of the antibiotic.

Patient's Story

A 37-year-old female with a history of using fluoxetine and an oral contraceptive pill presented to her dentist for evaluation of a toothache. A dental X-ray revealed a 'slight shadow' at the apex of the tooth, which was interpreted as a possible periapical abscess. The dentist prescribed a course of Clindamycin, to be taken every six hours.

Initial Assessment

Within 24 hours of initiating the Clindamycin, the patient began to experience severe symptoms of vulvovaginal candidiasis, including intense itching, irritation, and discharge. She described the symptoms as the most severe she had ever experienced. The patient contacted her gynecologist for management.

The Diagnostic Journey

Based on the classic symptoms and the recent initiation of antibiotic therapy, a presumptive diagnosis of vulvovaginal candidiasis was made. The gynecologist prescribed a single oral dose of fluconazole (150 mg). The patient reported approximately 24 hours of mild symptom relief before the symptoms returned with even greater severity. Over-the-counter topical antifungal treatments (e.g., miconazole) provided no relief. Distressed by the intractable symptoms and with two days remaining in her antibiotic course, the patient expressed a strong desire to discontinue the Clindamycin.

Final Diagnosis

1. Suspected Periapical Abscess.
2. Acute, Severe Vulvovaginal Candidiasis, secondary to antibiotic therapy.

Treatment Plan

The patient was strongly advised against the premature discontinuation of her antibiotic course, with the rationale that doing so could lead to treatment failure of the underlying dental infection and the potential for antibiotic resistance. The focus of management was shifted to more aggressive treatment of the secondary candidiasis. It was explained that while vaginitis is a known side effect of clindamycin, it does not typically warrant cessation of therapy. The patient was instructed to complete the Clindamycin as prescribed and to follow up with her gynecologist for a more robust antifungal regimen, such as a multi-dose oral fluconazole course or a longer-duration topical therapy, to manage the severe symptoms.

Outcome and Follow-up

Following counseling on the risks, the patient agreed to complete the full course of Clindamycin. She was managed concurrently by her gynecologist for the severe candidiasis. A note was added to the patient's medical record detailing this significant adverse reaction. It was recommended that for any future antibiotic prescriptions, prophylactic antifungal therapy should be strongly considered to prevent recurrence.