Vulvovaginal Candidiasis — DVA claim example

Diagnostic Assessment — Vulvovaginal Candidiasis

Example 1 of 1 · fictitious patient (Veteran CX)

Diagnostic Assessment

Vulvovaginal Candidiasis

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran CX, date of birth 26 April 1979, Australian Army, Signaller (Sergeant), enlisted 09 March 1998, medically discharged 14 December 2020. Operational service: East Timor, 12 October 2000 to 20 April 2001 (warlike); Afghanistan, 05 May 2011 to 30 November 2011 (warlike); Middle East Area of Operations (Iraq), 10 May 2016 to 25 November 2016 (warlike).

Occupational History

As an Army signaller the veteran operated communications equipment in vehicles, command posts and patrol bases, often in hot climates, wearing flame-resistant synthetic-blend combat uniform, body armour and load-carrying equipment for long shifts. Field and deployed postings involve restricted water for washing, infrequent showers and limited laundry facilities.

Deployed members are exposed to dust, smoke and respiratory irritants, with high rates of respiratory infection and asthma requiring antibiotics and oral corticosteroids, and female members are commonly prescribed continuous hormonal contraception for menstrual suppression before deployment. Shift work and irregular meals on deployment make diabetes harder to control.

History

Veteran CX, an Army signaller, developed vulvovaginal candidiasis in August 2016 on warlike service in Iraq, after antibiotics and oral corticosteroids for a dust-related asthma exacerbation and sinusitis, while her type 2 diabetes was poorly controlled on an SGLT2 inhibitor. The condition became recurrent and azole-resistant, and worsened during a field exercise in northern Australia in July 2017.

Timeline

• 18 Jan 2016 — The veteran's type 2 diabetes, diagnosed in March 2014, was poorly controlled on metformin, with an HbA1c of 8.4 per cent. Her medical officer added empagliflozin 10 mg daily, which she continued without interruption. She was taking a combined oral contraceptive containing ethinylestradiol 30 micrograms, taken continuously from November 2015 to suppress menstruation before deployment. No genital symptoms were recorded at her pre-deployment examination on 22 April 2016. "empagliflozin added, HbA1c 8.4"
• 12 Jun 2016 — On warlike service in Iraq the veteran developed an acute exacerbation of asthma after repeated exposure to dust storms and burn-pit smoke at her base. She was treated at the role 2 facility with prednisolone 50 mg daily for 14 days. Daily maximum temperatures were 44 to 48 degrees, and she wore flame-resistant combat uniform and body armour for 10 to 12 hours a day. "asthma exacerbation, prednisolone 50 mg"
• 28 Jul 2016 — The veteran was posted to a forward patrol base where water was rationed and showers were limited to twice a week, with no laundry facility. On 30 July 2016 she was treated for acute bacterial sinusitis with amoxicillin-clavulanate 875/125 mg twice daily for 10 days. Fingerprick glucose readings were 12 to 18 mmol/L on irregular deployed meals and shift work. "amoxicillin-clavulanate 10 days, showers rationed"
• 17 Aug 2016 — The veteran presented to the role 2 facility with three days of intense vulval itch, burning, soreness on passing urine and a thick white vaginal discharge. Examination showed vulval erythema and oedema with fissuring and curd-like discharge. Microscopy showed budding yeasts and pseudohyphae and vaginal pH was 4.2. HbA1c was 9.6 per cent. She was treated with a single dose of oral fluconazole 150 mg. "vulvovaginal candidiasis, budding yeasts"
• 24 Aug 2016 — Vaginal swab culture, sent to a coalition laboratory, grew Candida albicans. A medical officer confirmed vulvovaginal candidiasis. Symptoms recurred twice more before her return to Australia in November 2016, each treated with single-dose fluconazole as no follow-up culture or specialist review was available in theatre. "Candida albicans on culture"
• 08 Mar 2017 — A sexual health physician recorded four episodes since August 2016, the first and a fourth in February 2017 confirmed on culture as Candida albicans, and diagnosed recurrent vulvovaginal candidiasis. Six months of weekly fluconazole maintenance was commenced. HbA1c remained 8.9 per cent and empagliflozin was continued at the request of her endocrinologist. A gynaecology referral was placed but the first available appointment was in August 2017. "recurrent VVC, weekly fluconazole"
• 24 Jul 2017 — During a four-week field exercise in northern Queensland in heat and humidity, with showering limited to twice weekly, the veteran had received doxycycline for 14 days for infected insect bites and a further five-day course of prednisolone for asthma. She presented with severe symptoms despite weekly fluconazole. Culture grew fluconazole-resistant Candida glabrata as well as Candida albicans, and the physician recorded clinical worsening with azole resistance. "fluconazole-resistant Candida glabrata, worsening"

Symptoms

At onset the veteran had intense vulval itch, burning and soreness, pain on passing urine and on sitting, and a thick white discharge, with vulval redness, swelling and fissuring on examination.

After onset the symptoms recurred at least four times within twelve months and, from July 2017, became persistent despite weekly fluconazole. She now reports frequent flares of vulval itch and soreness, dyspareunia, vulval skin fissuring, distress and avoidance of exercise and heat, and the need for long-term antifungal therapy.

Imaging

No imaging is required to establish this diagnosis.

Onset Date

The most likely date of onset of this condition is 14 Aug 2016.

At that date the veteran was a serving Army sergeant on warlike service at a forward patrol base in Iraq. Daily temperatures exceeded 44 degrees, she was wearing flame-resistant uniform and body armour for 10 to 12 hours a day, showers were limited to twice a week, and she had recently completed prednisolone and amoxicillin-clavulanate while taking empagliflozin and a continuous combined oral contraceptive. From that day she had vulval itch, burning and discharge.

This date is appropriate because her pre-deployment examination on 22 April 2016 recorded no genital symptoms, and she presented on 17 August 2016 with three days of symptoms, confirmed on microscopy and on culture on 24 August 2016. The date falls within continuous full-time service.

For the antibiotic cause, the 4 weeks before onset run from 17 Jul 2016 to 14 Aug 2016, and she took amoxicillin-clavulanate from 30 July to 08 August 2016. For corticosteroids, the 3 months before onset run from 14 May 2016 to 14 Aug 2016 and include 14 days of prednisolone from 12 June 2016. For the SGLT2 inhibitor, the 4 weeks before onset were covered by daily empagliflozin from 18 January 2016. For the contraceptive, the 3 months before onset run from 14 May 2016 to 14 Aug 2016, and she took the combined pill continuously from November 2015. For the climate and clothing causes, the 4 weeks before onset run from 17 Jul 2016 to 14 Aug 2016, all spent in Iraq. For restricted bathing, the 2 weeks before onset run from 31 Jul 2016 to 14 Aug 2016, at the patrol base from 28 July. Her HbA1c was 9.6 per cent three days after onset.

For the worsening causes, the documented worsening was on 24 Jul 2017. The 4 weeks before it run from 26 Jun 2017 to 24 Jul 2017, during which she took doxycycline for 14 days and spent four weeks on exercise in heat with restricted bathing. The 3 months before it run from 24 Apr 2017 to 24 Jul 2017 and include the five-day prednisolone course. Empagliflozin continued throughout, and HbA1c was 8.9 per cent.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Vulvovaginal Candidiasis (ICD-10-AM B37.3), which became recurrent and azole-resistant.

Vulvovaginal candidiasis is infection of the vulva and vagina by Candida species, most often Candida albicans, causing vulval itch, burning, soreness, dysuria, dyspareunia and a thick white discharge, with redness, swelling and fissuring of the vulval skin. Candida is a normal commensal, and infection follows disruption of the protective vaginal flora by antibiotics, impaired local and systemic immunity from corticosteroids and hyperglycaemia, glycosuria from poorly controlled diabetes and SGLT2 inhibitors, high oestrogen states, and warm, moist, occlusive local conditions. Recurrent vulvovaginal candidiasis is defined as four or more episodes in a year, and non-albicans species such as Candida glabrata are often resistant to fluconazole.

The diagnosis followed oral corticosteroids, antibiotics and poorly controlled diabetes on an SGLT2 inhibitor during warlike service in Iraq in extreme heat with restricted bathing. It began on 14 August 2016, was confirmed on culture on 24 August 2016, became recurrent and worsened in July 2017.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

14 August 2016.

When did the veteran first present to a health / medical provider for this condition?

17 August 2016.

When was the condition confirmed / formally diagnosed?

24 August 2016.

When did the veteran first present to you (or your practice) for this condition?

30 April 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed on 17 August 2016 by typical symptoms and signs, vaginal pH of 4.2 and microscopy showing budding yeasts and pseudohyphae, and on 24 August 2016 by culture growing Candida albicans. Bacterial vaginosis and trichomoniasis were excluded by the normal pH and microscopy.

Four episodes within seven months, the first and fourth confirmed on culture, led a sexual health physician to diagnose recurrent vulvovaginal candidiasis on 08 March 2017. The worsening was confirmed on 24 July 2017 by persistent severe symptoms despite weekly fluconazole maintenance and culture of fluconazole-resistant Candida glabrata.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

No Statement of Principles has been determined by the Repatriation Medical Authority for vulvovaginal candidiasis. The claim is therefore decided on the sound medical-scientific evidence of what causes and worsens the condition, without the limits a Statement of Principles would impose. The recognised causes below are drawn from the infectious diseases, sexual health and gynaecology literature.

Legislation: the clinical onset of this condition was on 14 August 2016, after 1 July 2004, during continuous full-time service and while on warlike service in Iraq. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The veteran's warlike service in the Middle East in 2016, where the condition began, is operational service, and her field exercise in northern Queensland in 2017, where it worsened, is peacetime service. Each cause must be related to service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical onset of vulvovaginal candidiasis; — MET

- On warlike service in Iraq the veteran took amoxicillin-clavulanate 875/125 mg twice daily from 30 July to 08 August 2016 for bacterial sinusitis, within the 4 weeks before onset on 14 August 2016. Broad-spectrum antibiotics suppress the protective vaginal lactobacilli and are the commonest precipitant of vulvovaginal candidiasis.

Cause 2: taking a systemic corticosteroid for at least 7 days within the 3 months before the clinical onset of vulvovaginal candidiasis; — MET

- She took prednisolone 50 mg daily for 14 days from 12 June 2016 for an asthma exacerbation caused by dust and burn-pit smoke on warlike service in Iraq, within the 3 months before onset. Corticosteroids impair mucosal immunity and raise blood glucose.

Cause 3: having diabetes mellitus with an HbA1c of 8 per cent or more at the time of the clinical onset of vulvovaginal candidiasis; — MET

- The veteran had type 2 diabetes from March 2014, and her HbA1c was 9.6 per cent on 17 August 2016, three days after onset, worsened by the corticosteroid course and irregular meals and shift work on deployment. Hyperglycaemia increases glucose in vaginal secretions and impairs neutrophil function.

Cause 4: taking a sodium-glucose co-transporter 2 inhibitor for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis; — MET

- She took empagliflozin 10 mg daily from 18 January 2016, prescribed by her medical officer, continuously through the 4 weeks before onset. SGLT2 inhibitors cause glycosuria, and genital candidiasis is their most common adverse effect.

Cause 5: taking an oestrogen-containing hormonal contraceptive for at least the 3 months before the clinical onset of vulvovaginal candidiasis; — MET

- She took a combined oral contraceptive containing ethinylestradiol 30 micrograms continuously from November 2015, prescribed to suppress menstruation for deployment, throughout the 3 months before onset. Oestrogen increases vaginal glycogen and Candida adherence.

Cause 6: living or working in a hot climate, with daily maximum temperatures of at least 30 degrees Celsius, for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis; — MET

- On warlike service in Iraq the veteran worked outdoors and in vehicles and command posts in daily maximum temperatures of 44 to 48 degrees throughout the 4 weeks before onset, from 17 July to 14 August 2016.

Cause 7: wearing occlusive, non-breathable clothing over the genital area for at least 8 hours a day for at least the 4 weeks before the clinical onset of vulvovaginal candidiasis; — MET

- Throughout the 4 weeks before onset she wore flame-resistant synthetic-blend combat uniform, body armour and load-carrying equipment for 10 to 12 hours a day, as required on warlike service, causing persistent heat and moisture in the genital area.

Cause 8: having restricted access to bathing and laundry facilities for at least the 2 weeks before the clinical onset of vulvovaginal candidiasis; — MET

- From 28 July 2016 the veteran was at a forward patrol base in Iraq where water was rationed, showers were limited to twice a week and there was no laundry, throughout the 2 weeks before onset, from 31 July to 14 August 2016.

Worsening factors

Worsening 1: taking a systemic broad-spectrum antibiotic within the 4 weeks before the clinical worsening of vulvovaginal candidiasis; — MET

- During a field exercise in northern Queensland the veteran took doxycycline for 14 days for infected insect bites, within the 4 weeks before the documented worsening on 24 July 2017, when severe symptoms persisted despite maintenance fluconazole and culture grew fluconazole-resistant Candida glabrata.

Worsening 2: taking a systemic corticosteroid within the 3 months before the clinical worsening of vulvovaginal candidiasis; — MET

- She took a five-day course of prednisolone for asthma during the exercise, within the 3 months before the worsening, from 24 April to 24 July 2017.

Worsening 3: having diabetes mellitus with an HbA1c of 8 per cent or more, or taking a sodium-glucose co-transporter 2 inhibitor, at the time of the clinical worsening of vulvovaginal candidiasis; — MET

- Her HbA1c was 8.9 per cent in 2017 and she continued daily empagliflozin up to and at the worsening.

Worsening 4: living or working in hot or humid conditions with restricted access to bathing facilities for at least 2 weeks within the 4 weeks before the clinical worsening of vulvovaginal candidiasis; — MET

- She spent four weeks in the field in heat and humidity in northern Queensland, in combat uniform with showering limited to twice weekly, from late June 2017 to the worsening on 24 July 2017.

Worsening 5: inability to obtain appropriate clinical management for vulvovaginal candidiasis. — MET

- On deployment in Iraq the veteran's recurrences were treated empirically with single-dose fluconazole because no culture, susceptibility testing or specialist review was available, and after her return the first gynaecology appointment was five months away. Fluconazole-resistant Candida glabrata emerged and the condition worsened. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

The vulvovaginal candidiasis is a sequela of the veteran's accepted asthma, aggravated by dust and burn-pit smoke on deployment and treated with oral corticosteroids, and of her type 2 diabetes and its treatment with an SGLT2 inhibitor. It has in turn caused chronic vulval fissuring and dyspareunia, which should be considered as sequelae.

Unintended Consequence

Met. The vulvovaginal candidiasis is an unintended consequence of medical treatment provided by the Commonwealth while the veteran was serving: amoxicillin-clavulanate, prednisolone, empagliflozin and the continuous combined oral contraceptive prescribed for deployment, and the doxycycline and prednisolone given on exercise (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. While deployed in Iraq the veteran had three episodes treated only with empirical single-dose fluconazole, as no culture, susceptibility testing or specialist gynaecological care was available in theatre, and the precipitating empagliflozin was not reviewed. After her return the first available gynaecology appointment was in August 2017, five months after referral. In that time fluconazole-resistant Candida glabrata emerged and the condition worsened. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the absence of appropriate investigation and specialist treatment for reasons beyond her control amounts to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 18 Jan 2016, Outpatient health record, Medical Officer, Garrison health centre
2. 22 Apr 2016, Pre-deployment medical examination, Medical Officer
3. 12 Jun 2016, Role 2 treatment record, Medical Officer, Iraq
4. 30 Jul 2016, Role 2 treatment record, Medical Officer, Iraq
5. 17 Aug 2016, Role 2 treatment record and vaginal microscopy, Medical Officer, Iraq
6. 24 Aug 2016, Microbiology culture report, Coalition laboratory
7. 08 Mar 2017, Sexual health consultation, Sexual health physician
8. 24 Jul 2017, Field health record and microbiology culture with susceptibilities, Medical Officer and microbiologist
9. Recognised causes of vulvovaginal candidiasis, infectious diseases, sexual health and gynaecology literature (no Statement of Principles)