What is the cause of a 24-year-old female-to-male transgender individual's pale, white, thin vaginal discharge, despite recent completion of antibiotics for Mycoplasma genitalium (M. genitalium) and negative testing for other sexually transmitted infections (STIs), including yeast, bacterial vaginosis (BV), Gonorrhea, Chlamydia, Human Immunodeficiency Virus (HIV), Hepatitis C (Hep C), and Syphilis?

From the Guidelines

The patient's white discharge is likely related to persistent or recurrent Mycoplasma genitalium infection, and I recommend treatment with moxifloxacin 400mg orally once daily for 14 days. This extended course is necessary because the initial antibiotic treatment appears to have been ineffective, suggesting possible antibiotic resistance 1. Before starting treatment, a repeat test for M. genitalium should be performed, ideally with antimicrobial resistance testing if available. The patient should abstain from sexual activity during treatment and for 7 days after completing antibiotics to prevent reinfection, as recommended by the CDC guidelines for treatment of sexually transmitted diseases 1. Additionally, any sexual partners from the past 60 days should be tested and treated to prevent reinfection. M. genitalium is notoriously difficult to eradicate and may require multiple treatment attempts. The white discharge is a common symptom of this infection, which can persist in the genital tract despite initial antibiotic therapy. If this treatment fails, consultation with an infectious disease specialist would be appropriate for consideration of alternative regimens.

Some key points to consider in the management of this patient include:

• The importance of antimicrobial resistance testing, if available, to guide treatment decisions 1
• The need for careful follow-up and potential re-treatment, as M. genitalium can be persistent despite initial therapy 1
• The importance of partner testing and treatment to prevent reinfection, as recommended by the CDC guidelines for treatment of sexually transmitted diseases 1
• The potential for alternative treatment regimens, such as azithromycin or doxycycline, if moxifloxacin is not effective or not tolerated 1

It is also important to note that the patient's recent STI testing was negative for other common causes of vaginal discharge, such as yeast, BV, Gonorrhea, chlamydia, HIV, Hep C, and syphilis, which supports the diagnosis of M. genitalium infection. However, it is still important to consider other potential causes of the patient's symptoms and to monitor for any changes or worsening of symptoms during treatment.

From the Research

Patient Presentation

The patient is a 24-year-old female-to-male transgender individual who has undergone a total hysterectomy and presents for follow-up after being treated for a sexually transmitted infection (STI). The patient was prescribed antibiotics and completed the course as directed. However, 2-3 days prior to the presentation, the patient started experiencing a pale, white, thin discharge. The patient reports no new sexual partners or any partners recently. Recent STI testing was negative for yeast, bacterial vaginosis (BV), gonorrhea, chlamydia, HIV, hepatitis C, and syphilis, but was recently positive for Mycoplasma genitalium.

Mycoplasma Genitalium Infection

• Mycoplasma genitalium infection is a significant cause of non-gonococcal urethritis in men and is associated with cervicitis and pelvic inflammatory disease (PID) in women 2.
• Transmission of M. genitalium occurs through direct mucosal contact, and asymptomatic infections are frequent 2.
• Symptoms of M. genitalium infection in women include vaginal discharge, dysuria, or symptoms of PID, such as abdominal pain and dyspareunia 2.
• Diagnosis of M. genitalium infection is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations 2.

Treatment of Mycoplasma Genitalium Infection

• The recommended treatment for uncomplicated M. genitalium infection without macrolide resistance mutations is azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral) 2.
• Second-line treatment for uncomplicated M. genitalium infection with macrolide resistance mutations is moxifloxacin 400 mg once daily for 7 days (oral) 2.
• A meta-analysis of the efficacy of moxifloxacin in treating M. genitalium infection found a pooled microbial cure rate of 96% (95% CI, 90%-99%) 3.
• A systematic review and meta-analysis of the efficacy and safety of azithromycin versus moxifloxacin for the initial treatment of M. genitalium infection found that moxifloxacin improved the microbiologic cure rate compared with azithromycin (OR 2.79,95% CI, 1.06-7.35) 4.

Clinical Considerations

• The patient's recent positive test for M. genitalium and symptoms of vaginal discharge suggest that treatment for M. genitalium infection is necessary.
• Given the patient's recent completion of antibiotic treatment for an STI, it is essential to consider the possibility of antibiotic resistance and to select an appropriate treatment regimen for M. genitalium infection.
• The Centers for Disease Control and Prevention (CDC) guidelines recommend testing for M. genitalium in patients with persistent male urethritis, cervicitis, and proctitis, and state that testing should be considered in cases of PID 5.
• The CDC recommends 2-step treatment with doxycycline followed by azithromycin or moxifloxacin for M. genitalium infection, with moxifloxacin recommended if resistance testing is unavailable or testing demonstrates macrolide resistance 5.