In a perimenopausal woman suspected of desquamative inflammatory vaginitis (DIV), which finding supports the diagnosis?

Desquamative Inflammatory Vaginitis: Diagnostic Findings

The absence of ulcerative lesions of the vaginal mucosa (Option B) supports the diagnosis of desquamative inflammatory vaginitis, as DIV characteristically presents with diffuse erythema, petechiae, and ecchymotic findings rather than ulceration. 1, 2, 3

Key Diagnostic Features of DIV

Clinical Examination Findings

• Vaginal erythema with ecchymotic findings or confluent redness is the hallmark examination finding, occurring in approximately 90% of cases, with classic ecchymotic findings in 54% and confluent erythema in 36% 3

• Petechiae and increased erythema of the vaginal walls are characteristic, but ulcerative lesions are notably absent 2, 3

• Purulent vaginal discharge is a defining feature, though heavy discharge may only be present in a minority (2%) of cases 3

• Vestibular involvement occurs in approximately 72% of patients, indicating this is a process affecting both vagina and vestibule 1

Laboratory Findings

• Elevated vaginal pH >4.5 is always present in DIV 2, 3

• Increased inflammatory cells (>10 WBCs per high power field) on wet mount microscopy is a defining laboratory criterion 2, 3

• Parabasal epithelial cells (immature squamous cells) are characteristically increased, reflecting the epithelial cell exfoliation that gives the condition its name 4, 2

• Abnormal vaginal flora is present, though 54% may have no significant abnormality on microbiological testing, and 20% may show pure growth of commensal organisms (particularly group B streptococci) 3

Why the Other Options Are Incorrect

Option A: Pale Vaginal Mucosa

• DIV presents with increased erythema and inflammation, not pallor 1, 2
• Pale mucosa would suggest atrophic vaginitis, not the inflammatory process characteristic of DIV 2

Option C: Malodorous Discharge

• While DIV causes purulent discharge, malodor is not a characteristic feature 4, 2
• Malodorous discharge is more typical of bacterial vaginosis or trichomoniasis 5

Option D: Presence of Oral Wickham's Striae

• Wickham's striae are pathognomonic for lichen planus, which is a distinct entity from DIV 3
• DIV must be differentiated from vaginal lichen planus through careful clinical evaluation 3

Clinical Context

• DIV occurs almost exclusively in white women (97-100% in case series) with peak occurrence in the perimenopause (mean age 48.6 years, 50% postmenopausal) 1, 2

• This is a diagnosis of exclusion requiring elimination of other causes of purulent vaginitis including infections, contact irritant vaginitis, immunobullous diseases, and lichen planus 2, 3

• Historical triggers (particularly diarrhea or antibiotic treatment) are present in 56% of cases, significantly more than in lichen planus controls (15%, p<0.0001) 3