257
4 Faro S. Group B beta-hemolytic streptococci and puerperal infections. Am J Obstet Gynecol 1981;139:686-689. 5 Pass MA, Gray BM, Dillon HC Jr. Puerperal and perinatal infection with group B streptococci. Am J Obstet Gynecol 1982;143:147-152. 6 Strasberg GD: Postpartum group B streptococcal endocarditis associated with mitral valve prolapse. Obstet Gynecol 1987;70:485-487. 7 Aharoni A, Potasman I, Levitan Z, Golan D, Sharf M: Postpartum maternal group B streptococcal meningitis. Rev Infect Dis 1990;12:273-276.
*
8 Stevens DL, Haburchak DR, McNitt TR, Everett ED. Group B streptococcal osteomyelitis in adults. South Med J 1978;71:1450-1451. 9 Sutton GP, Smirz LR, Clark DH, Bennett JE. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66:733-736. 10 Berkowitz K, McCaffrey R. Postpartum osteomyelitis caused by group B streptococcus. Am J Obstet Gynecol 1990:163:1200-1201.
*
*
European Journal of Obstetrics & Gynecology and Reproductive Biology, 47 (1992) 257-260
0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00
EUROBS 01433
Pulmonary complications of antepartum pyelonephritis: more alertness is needed Zeev Weiner and Peter Jakobi Department of Obstetrics and Gynecology, Rambam Medical Center (Faculty of Medicine Technion, Rappaport Institute), Haija, Israel
Accepted for publication 1 September 1992
Summary Three cases of pulmonary complications associated with antepartum pyelonephritis are presented, in two of them tracheal intubation and mechanical ventilation were required. All three cases were related to recurrent urinary infections with failure of first line antimicrobial therapy and a concomitant usage of tocolytic therapy. The possible etiology, risk factors and clinical approach, aimed to prevent pulmonary complications in antepartum pyelonephritis are discussed. Pulmonary injury; Pyelonephritis; Ritodrin therapy
Introduction Correspondence
to: Zeev Weiner, M.D., Department
of Obstetrics and Gynecology ‘A’, Rambam Medical Center, Haifa, Israel.
The first report tion of antepartum
of pulmonary pyelonephritis
injury as a complicaappeared in 1984 [l]
258 and since then few more reports have been published [2-41. However, this potentially serious complication of pyelonephritis in pregnancy is probably underdiagnosed and under-reported, because of the unawareness of the attending physicians to this diagnosis. Many issues concerning the etiology and the pathophysiology of the pregnancy-enhanced susceptibility to pulmonary injury at the time of pyelonephritis are still unresolved. It is important to report more such cases in order to shed more light on this recently described syndrome and to increase the awareness to diagnosis. Case reports Case I A 39-year-old primigravida at 32 weeks’ gestation was admitted with signs and symptoms of right-sided acute pyelonephritis: temperature of 39”C, right flank pain and tenderness. The laboratory investigation revealed a blood hematocrit of 31%, 13,900 white blood cells, 309,000 platelets, and many white cells in the urine sediment. The urine culture with a significant growth of E. coli confirmed the initial diagnosis. Blood cultures were negative. At admission hydration and Cefazolin therapy were started. Since painful uterine contractions appeared every 3 minutes, intravenous Ritodrin therapy was initiated. The symptoms disappeared after 24 hours and she was discharged on the third day continuing oral Cefalexin therapy for 1 week and oral Ritodrin therapy for 2 weeks. Two weeks later the patient was re-admitted, again with a temperature of 39°C and right acute pyelonephritis. This time, however, cough and dyspnea were also noticed. On physical examination right costovertebral tenderness and diminished breath sounds
on the right lung were found. The laboratory results, compared to the previous ones, were different for the hematocrit and platelets, which decreased to 26.2% and 129,000, respectively. The chest radiograph demonstrated bilateral lung infiltrates. Arterial blood gas analysis showed p0, of 54 mmHg, pC0, of 23 mmHg and pH of 7.49. The blood and sputum cultures were sterile. Intravenous fluid and erythromycin therapy were started and oral Ritodrin therapy was discontinued. The central venous pressure was 6 mmHg. Because of deterioration in the respiratory functions a tracheal intubation with mechanical ventilation was indicated. The patient was extubated after 24 hours. During the following days the radiographic picture improved and she was discharged after 10 days. At 38 weeks’ gestation she spontaneously delivered a healthy infant. Case 2 A 26-year-old primigravida presented at 29 weeks’ gestation with acute pyelonephritis. During the previous month she had been treated with Cefalexin because of urinary tract infection. On admission the temperature was 38.2”C, hematocrit 27%, 7200 white blood cells, 223,000 platelets and many white blood cells in the urine. The urine culture was positive for E. coli but the blood cultures were sterile. Because of symptomatic uterine contractions, confirmed by the external tocotransducer, intravenous fluids, Cefazolin and Ritodrin therapy was started. After 24 hours the uterine contractions disappeared and intravenous Ritodrin was changed to an oral dose of 120 mg per day. Two days later she developed dyspnea, tachypnea and cough. The platelets count was 111,000, without a change
Fig. 1. (A) Chest X-ray with bilateral pulmonary infiltrates in a woman with pulmonary complication of antepartum pyelonephritis. (B) Normal chest X-ray 4 days later.
259
in the values of hematocrit or leucocytes. The arterial blood gases showed a p0, of 69 mmHg, a pCOZ of 19 mmHg and a pH of 7.49. Chest radiograph demonstrated bilateral infiltrates (Fig. 1A). Because the hypoxemia did not improve with oxygen therapy, a tracheal intubation with mechanical ventilation was performed. Treatment with Piperacillin and Gentamicin was started and Ritodrin therapy was discontinued. During the next 24 hours clinical and radiographic improvement was observed and extubation was performed. Three days later the chest X-ray was normal (Fig. 1B). She spontaneously delivered a healthy child at 38 weeks’ gestation. Case 3 A 20-year-old, gravida 2, was admitted at 32 weeks’ gestation with right acute pyelonephritis. At 29 weeks’ gestation, she was treated with intravenous Cefazolin because of urinary tract infection. At admission she had a temperature of 38S”C, hematocrit 27.0%, 8100 leucocytes and 292,000 platelets. The urine culture was positive for E. coli but blood cultures were sterile. Hydration and cefazolin therapy were started again and indomethacin was added because of regular uterine contractions. The Indomethacin therapy was discontinued the next day and therapy with oral Ritodrin 120 mg per day was started. On the third day the patient developed dyspnea and tachypnea. Arterial blood p0, was 63 mmHg, pC0, 29 mmHg and pH 7.41. The chest radiograph revealed right lower lobe infiltrates. Treatment with Piperacillin and Gentamicin was started and oral Ritodrin therapy was discontinued. Clinical improvement was observed after administration of 40% oxygen by mask, and 24 hours later the chest radiograph appeared normal. She was discharged on the ninth day and delivered uneventfully at 40 weeks’ gestation, Discussion
According to the first reports in the literature [l] pulmonary injury was considered a rare complication of pyelonephritis with an incidence of 2% 141.Towers et al. conducted a retrospective survey of their patients with antepartum pyelonephritis and found an 8.5% rate of pulmonary injury associated with the disease [9]. The 3 cases presented by us appeared in an 18 months period, during which time we treated 60 cases of antepartum pyelonephritis, an incidence of 5%. It appears that this serious complication of antepartum pyelonephritis is not so rare but rather unknown and therefore undiagnosed and not reported.
Cunningham et al. postulated that the pulmonary injury is the result of endotoxin-mediated capillary damage, a theory that was supported by laboratory and clinical findings [4]. The presence of anemia in all of our cases and the decreasing platelets count in two of the cases support the endotoxin-mediated theory as the etiology of the pulmonary injury [5,6]. Other evidence for disseminated endotoxin damage was not found. Antepartum pyelonephritis is often accompanied by uterine contractions and therefore tocolytic therapy is used frequently in these patients. Ritodrin may cause pulmonary edema, especially when the premature uterine contractions are associated with infection [7,8]. All our cases were treated with oral Ritodrin before the appearance of the pulmonary injury. We did not have other cases of pulmonary injury during the usage of oral Ritodrin in our patients. This observation suggests that even oral Ritodrin, in pregnant patients with pyelonephritis, may precipitate pulmonary injury. A similar observation was noticed by Towers et al. 191, with other tocolytic agents such as Terbutaline and magnesium sulfate. Therefore, we agree that tocolytic agents should be used in these patients only with documented cervical changes. All our cases presented with recurrent urinary tract infections 2-4 weeks following treatment with Cefalexin or Cefazolin. We suggest that an early recurrence of symptomatic upper urinary tract infection, following treatment with a first-line antimicrobial drug, is a further risk factor for the development of pulmonary injury. Therefore, a more aggressive drug therapy should be considered in recurrent pyelonephritis during pregnancy. The risk of antepartum pyelonephritis and its complications can be reduced by routine antenatal screening for asymptomatic bacteriuria and its treatment, even by a single dose antimicrobial therapy [Ill. Failure of therapy of asymptomatic bacteriuria with a single dose of antibiotics identifies patients at high risk for recurrent urinary tract infections and their sequelae during pregnancy [lo]. Physicians must be more alert to the severe complications of anteparturn pyelonephritis and the importance of its prevention. References
1 Cunningham FG, Leveno KJ, Hankins GD, Whalley PJ. Respiratory insufficiency associated with pyelonephritis during pregnancy. Obstet Gynecol 1984;63:121-125. 2 Elkington KW, Greb LC. Adult respiratory distress syndrome as a complication of acute pyelonephritis during pregnancy: case report and discussion. Obstet Gynecol 1986;67(suppl):18-20.
260
3
4
5
6
7
8 Benedetti TJ. Life-threatening complications of betamimetic therapy from preterm labor inhibition. Clin Perinatol 1986;13 (4):843-52. 9 Towers CV, Kaminskas CM, Garite TJ, Nageotte MP, Dorchester W. Pulmonary injury associated with anteparturn pyelonephritis: Can patients at risk be identified? Am J Obstet Gynecol 1991;164:974-980. 10 Jakobi P, Neiger R, Merzbach D, Paldi E. Single dose antimicrobial therapy in the treatment of asymptomatic bacteriuria in pregnancy. Am J Obstet Gynecol 1987156: 1148-1152. 11 Jakobi P, Paldi E. Asymptomatic bacteriuria in pregnancy. An overview. Am J Gynecol Health 1989;111(2):17-21.
Pruett K, Faro S. Pyelonephritis associated with respiratory distress. Obstet Gynecol 19&X769:444-446. Cunningham FG, Lucas MJ, Hankins GD. Pulmonary injury complicating antepartum pyelonephritis. Am J Obstet Gynecol 1987;156:797-807. Kelton JG, Heame PB, Gauldie J et al. Elevated platelet associated IgG on the thrombocytopenia of septicemia. N Engl J Med. 1979;300:760-764. Cox SM, Shelburne P, Mason R, Guss S, Cunningham FG. Mechanisms of hemolysis and anemia associated with acute antepartum pyelonephritis. Am J Obstet Gynecol 1991; 164:587-590. Besinger RE, Niebyl JR. The safety and efficacy of tocolytic agents for the treatment of preterm labor. Obstet Gynecol Sutv 1990;45:415-434.
*
*
*
European Journal of Obstetrics & Gynecology and Reproductive Biology, 47 (1992) 260-263 0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01426
Unsuspected
involvement of the female genitalia in pemphigus vulgaris
Ariel Zosmer a, Sophia Kogan a, Azriel Frumkin b, Ram Dgani a and Beatriz Lifschitz-Mercer ’ ’ Depatimeni of Obstettics and Gynecology, b Unit of Dermatology and ’ Institute of Pathology, Kaplan Hospital (Affdiated to the Hadassah Medical School of the Hebrew University), Rehovot, Israel Accepted for publication 13 August 1992
Summary A 56-year-old woman had erosions due to pemphigus vulgaris in the inner thighs and perineum. The cutaneous lesions cleared following intramuscular gold therapy. However, because of complaints of dyspareunia, a colposcopic examination was performed and involvement of the cervix was demonstrated. The need for a vaginal examination in the monitoring of pemphigus vulgaris is emphasized. Pemphigus vulgaris; Female genitalia; Colposcopy
Correspondence to: R. Dgani, M.D., Department
of Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
4 Faro S. Group B beta-hemolytic streptococci and puerperal infections. Am J Obstet Gynecol 1981;139:686-689. 5 Pass MA, Gray BM, Dillon HC Jr. Puerperal and perinatal infection with group B streptococci. Am J Obstet Gynecol 1982;143:147-152. 6 Strasberg GD: Postpartum group B streptococcal endocarditis associated with mitral valve prolapse. Obstet Gynecol 1987;70:485-487. 7 Aharoni A, Potasman I, Levitan Z, Golan D, Sharf M: Postpartum maternal group B streptococcal meningitis. Rev Infect Dis 1990;12:273-276.
*
8 Stevens DL, Haburchak DR, McNitt TR, Everett ED. Group B streptococcal osteomyelitis in adults. South Med J 1978;71:1450-1451. 9 Sutton GP, Smirz LR, Clark DH, Bennett JE. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol 1985;66:733-736. 10 Berkowitz K, McCaffrey R. Postpartum osteomyelitis caused by group B streptococcus. Am J Obstet Gynecol 1990:163:1200-1201.
*
*
European Journal of Obstetrics & Gynecology and Reproductive Biology, 47 (1992) 257-260
0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00
EUROBS 01433
Pulmonary complications of antepartum pyelonephritis: more alertness is needed Zeev Weiner and Peter Jakobi Department of Obstetrics and Gynecology, Rambam Medical Center (Faculty of Medicine Technion, Rappaport Institute), Haija, Israel
Accepted for publication 1 September 1992
Summary Three cases of pulmonary complications associated with antepartum pyelonephritis are presented, in two of them tracheal intubation and mechanical ventilation were required. All three cases were related to recurrent urinary infections with failure of first line antimicrobial therapy and a concomitant usage of tocolytic therapy. The possible etiology, risk factors and clinical approach, aimed to prevent pulmonary complications in antepartum pyelonephritis are discussed. Pulmonary injury; Pyelonephritis; Ritodrin therapy
Introduction Correspondence
to: Zeev Weiner, M.D., Department
of Obstetrics and Gynecology ‘A’, Rambam Medical Center, Haifa, Israel.
The first report tion of antepartum
of pulmonary pyelonephritis
injury as a complicaappeared in 1984 [l]
258 and since then few more reports have been published [2-41. However, this potentially serious complication of pyelonephritis in pregnancy is probably underdiagnosed and under-reported, because of the unawareness of the attending physicians to this diagnosis. Many issues concerning the etiology and the pathophysiology of the pregnancy-enhanced susceptibility to pulmonary injury at the time of pyelonephritis are still unresolved. It is important to report more such cases in order to shed more light on this recently described syndrome and to increase the awareness to diagnosis. Case reports Case I A 39-year-old primigravida at 32 weeks’ gestation was admitted with signs and symptoms of right-sided acute pyelonephritis: temperature of 39”C, right flank pain and tenderness. The laboratory investigation revealed a blood hematocrit of 31%, 13,900 white blood cells, 309,000 platelets, and many white cells in the urine sediment. The urine culture with a significant growth of E. coli confirmed the initial diagnosis. Blood cultures were negative. At admission hydration and Cefazolin therapy were started. Since painful uterine contractions appeared every 3 minutes, intravenous Ritodrin therapy was initiated. The symptoms disappeared after 24 hours and she was discharged on the third day continuing oral Cefalexin therapy for 1 week and oral Ritodrin therapy for 2 weeks. Two weeks later the patient was re-admitted, again with a temperature of 39°C and right acute pyelonephritis. This time, however, cough and dyspnea were also noticed. On physical examination right costovertebral tenderness and diminished breath sounds
on the right lung were found. The laboratory results, compared to the previous ones, were different for the hematocrit and platelets, which decreased to 26.2% and 129,000, respectively. The chest radiograph demonstrated bilateral lung infiltrates. Arterial blood gas analysis showed p0, of 54 mmHg, pC0, of 23 mmHg and pH of 7.49. The blood and sputum cultures were sterile. Intravenous fluid and erythromycin therapy were started and oral Ritodrin therapy was discontinued. The central venous pressure was 6 mmHg. Because of deterioration in the respiratory functions a tracheal intubation with mechanical ventilation was indicated. The patient was extubated after 24 hours. During the following days the radiographic picture improved and she was discharged after 10 days. At 38 weeks’ gestation she spontaneously delivered a healthy infant. Case 2 A 26-year-old primigravida presented at 29 weeks’ gestation with acute pyelonephritis. During the previous month she had been treated with Cefalexin because of urinary tract infection. On admission the temperature was 38.2”C, hematocrit 27%, 7200 white blood cells, 223,000 platelets and many white blood cells in the urine. The urine culture was positive for E. coli but the blood cultures were sterile. Because of symptomatic uterine contractions, confirmed by the external tocotransducer, intravenous fluids, Cefazolin and Ritodrin therapy was started. After 24 hours the uterine contractions disappeared and intravenous Ritodrin was changed to an oral dose of 120 mg per day. Two days later she developed dyspnea, tachypnea and cough. The platelets count was 111,000, without a change
Fig. 1. (A) Chest X-ray with bilateral pulmonary infiltrates in a woman with pulmonary complication of antepartum pyelonephritis. (B) Normal chest X-ray 4 days later.
259
in the values of hematocrit or leucocytes. The arterial blood gases showed a p0, of 69 mmHg, a pCOZ of 19 mmHg and a pH of 7.49. Chest radiograph demonstrated bilateral infiltrates (Fig. 1A). Because the hypoxemia did not improve with oxygen therapy, a tracheal intubation with mechanical ventilation was performed. Treatment with Piperacillin and Gentamicin was started and Ritodrin therapy was discontinued. During the next 24 hours clinical and radiographic improvement was observed and extubation was performed. Three days later the chest X-ray was normal (Fig. 1B). She spontaneously delivered a healthy child at 38 weeks’ gestation. Case 3 A 20-year-old, gravida 2, was admitted at 32 weeks’ gestation with right acute pyelonephritis. At 29 weeks’ gestation, she was treated with intravenous Cefazolin because of urinary tract infection. At admission she had a temperature of 38S”C, hematocrit 27.0%, 8100 leucocytes and 292,000 platelets. The urine culture was positive for E. coli but blood cultures were sterile. Hydration and cefazolin therapy were started again and indomethacin was added because of regular uterine contractions. The Indomethacin therapy was discontinued the next day and therapy with oral Ritodrin 120 mg per day was started. On the third day the patient developed dyspnea and tachypnea. Arterial blood p0, was 63 mmHg, pC0, 29 mmHg and pH 7.41. The chest radiograph revealed right lower lobe infiltrates. Treatment with Piperacillin and Gentamicin was started and oral Ritodrin therapy was discontinued. Clinical improvement was observed after administration of 40% oxygen by mask, and 24 hours later the chest radiograph appeared normal. She was discharged on the ninth day and delivered uneventfully at 40 weeks’ gestation, Discussion
According to the first reports in the literature [l] pulmonary injury was considered a rare complication of pyelonephritis with an incidence of 2% 141.Towers et al. conducted a retrospective survey of their patients with antepartum pyelonephritis and found an 8.5% rate of pulmonary injury associated with the disease [9]. The 3 cases presented by us appeared in an 18 months period, during which time we treated 60 cases of antepartum pyelonephritis, an incidence of 5%. It appears that this serious complication of antepartum pyelonephritis is not so rare but rather unknown and therefore undiagnosed and not reported.
Cunningham et al. postulated that the pulmonary injury is the result of endotoxin-mediated capillary damage, a theory that was supported by laboratory and clinical findings [4]. The presence of anemia in all of our cases and the decreasing platelets count in two of the cases support the endotoxin-mediated theory as the etiology of the pulmonary injury [5,6]. Other evidence for disseminated endotoxin damage was not found. Antepartum pyelonephritis is often accompanied by uterine contractions and therefore tocolytic therapy is used frequently in these patients. Ritodrin may cause pulmonary edema, especially when the premature uterine contractions are associated with infection [7,8]. All our cases were treated with oral Ritodrin before the appearance of the pulmonary injury. We did not have other cases of pulmonary injury during the usage of oral Ritodrin in our patients. This observation suggests that even oral Ritodrin, in pregnant patients with pyelonephritis, may precipitate pulmonary injury. A similar observation was noticed by Towers et al. 191, with other tocolytic agents such as Terbutaline and magnesium sulfate. Therefore, we agree that tocolytic agents should be used in these patients only with documented cervical changes. All our cases presented with recurrent urinary tract infections 2-4 weeks following treatment with Cefalexin or Cefazolin. We suggest that an early recurrence of symptomatic upper urinary tract infection, following treatment with a first-line antimicrobial drug, is a further risk factor for the development of pulmonary injury. Therefore, a more aggressive drug therapy should be considered in recurrent pyelonephritis during pregnancy. The risk of antepartum pyelonephritis and its complications can be reduced by routine antenatal screening for asymptomatic bacteriuria and its treatment, even by a single dose antimicrobial therapy [Ill. Failure of therapy of asymptomatic bacteriuria with a single dose of antibiotics identifies patients at high risk for recurrent urinary tract infections and their sequelae during pregnancy [lo]. Physicians must be more alert to the severe complications of anteparturn pyelonephritis and the importance of its prevention. References
1 Cunningham FG, Leveno KJ, Hankins GD, Whalley PJ. Respiratory insufficiency associated with pyelonephritis during pregnancy. Obstet Gynecol 1984;63:121-125. 2 Elkington KW, Greb LC. Adult respiratory distress syndrome as a complication of acute pyelonephritis during pregnancy: case report and discussion. Obstet Gynecol 1986;67(suppl):18-20.
260
3
4
5
6
7
8 Benedetti TJ. Life-threatening complications of betamimetic therapy from preterm labor inhibition. Clin Perinatol 1986;13 (4):843-52. 9 Towers CV, Kaminskas CM, Garite TJ, Nageotte MP, Dorchester W. Pulmonary injury associated with anteparturn pyelonephritis: Can patients at risk be identified? Am J Obstet Gynecol 1991;164:974-980. 10 Jakobi P, Neiger R, Merzbach D, Paldi E. Single dose antimicrobial therapy in the treatment of asymptomatic bacteriuria in pregnancy. Am J Obstet Gynecol 1987156: 1148-1152. 11 Jakobi P, Paldi E. Asymptomatic bacteriuria in pregnancy. An overview. Am J Gynecol Health 1989;111(2):17-21.
Pruett K, Faro S. Pyelonephritis associated with respiratory distress. Obstet Gynecol 19&X769:444-446. Cunningham FG, Lucas MJ, Hankins GD. Pulmonary injury complicating antepartum pyelonephritis. Am J Obstet Gynecol 1987;156:797-807. Kelton JG, Heame PB, Gauldie J et al. Elevated platelet associated IgG on the thrombocytopenia of septicemia. N Engl J Med. 1979;300:760-764. Cox SM, Shelburne P, Mason R, Guss S, Cunningham FG. Mechanisms of hemolysis and anemia associated with acute antepartum pyelonephritis. Am J Obstet Gynecol 1991; 164:587-590. Besinger RE, Niebyl JR. The safety and efficacy of tocolytic agents for the treatment of preterm labor. Obstet Gynecol Sutv 1990;45:415-434.
*
*
*
European Journal of Obstetrics & Gynecology and Reproductive Biology, 47 (1992) 260-263 0 1992 Elsevier Science Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01426
Unsuspected
involvement of the female genitalia in pemphigus vulgaris
Ariel Zosmer a, Sophia Kogan a, Azriel Frumkin b, Ram Dgani a and Beatriz Lifschitz-Mercer ’ ’ Depatimeni of Obstettics and Gynecology, b Unit of Dermatology and ’ Institute of Pathology, Kaplan Hospital (Affdiated to the Hadassah Medical School of the Hebrew University), Rehovot, Israel Accepted for publication 13 August 1992
Summary A 56-year-old woman had erosions due to pemphigus vulgaris in the inner thighs and perineum. The cutaneous lesions cleared following intramuscular gold therapy. However, because of complaints of dyspareunia, a colposcopic examination was performed and involvement of the cervix was demonstrated. The need for a vaginal examination in the monitoring of pemphigus vulgaris is emphasized. Pemphigus vulgaris; Female genitalia; Colposcopy
Correspondence to: R. Dgani, M.D., Department
of Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
