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Resistant yeast in Lupus mom/baby

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  • Resistant yeast in Lupus mom/baby

    I have a complicated case involving a mom who has Lupus. Her baby was tongue tied (was revised at 1 wk). Mom was dx'd with vaginal yeast shortly PP when her delivery repairs were not healing. The baby's latch improved post clip but still not ideal (high palate, poor mechanics); baby dx'd w/reflux (sloppy swallowing?)and put on prilosec, with only slight improvement. Mom was initially given a script for a single 150mg tab of diflucan for her vaginal yeast. Came to me initially at 10 days of age for nipple pain that had been getting better after clip, becoming worse and "burning". I observed heavy white at back of baby's tongue. At that time her OB provider gave her 6 additional 150mg tabs of diflucan to be used once per week. After no real improvement, despite adding a repeated course of gential violet, and APNO, with very little change, provider was pursuaded to provide diflucan per MMM 2012 for 3 weeks. Baby now 2 mo, yeast is persistent, and although baby is much better at breast (having been seen repeatedly by IBCLC home visiting nurse), mom is still having nipple pain and thrush is still visible on baby's tongue. Is this likely a resistant form of yeast that mom's autoimmune issue is unable to conquer? Mom has h/o previously needing ketoconazole for yeast. What would you suggest?

  • #2
    Hi, thanks for your post.

    I have consulted Dr. Hale on this question. We were not entirely clear from your note who is receiving the diflucan and the gentian violet, but we are making the assumption that it is the mother.

    There is almost no Candida resistance to diflucan and / or gentian violet so it is unlikely to be that, especially if her vaginal yeast resolved with the original dose. If the baby has persistent thrush, it is prudent to treat him directly with diflucan and gentian violet. Decreased irritation in the baby's mouth will cause less trauma to the mother's nipple.

    Consider a possible alternate / concurrent diagnosis of vasospasm or Raynaud's. Her experience with poor infant attachment and her history of lupus both support this theory. Blanching of the nipples immediately after feeding time would be a typical feature.

    Have we misunderstood your case description?

    -James Abbey, MD
    and
    -Thomas W. Hale, Ph.D.

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    • #3
      yeast/lupus mom

      Thank you for your response. Sorry I wasn't clear but you made the right assumptions. what has me most puzzled is the baby's lack of response to the repeated courses of GV (Most recently, a week after few days break), just finished last night, but mom is reluctant to continue as she says the baby's mouth/lips are getting very dry (with cracking lips). I could not reach her after your response but will review the Raynauds issue with her - I did not note s/s of this when I saw them, but I might have missed it being focused on the baby's tongue (yeast visible through the GV purple.) I will also suggest that she request diflucan specifically for the baby - so far they've only wanted to do nystatin (which hasn't worked).

      It has been my experience that many TT babies never really get GOOD at BF (so many having dome palates), and this may be one. But I am very convinced there is yeast here too, at least for the baby. How would you write for diflucan (dosing, etc) for the baby?

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      • #4
        Mom just told me that her ob provider had warned her when giving the rx for the 3 wks of diflucan, that the antifungal "might cause her to have a recurrance of her perineal tear infection". She went in today (after 20 days) and was dx'd with that, the provider cultured, it was "equivocal" with no specific organism identified, but she was put back on abx therapy. Given that, should I try to get them to renew/extend her diflucan? Mom is convinced that it has helped (nipples are not on fire or bright red anymore). Should we ask for extended preventive (if we ever get cleared?). Mom has been a real trouper but is understandably very tired of the whole thing. I have always understood abx can trigger yeast, but was unaware (recertified 4 times) that diflucan could trigger bacterial infection? How'd I miss that?

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        • #5
          In some areas of the country, Candida has developed substantial resistance to nystatin. If the baby's mouth does not respond to oral diflucan, you may need to get a culture and susceptibility study on the white material you are observing.

          Per Harriet Lane: In term infants >7 days old, PO fluconazole is given with a 12mg/kg loading dose then 6mg/kg q24hr until clinical resolution of symptoms, then an additional 3 days.

          There is no mention of increased bacterial infections in the Diflucan post-marketing data published by the manufacturer. Some people have developed neutropenia, but that does not seem likely in your case without lab data saying otherwise. I am not questioning the judgement of the OB/GYN who is much more familiar with this patient's particulars, I am only saying that you did not miss some well-known piece of Diflucan trivia.

          My instinct is that resolution of the baby's symptoms with lead to resolution of mother's nipple irritation. Return to APNO for the time being and let the OB/GYN decide about systemic Diflucan in the mom.

          -James Abbey, MD

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          • #6
            Originally posted by kay.mckee View Post
            Mom just told me that her ob provider had warned her when giving the rx for the 3 wks of diflucan, that the antifungal "might cause her to have a recurrance of her perineal tear infection". She went in today (after 20 days) and was dx'd with that, the provider cultured, it was "equivocal" with no specific organism identified, but she was put back on abx therapy. Given that, should I try to get them to renew/extend her diflucan? Mom is convinced that it has helped (nipples are not on fire or bright red anymore). Should we ask for extended preventive (if we ever get cleared?). Mom has been a real trouper but is understandably very tired of the whole thing. I have always understood abx can trigger yeast, but was unaware (recertified 4 times) that diflucan could trigger bacterial infection? How'd I miss that?
            agree with your answer this.

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            • #7
              I am looking for a research article that a vaginal yeast infection that is persistent and seemingly creates a full body yeast imbalance could impact milk supply. Any direction would be helpful. Thanks!

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              • #8
                Jenn:

                I've never heard of 'vaginal' yeast producing an effect on milk supply. It does not sound reasonable to me. I'd suggest you go online to PubMed (http://www.ncbi.nlm.nih.gov/pubmed) and do some searching.

                Tom Hale PhD.

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