Box 1 Clinical summary of rituximab-associated vaginitis

Presentation: Vaginal discharge (often copious), vaginal pain, pain during sex, vaginal or vulvar irritation

Differential diagnosis: Bacterial vaginosis, vulvovaginal candidiasis, vulvar hypersensitivity, vulvodynia, herpes, cervicitis, sexually transmitted infection

Workup to consider: Vaginal pH, wet mount or gram stain of vaginal fluid, yeast culture or Candida PCR, testing for herpes simplex virus, Trichomonas vaginalis, Neisseria gonorrhoeae and Chlamydia trachomatis

Findings suggestive of Rituximab-associated vaginitis: Vaginal pH > 5, Wet mount or gram stain showing > 1 WBC/epithelial cell per high power microscope field, absence of other infectious etiology

Potential Treatments: Consistent with recommendations for desquamative inflammatory vaginitis [11]

Vaginal clindamycin 2% cream, 5 g daily for 4–6 weeks OR Vaginal hydrocortisone 10% compounded cream, daily for 4–6 weeks OR Vaginal hydrocortisone compounded 100 g suppository, daily for 4–6 weeks

If symptoms persist, continue to significantly affect quality of life, and if medically feasible, a trial of discontinuation of Rituximab to allow B cell return may be benficial