A 35-year-old HIV-positive man comes to the physician because of acute-onset severe perianal pain for the last 24 hours. His pain is 9/10 and burning in quality. He denies fever, chills, dysuria, or pain when moving his bowels. His other medical problems include anxiety disorder and hypertension. His last CD4 count was 340 cells/µL. His medications include antiretroviral therapy, losartan, and amlodipine. He ended his 8-year relationship with his male partner one week ago, and he denies any other recent sexual encounters. He does not use tobacco, alcohol, or recreational drugs.
His temperature is 37.2 C (99 F), blood pressure is 144/89 mm Hg, and pulse is 104/min. Physical examination reveals 3 superficial, highly tender, ulcerated lesions located in the perianal skin area. There is mild, non-tender, generalized lymphadenopathy. The remainder of his physical examination is unremarkable.
Which of the following is the most likely cause of this patient's current condition?

Question

A 35-year-old HIV-positive man comes to the physician because of acute-onset severe perianal pain for the last 24 hours.  His pain is 9/10 and burning in quality.  He denies fever, chills, dysuria, or pain when moving his bowels.  His other medical problems include anxiety disorder and hypertension.  His last CD4 count was 340 cells/µL.  His medications include antiretroviral therapy, losartan, and amlodipine.  He ended his 8-year relationship with his male partner one week ago, and he denies any other recent sexual encounters.  He does not use tobacco, alcohol, or recreational drugs.
His temperature is 37.2 C (99 F), blood pressure is 144/89 mm Hg, and pulse is 104/min.  Physical examination reveals 3 superficial, highly tender, ulcerated lesions located in the perianal skin area.  There is mild, non-tender, generalized lymphadenopathy.  The remainder of his physical examination is unremarkable.
Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec193a_984c_5704_853d_df4fc2184ce5_MD0002_00 11ec193a_984c_5705_853d_0fe738d438e7_MD0002_00 This patient presents with multiple painful genital ulcers. Painful ulcers are more likely due to herpes simplex virus (HSV) or chancroid, both of which usually cause multiple ulcers. Painless ulcers are more common with syphilis, lymphogranuloma venereum (LGV), and granuloma inguinale. However, the variation in presentations makes the history and physical examination frequently inaccurate in confirming the clinical diagnosis. In addition, more than one etiologic agent (e.g., herpes and syphilis) can be present concurrently. In the United States, HSV is the most common cause of ulcerative sexually transmitted disease, followed by syphilis. Thus, all patients with genital, anal, or perianal ulcers should be evaluated initially for syphilis (e.g., serology and darkfield microscopy) and herpes (e.g., viral culture and/or serology). Based on these results and the response to therapy, other tests (e.g., chancroid, LGV, biopsy) may be needed to identify the ulcer etiology. HIV testing should also be performed on all persons with these ulcers and/or those with generalized lymphadenopathy who are not known to have HIV infection. (Choice A) Candidal infections commonly occur in warm moist body areas (e.g., axilla, groin) and present with pruritic and burning lesions, sometimes with satellite lesions. This patient's discrete painful lesions make this diagnosis less likely. (Choice B) Chlamydia trachomatis serovars L1-3 cause lymphogranuloma venereum (LGV). Lymphogranuloma venereum initially presents with painless ulcers, which usually heal spontaneously. This is followed by regional lymph node suppuration or matting and sinus tract development. This condition is not common in the United States. (Choice D) The human papilloma virus usually presents with transient or permanent warts that sometimes predispose patients to a secondary bacterial cellulitis; however, it usually does not present as painful ulcerated lesions. (Choice E) Klebsiella granulomatis causes granuloma inguinale, which usually presents as a painless ulcer on the penile shaft or perineum. The ulcers can eventually destroy the tissue and cause open, oozing lesions that look like granulation tissue. This condition is quite rare in United States. Educational objective: Genital ulcers are most commonly due to herpes simplex virus (HSV) or syphilis. Syphilis usually causes a single ulcer. Painful genital ulcers are more likely due to HSV or chancroid. Medical history and physical examination are not completely accurate, and all patients should be tested for both HSV and syphilis. Further testing for other pathogens is based on these initial results and the response to therapy. __________ References: Genital and perianal herpes simplex simulating neoplasia in patients with AIDS (http://www.ncbi.nlm.nih.gov/pubmed/19302018) Increasing relative prevalence of HSV-2 infection among men with genital ulcers from a mining community in South Africa (http://www.ncbi.nlm.nih.gov/pubmed/12794202) Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection (http://www.ncbi.nlm.nih.gov/pubmed/10654864)

A 35-Year-Old HIV-Positive Man Comes to the Physician Because of Acute-Onset