A 35-year-old woman comes to the office with a tongue lesion that she noticed recently. She has no pain or difficulty swallowing. A few months earlier, she had a sexual encounter that included oral sex with a new male partner.
On examination, there is a 2-cm ulcer with induration on the dorsal aspect of the tongue. Multiple, nontender, cervical lymph nodes are present. The rest of her skin and genital examination is unremarkable.
Which of the following is the most appropriate next step in management of this patient's tongue lesion?

Question

A 35-year-old woman comes to the office with a tongue lesion that she noticed recently.  She has no pain or difficulty swallowing.  A few months earlier, she had a sexual encounter that included oral sex with a new male partner.
On examination, there is a 2-cm ulcer with induration on the dorsal aspect of the tongue.  Multiple, nontender, cervical lymph nodes are present.  The rest of her skin and genital examination is unremarkable.
Which of the following is the most appropriate next step in management of this patient's tongue lesion?

Quizplus · Accepted Answer

The chancre of primary syphilis typically develops at the inoculation site. Although this occurs most commonly on the external genitalia, other sites include the posterior pharynx (as seen in this patient), anus, and vagina. The 1- to 2-cm lesions (teeming with treponemal spirochetes) are classically painless with a nonexudative base and an indurated margin; they are generally associated with nontender bilateral lymphadenopathy. Syphilis testing should be performed given this patient's recent history of oral sex, the potential high infectivity of chancres, and the complication risks of untreated syphilis. For cost-related reasons, many laboratories have switched to using treponemal tests (eg, Treponema pallidum enzyme immunoassay) before nontreponemal tests (eg, rapid plasma reagin) for diagnosis. (Choice A) Oral ulcers and a positive antinuclear antibody screen can be seen with systemic lupus erythematous (SLE), but this patient has no other manifestations of SLE. systemic lupus erythematous (Choice B) Herpetic ulcers usually present as multiple painful lesions that typically progress from vesicles. (Choice C) An incisional biopsy would be the appropriate test if squamous cell carcinoma were suspected (eg, persistent lesions). (Choice E) Triamcinolone acetonide is used in the management of aphthous ulcers, which typically present as multiple painful lesions. Educational objective: The chancre of primary syphilis typically develops at the inoculation site (eg, external genitalia, posterior pharynx, anus, vagina). __________ References: Syphilis: A reemerging infection. (http://www.ncbi.nlm.nih.gov/pubmed/22963062)

A 35-Year-Old Woman Comes to the Office with a Tongue