A 24-year-old woman comes to the office due to vulvar pain and dysuria for the past 2 days. The patient has not had these symptoms before and has had no increased urinary frequency or flank pain. She returned from a trip to the Caribbean 2 weeks ago and had an intermittent fever and malaise for the last week. The patient is sexually active and has had 3 new male partners over the last 6 months. She has no chronic medical conditions, and her only medication is a combination oral contraceptive. Vital signs are normal. Physical examination shows grouped, shallow ulcers with surrounding erythema on the left labia minora. The left inguinal lymph nodes are tender to palpation. Urinalysis shows 5-10 leukocytes/hpf and 1-2 erythrocytes/hpf. Urine culture is negative. Which of the following pathogens is the most likely cause of this patient's symptoms?

Question

A 24-year-old woman comes to the office due to vulvar pain and dysuria for the past 2 days.  The patient has not had these symptoms before and has had no increased urinary frequency or flank pain.  She returned from a trip to the Caribbean 2 weeks ago and had an intermittent fever and malaise for the last week.  The patient is sexually active and has had 3 new male partners over the last 6 months.  She has no chronic medical conditions, and her only medication is a combination oral contraceptive.  Vital signs are normal.  Physical examination shows grouped, shallow ulcers with surrounding erythema on the left labia minora.  The left inguinal lymph nodes are tender to palpation.  Urinalysis shows 5-10 leukocytes/hpf and 1-2 erythrocytes/hpf.  Urine culture is negative.  Which of the following pathogens is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_da04_b0dd_bc81_9b70b267f6c6_MD0003_00 This patient's grouped, shallow genital ulcers and tender lymphadenopathy are consistent with herpes simplex virus (HSV) infection. Individuals with HSV typically have primary and recurrent infections; those with a primary infection (such as this patient) often have systemic symptoms (eg, fever, malaise) in addition to genital lesions. HSV lesions initially appear as a group of painful vesicles on an erythematous base that evolve into a group of shallow ulcers that eventually crust over. Patients can have painful urination due to urine contact on the open ulcers and a sterile pyuria (leukocytes on urinalysis but negative urine culture) due to vulvar inflammation. Those with severe primary disease may also develop a viral infection within the lumbosacral plexus, which causes autonomic nervous system dysfunction and resultant acute urinary retention. Primary HSV infections are managed with antivirals (eg, acyclovir, valacyclovir), which can decrease symptom severity and duration. (Choice A) Serovars L1-L3 of Chlamydia trachomatis cause lymphogranuloma venereum, a genital ulcer disease common in tropical and subtropical areas (eg, Caribbean). Patients typically have small, painless ulcers followed weeks later by large, painful, suppurative inguinal lymphadenopathy (buboes). (Choice B) Haemophilus ducreyi causes chancroid, a sexually transmitted infection more common in developing countries. Patients have a single large (1- to 2-cm), painful genital ulcer with a gray/yellow exudate and tender, suppurative lymphadenopathy. (Choice D) Klebsiella granulomatis causes granuloma inguinale (ie, donovanosis), which is endemic in tropical and subtropical climates (eg, India, Guyana, New Guinea). Patients have extensive painless genital ulcers, typically with no associated lymphadenopathy. (Choice E) Mycoplasma genitalium is a cause of acute cervicitis and pelvic inflammatory disease, which can present with fever, malaise, and dysuria. M genitalium does not cause genital ulcers. (Choice F) Treponema pallidum causes syphilis. Patients with primary syphilis typically have a single painless ulcer (ie, chancre) and bilateral nontender lymphadenopathy. Patients with secondary syphilis may have systemic symptoms (eg, fever, malaise) and typically develop raised, flat genital lesions (ie, condyloma lata) rather than ulcerative lesions. Educational objective: Primary herpes simplex virus (HSV) infections can present with systemic symptoms (eg, fever, malaise) and a cluster of painful ulcers with associated tender lymphadenopathy. Some patients can have painful urination and a sterile pyuria. Primary HSV is managed with antivirals (eg, acyclovir, valcyclovir), which decrease symptom severity and duration. References: Diagnosis and management of genital ulcers. (http://www.ncbi.nlm.nih.gov/pubmed/22335265) Clinical practice: genital herpes. (http://www.ncbi.nlm.nih.gov/pubmed/27532832) Current concepts for genital herpes simplex virus infection: diagnostics and pathogenesis of genital tract shedding. (http://www.ncbi.nlm.nih.gov/pubmed/26561565)

A 24-Year-Old Woman Comes to the Office Due to Vulvar