A 45-year-old man comes to the office with groin pain and swelling. About a month ago, he noticed a sore on his penis but did not seek medical attention because the ulcer was not painful and disappeared within a week. Several days ago, he began to experience painful swelling in his inguinal region, with inflammation of the overlying skin and eventual formation of several draining ulcers. He also has mild fever and malaise that began around the same time as his groin symptoms. The patient is a sailor. His other medical problems include well-controlled hypertension and hyperlipidemia. Cell scrapings from his lesions show cytoplasmic inclusion bodies. Which of the following is the most likely cause of this patient's condition?

Question

A 45-year-old man comes to the office with groin pain and swelling.  About a month ago, he noticed a sore on his penis but did not seek medical attention because the ulcer was not painful and disappeared within a week.  Several days ago, he began to experience painful swelling in his inguinal region, with inflammation of the overlying skin and eventual formation of several draining ulcers.  He also has mild fever and malaise that began around the same time as his groin symptoms.  The patient is a sailor.  His other medical problems include well-controlled hypertension and hyperlipidemia.  Cell scrapings from his lesions show cytoplasmic inclusion bodies.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_3841_081b_9249_0ba82b12e5ff_MD0001_00 Chlamydia trachomatis is a small, gram-negative (albeit difficult to stain), obligate intracellular bacterium. Serotypes A through C cause ocular infection (trachoma) in children; serotypes D through K cause urogenital (sexually transmitted) infections and inclusion conjunctivitis; and serotypes L1 through L3 cause lymphogranuloma venereum (LGV). LGV is characterized initially by a painless, small, shallow genital ulcer containing infected cells. The painless nature helps distinguish LGV from other diseases. The appearance of the ulcer is followed weeks later by swollen, painful, coalescing inguinal nodes ("buboes") that can develop stellate abscesses and rupture. If left untreated, LGV can cause fibrosis, lymphatic obstruction, and anogenital strictures and fistulas. Histologically, LGV lesions contain areas of mixed granulomatous and neutrophilic inflammation with intracytoplasmic chlamydial inclusion bodies in epithelial and inflammatory cells. Doxycycline is recommended. Although it is relatively uncommon in the United States or Western Europe, LGV is endemic in some parts of the world. (Choice B) Haemophilus ducreyi causes chancroid, an ulcerative, sexually transmitted infection characterized by painful (rather than painless) red papules on the genitals that eventually erode to become tender ulcers (you "do cry" with H ducreyi). Regional lymph nodes may swell and become chronic ulcers. (Choice C) Herpes simplex virus type 2 is the most common cause of genital herpes, characterized by vesicles that develop into shallow ulcers. These lesions are often painful and heal within 10 days. Histologically, multinucleated giant cells and large pinkish-purple intranuclear (not intracytoplasmic) inclusions, termed Cowdry type A bodies, are present. (Choice D) Klebsiella granulomatis causes granuloma inguinale (donovanosis), which also initially manifests as a painless genital papule that eventually ulcerates; however, lymphadenopathy is uncommon. Intracytoplasmic Donovan bodies are diagnostic. If donovanosis is untreated, scarring and strictures can lead to severe lymphatic obstruction and lymphedema (elephantiasis). (Choice E) Syphilis, caused by the gram-negative spirochete Treponema pallidum, is initially characterized by a painless lesion (chancre) that heals without treatment within weeks. It does not typically develop into buboes and is not characterized by cytoplasmic inclusion bodies. Educational objective: Chlamydia trachomatis serotypes L1 through L3 cause lymphogranuloma venereum, a sexually transmitted disease characterized initially by painless ulcers with later progression to painful inguinal lymphadenopathy ("buboes") and ulceration. Chlamydial inclusion bodies are seen in host cell cytoplasm. __________ References: Prevention and treatment of sexually transmitted diseases: an update. (http://www.ncbi.nlm.nih.gov/pubmed/18217521)

A 45-Year-Old Man Comes to the Office with Groin Pain