A 35-year-old woman comes to the office due to a vulvar lesion. She has also experienced occasional headaches and memory loss recently. The patient has had unprotected sexual intercourse with multiple partners. Cardiovascular examination is notable for a diastolic murmur with a prominent second heart sound. There is a painless indurated nodule on her vulva. Cervical cultures are negative for gonorrhea, but a serum Venereal Disease Research Laboratory (VDRL) test is positive. Chest x-ray reveals calcifications at the level of the ascending aortic arch. Blood cultures are negative. Lumbar puncture shows mild pleocytosis and a positive VDRL result. HIV testing is negative. Which of the following best describes this patient's vulvar lesion?

Question

A 35-year-old woman comes to the office due to a vulvar lesion.  She has also experienced occasional headaches and memory loss recently.  The patient has had unprotected sexual intercourse with multiple partners.  Cardiovascular examination is notable for a diastolic murmur with a prominent second heart sound.  There is a painless indurated nodule on her vulva.  Cervical cultures are negative for gonorrhea, but a serum Venereal Disease Research Laboratory (VDRL) test is positive.  Chest x-ray reveals calcifications at the level of the ascending aortic arch.  Blood cultures are negative.  Lumbar puncture shows mild pleocytosis and a positive VDRL result.  HIV testing is negative.  Which of the following best describes this patient's vulvar lesion?

Quizplus · Accepted Answer

This patient with neurosyphilis (headaches, memory loss, cerebrospinal fluid with Venereal Disease Research Laboratory positivity, pleocytosis) likely has cardiovascular syphilis (asymptomatic murmur with loud second heart sound [S2], ascending aortic arch calcification). She therefore has late (tertiary) syphilis, and her vulvar lesion is most likely a gumma. A chancre would be seen in primary syphilis (Choice A), and condylomata lata occur during secondary syphilis (Choice C). The clinical presentation of syphilis occurs in well-defined stages: Neurosyphilis, which may be asymptomatic or cause subacute meningoencephalitis, tabes dorsalis, or other neurologic sequelae, is a common manifestation of late syphilis but can occur at any stage. (Choice B) Condylomata acuminata are anogenital warts due to human papillomavirus (HPV), the causative agent of cervical cancer. Common strains associated with condylomata acuminata are HPV 6 and 11, which have low oncogenic potential. (Choice D) Patients with granuloma inguinale, a sexually transmitted disease caused by Klebsiella granulomatis (previously Calymmatobacterium granulomatis), can have inguinal swelling, ulcers, abscesses, and fistulas. Gram staining of the lesions reveals cells with rod-shaped intracytoplasmic inclusions (Donovan bodies). Educational objective: The clinical presentation of tertiary syphilis includes cardiovascular involvement and gummas. Gummas are necrotizing granulomas occurring on the skin, mucosa, subcutaneous tissue, and bones and within other organs. Neurosyphilis can occur at any stage of infection.

A 35-Year-Old Woman Comes to the Office Due to a Vulvar