A 22-year-old college student comes to the clinic due to a solitary penile lesion. Three days ago, he noticed a small red papule, and it has been enlarging. The patient has been sexually active with 1 female partner over the preceding 6 months and consistently uses condoms. He has had no prior sexually transmitted infections but does get occasional shallow, tender ulcers along his inner lip once or twice a year. Temperature is 36.7 C (98.1 F). There is a nontender, nonexudative, 2-cm circular ulcer at the dorsal base of the penile shaft. Palpation reveals nontender enlargement of the inguinal lymph nodes measuring 2.5 cm on the left and 2 cm on the right. The rest of the examination is unremarkable. Which of the following is the most appropriate management for this patient's penile lesion?

Question

A 22-year-old college student comes to the clinic due to a solitary penile lesion.  Three days ago, he noticed a small red papule, and it has been enlarging.  The patient has been sexually active with 1 female partner over the preceding 6 months and consistently uses condoms.  He has had no prior sexually transmitted infections but does get occasional shallow, tender ulcers along his inner lip once or twice a year.  Temperature is 36.7 C (98.1 F).  There is a nontender, nonexudative, 2-cm circular ulcer at the dorsal base of the penile shaft.  Palpation reveals nontender enlargement of the inguinal lymph nodes measuring 2.5 cm on the left and 2 cm on the right.  The rest of the examination is unremarkable.  Which of the following is the most appropriate management for this patient's penile lesion?

Quizplus · Accepted Answer

11ec25c8_d288_300e_bc81_0b481a7b9046_MD0003_00 This patient's painless penile ulcer is consistent with a chancre, the characteristic lesion of primary syphilis. Syphilis, caused by Treponema pallidum, is spread via direct sexual contact with an infectious lesion. Although condom use decreases transmission, it is effective only when covering the active lesion. In particular, the base of the penile shaft may remain exposed and susceptible to infection despite condom use, as seen in this patient. Primary syphilis typically begins as a small, erythematous papule at the site of inoculation weeks to months after exposure. The lesion then develops into the classic chancre, a nonexudative, painless ulcer with a raised edge. Bilateral inguinal lymphadenopathy, as seen in this patient, is common. Although spontaneous resolution of the ulcer typically occurs within 6 weeks, systemic spread of infection leads to secondary and/or late syphilis without proper treatment. chancre Penicillin is the first-line treatment for syphilis and is given as a single intramuscular dose in patients with early disease. Doxycycline is an alternate antibiotic for patients with penicillin allergy. (Choices A and B) Azithromycin or ceftriaxone may be used to treat a chancroid (caused by Haemophilus ducreyi), which is a painful ulcer with an exudative base that may be accompanied by tender, suppurative lymphadenopathy. Azithromycin is also a preferred treatment for granuloma inguinale (caused by Klebsiella granulomatis), which presents with painless, beefy red, friable genital ulcers without lymphadenopathy. In contrast, this patient has a painless ulcer with bilateral lymphadenopathy. (Choice C) Doxycycline is the first-line treatment for lymphogranuloma venereum caused by Chlamydia trachomatis. Small (2-3 mm), painless genital ulcers appear and then resolve before the development of painful, suppurative inguinal nodes. This patient's 2-cm solitary ulcer with concomitant lymphadenopathy makes syphilis more likely. (Choice E) Valacyclovir is used to treat herpes simplex virus infection, which causes painful clusters of vesicles/ulcers on an erythematous base. In contrast, this patient's single lesion is painless. His occasional lip ulcers are more consistent with aphthous stomatitis ("canker sores"), sometimes treated with topical corticosteroids, than with oral herpes ("cold sores"), which typically presents as painful vesicles at the vermillion border. Educational objective: A syphilitic chancre (nonexudative, painless genital ulcer) can result from direct sexual contact with an infectious lesion in an exposed area despite condom use (eg, base of penile shaft). Penicillin is the first-line treatment. References: Syphilis transmission: a review of the current evidence. (http://www.ncbi.nlm.nih.gov/pubmed/25702043) A systematic review of epidemiologic studies assessing condom use and risk of syphilis. (http://www.ncbi.nlm.nih.gov/pubmed/19455075)

A 22-Year-Old College Student Comes to the Clinic Due to a Solitary