A 32-year-old woman comes to the office for evaluation of postcoital bleeding. She has monthly menstrual cycles with 4 days of light vaginal bleeding, but for the past 2 months she has also had postcoital bleeding. Three years ago, the patient was diagnosed with HIV, but she stopped taking antiretroviral therapy due to medication side effects and has not seen a provider since then. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. On examination, the uterus is small, mobile, and nontender. There is an ulcerative lesion on the posterior aspect of the cervix that bleeds with contact. The rest of the cervix has no lesions, and there is no endocervical discharge. The left inguinal lymph nodes are enlarged and nontender. Which of the following pathogens is the most likely cause of this patient's presentation?

Question

A 32-year-old woman comes to the office for evaluation of postcoital bleeding.  She has monthly menstrual cycles with 4 days of light vaginal bleeding, but for the past 2 months she has also had postcoital bleeding.  Three years ago, the patient was diagnosed with HIV, but she stopped taking antiretroviral therapy due to medication side effects and has not seen a provider since then.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  On examination, the uterus is small, mobile, and nontender.  There is an ulcerative lesion on the posterior aspect of the cervix that bleeds with contact.  The rest of the cervix has no lesions, and there is no endocervical discharge.  The left inguinal lymph nodes are enlarged and nontender.  Which of the following pathogens is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d9af_b27e_bc81_db551eda2baf_MD0003_00 This patient with HIV has an ulcerative cervical lesion concerning for cervical cancer, which is caused by high-risk strains (types 16 and 18) of human papillomavirus (HPV). In HIV-positive patients, cervical cancer is an AIDS-defining illness because it indicates severe immunocompromise. In immunocompromised patients, HPV can cause cervical dysplasia that rapidly progresses to cancer (eg, within months). For this reason, HIV-positive patients require cervical cancer screening (eg, Pap testing) at the time of HIV diagnosis, followed by close-interval repeat testing (eg, in 6-12 months). Cervical cancer invades the cervix and becomes increasingly vascular. Therefore, the most common presenting symptom of undiagnosed cervical cancer is abnormal vaginal bleeding (ie, intermenstrual or postcoital bleeding), as seen in this patient. On examination, cervical cancer may appear as either an exophytic, friable lesion (due to tumor growth) or a painless, ulcerative lesion (due to tumor necrosis). In those with advanced-stage disease, metastases can develop and cause painless inguinal lymphadenopathy. Diagnosis is confirmed with biopsy of the lesion. Treatment (eg, pelvic radiation) depends on cancer staging. (Choice A) Chlamydia trachomatis serovars L1-L3 can cause lymphogranuloma venereum (LGV), which may present with a painless genital ulcer. In contrast to this patient, those with LGV have painful inguinal lymphadenitis. (Choice B) Gardnerella vaginalis (ie, bacterial vaginosis) causes a malodorous, fishy vaginal discharge without genital tract inflammation. It does not cause abnormal vaginal bleeding, cervical lesions, or lymphadenopathy. (Choice C) In contrast to this patient, those with Haemophilus ducreyi infection (ie, chancroid) typically have painful genital ulcers and painful, suppurative inguinal lymphadenitis (ie, buboes). (Choice E) Treponema pallidum infection (ie, syphilis) can present with a single, painless ulcer (ie, chancre) and painless inguinal lymphadenopathy during the primary stage; however, it is not associated with postcoital bleeding or cervical lesions. (Choice F) Trichomonas vaginalis infection may present with postcoital bleeding due to punctate hemorrhages of the cervix (ie, strawberry cervix); however, it is not associated with inguinal lymphadenopathy. Educational objective: Cervical cancer, an AIDS-defining illness in patients with HIV, is caused by high-risk strains (types 16 and 18) of human papillomavirus. Cervical cancer can present with postcoital bleeding, a painless ulcerative lesion, and painless inguinal lymphadenopathy. References: Malignancies in women with HIV infection. (http://www.ncbi.nlm.nih.gov/pubmed/27849632) Evolving epidemiology of HIV-associated malignancies. (http://www.ncbi.nlm.nih.gov/pubmed/27749369) Cervical cancer screening in immunocompromised women. (http://www.ncbi.nlm.nih.gov/pubmed/23732035)

A 32-Year-Old Woman Comes to the Office for Evaluation of Postcoital