A 34-year-old woman comes to the office for evaluation of vulvar lesions that have worsened over the past 3 months. She has had 2 sexual partners in the last year. Medical history includes genital infection with herpes simplex virus diagnosed at age 23; when she was 25, her sexual partner was diagnosed with syphilis. Cervical cancer screening last year revealed atypical squamous cells of undetermined significance, with negative testing for high-risk human papillomavirus. The patient smokes cigarettes but does not use alcohol or illicit drugs. Examination reveals multiple nontender, fleshy, verrucous growths clustered at the vestibule of the vulva and over the labia majora. A few lesions are friable and bleed on manipulation. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis in this patient?

Question

A 34-year-old woman comes to the office for evaluation of vulvar lesions that have worsened over the past 3 months.  She has had 2 sexual partners in the last year.  Medical history includes genital infection with herpes simplex virus diagnosed at age 23; when she was 25, her sexual partner was diagnosed with syphilis.  Cervical cancer screening last year revealed atypical squamous cells of undetermined significance, with negative testing for high-risk human papillomavirus.  The patient smokes cigarettes but does not use alcohol or illicit drugs.  Examination reveals multiple nontender, fleshy, verrucous growths clustered at the vestibule of the vulva and over the labia majora.  A few lesions are friable and bleed on manipulation.  The remainder of the physical examination is normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d9fb_b01d_bc81_07ced8280652_MD0003_00 This patient most likely has condylomata acuminata (anogenital warts) caused by human papillomavirus (HPV), a common sexually transmitted infection. Condyloma acuminata occur due to persistent infection with low-risk HPV strains 6 and 11, and patients with chronic tobacco use (as in this patient) or immunosuppression (eg, HIV) have an elevated risk. Anogenital warts typically appear as clusters of soft, pink or skin-colored (fleshy) lesions in the internal or external vaginal, vulvar, and anal regions in women. Most lesions are exophytic, dry-appearing, and verrucous (ie, cauliflower-like), although some may appear sessile and flat. Genital warts are typically asymptomatic and nontender, although pruritic, friable lesions (eg, those that bleed with manipulation) may occur. Diagnosis is primarily clinical, based on the characteristic appearance of the lesions. Small anogenital warts are treated with topical agents that either chemically injure the lesion (eg, trichloroacetic acid, podophyllin resin) or stimulate an immune response to it (eg, imiquimod). Surgical excision may be required for larger lesions. Recurrence rates are high, regardless of treatment modality. (Choice B) Condylomata lata, caused by secondary syphilis, are raised, gray-white lesions that develop on mucosal surfaces (eg, mouth, perineum). In contrast to condylomata acuminata, condylomata lata typically have a broader base and a smooth, rather than a verrucous, surface. (Choice C) Herpes simplex virus presents as tender ulcerative blisters or pustules, not fleshy, verrucous growths. Herpes simplex virus (Choice D) Vulvar lichen planus creates pruritic, glassy, bright red-purple lesions with overlying white reticular lines (ie, "Wickham striae"). (Choice E) Vulvar lichen sclerosus presents as pruritic, white labial lesions that appear thin and wrinkled and result in obliteration of the normal vulvar architecture. Vulvar lichen sclerosus (Choice F) Molluscum contagiosum, caused by a poxvirus, is characterized by small, painless, "pearly" (eg, smooth, firm) nodules with central dimpling. Molluscum contagiosum (Choice G) Smokers are at increased risk for vulvar cancer, which can present as a single friable, fleshy vulvar lesion. Vulvar cancer is associated with high-risk HPV strains (eg, types 16 and 18), making this diagnosis unlikely in this patient with recent negative high-risk HPV testing. Educational objective: Condylomata acuminata, or anogenital warts, are caused by the low-risk strains of human papillomavirus (eg, types 6 and 11) and typically present as nontender, verrucous genital lesions that may be friable. Treatment is with topical medications (eg, trichloroacetic acid) or surgical excision. References: Management of external genital warts. (http://www.ncbi.nlm.nih.gov/pubmed/25251091) Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/27034016) Genital warts and other HPV infections: established and novel therapies. (http://www.ncbi.nlm.nih.gov/pubmed/24559567)

A 34-Year-Old Woman Comes to the Office for Evaluation of Vulvar