A 26 year old lady who has 3 sons and a daughter comes to you with an ulcer in the vulvar region. She does not have dysuria or vaginal discharge. The patient is unsure of the duration of the rash. Denies any pain or burning.
On examination, the patient appears well, has a soft systolic murmur in the aortic area, no conjunctivitis or keratitis. Abdomen is soft and non-tender, extremities are normal.
The ulcer is firm, non-tender and has vertical margins. The base of the ulcer is clean.
Which of the following statements is true about this patient?
The patient is unlikely to be infective at this time
The same organism causes severe conjunctivitis
In a patient allergic to beta lactam antibiotics, Spectinomycin should be used
Keratitis is a known complication of this disease
Lymphadenopathy associated with this condition is painful and full of pus.
The answer is choice d. The possibilities with genital ulcers are
Herpes simplex - extremely painful - especially the first episode. Diagnosis is clinical. Treatment is with Acyclovir/Valacyclovir/Famciclovir.
Chancroid - Painful and has lymphadenopathy associated and the lymph nodes are filled with pus. Diagnosis is Treatment is with Ceftriaxone 250 mg single dose or with Azithromicin.
Syphilis - Painless lesion with firm base. Infective when the lesion is open and very infective when secondary syphilis lesions come. Arteries and cornea can be affected. Thoracic aortic aneurysm and dissection can be caused after decades of having the condition Treatment should be with penicillin.
This patient has primary syphilis. It is so infective that it is reported that a man got it on his shoulder from a lady sitting on his shoulders during a festival in which he carried her around. The chancre looks like a cut out/punched out lesion. It should be immediately treated with penicillin and the patient should be offered testing for HIV too. Early in the course of the illness, the RPR may be negative but dark field microscopy can detect the spirochete.
CDC Guidelines for Management of patients who have genital ulcers
In the United States, most young, sexually active patients who have genital ulcers have either genital herpes, syphilis, or chancroid. The relative frequency of each differs by geographic area and patient population; however, in most areas of the United States, genital herpes is the most prevalent of these diseases. More than one of these diseases could be present in a patient who has genital ulcers. Each disease has been associated with an increased risk for HIV infection.
A clinical diagnosis often is inaccurate. Therefore, all patients who have genital ulcers should have a serologic test for syphilis and evaluation for herpes. Ideally, all of these tests should be conducted for each patient who has a genital ulcer.
Specific tests for the evaluation of genital ulcers include the following:
Darkfield examination or direct immunofluorescence test for Treponema pallidum,
Culture or antigen test for HSV, and
Culture for Haemophilus ducreyi.
HIV testing should be a) performed in the management of patients who have genital ulcers caused by T. pallidum or H. ducreyi and b) considered for those who have ulcers caused by HSV (see sections on Syphilis, Chancroid, and Genital Herpes).
Before test results are available, the clinician should treat for the diagnosis considered most likely. If the diagnosis is unclear, treat for syphilis, or for both syphilis and chancroid if the patient resides in a community in which H. ducreyi is common. However, even after complete diagnostic evaluation, at least 25% of patients have no laboratory-confirmed diagnosis.