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A 26-year-old woman comes to the office due to a vulvar lesion that she noticed 2 days ago. The lesion began as a papule, but this morning it developed a small ulcer in the center. The patient has mild burning with urination but no fever, abnormal vaginal discharge, or oral ulcers. She is sexually active and has had 5 male partners over the past year. Her only medication is an oral contraceptive. The patient smokes 1 pack of cigarettes daily but does not use alcohol or illicit drugs. Vital signs are normal. Vulvar examination shows a 2-cm ulcer with a nonexudative base and a raised, indurated margin. There is no tenderness with palpation. Moderate, painless bilateral inguinal lymphadenopathy is present.
Item 1 of 2
Which of the following is the most likely diagnosis in this patient?
Characteristics of ulcerative sexually transmitted diseases | |||
Disease | Causative agent | Features of primary lesion | Initial lesion painful? |
Chancroid | Haemophilus ducreyi |
| Yes |
Genital herpes | Herpes simplex virus 1 & 2 |
| Yes |
Granuloma inguinale (donovanosis) | Klebsiella granulomatis |
| No |
Syphilis | Treponema pallidum |
| No |
Lymphogranuloma venereum | Chlamydia trachomatis |
| No |
Patients with multiple sexual partners are at high risk for sexually transmitted infections. This patient has classic symptoms of primary syphilis: a painless genital chancre and painless, bilateral inguinal lymphadenopathy. Syphilitic chancres form at the site of direct inoculation with Treponema pallidum. After exposure (3-60 days), patients develop a single papule that turns into a shallow, painless, nonexudative ulcer with indurated edges. Mild to moderate bilateral inguinal lymphadenopathy can develop. Syphilitic chancres are exceedingly infectious, with rates of T pallidum transmission as high as 30%. If untreated, most chancres resolve spontaneously in 6-8 weeks, but the systemic spread of T pallidum results in continued infection.
(Choices A, B, and C) Behçet syndrome, chancroid, and genital herpes are characterized by multiple, painful genital lesions, not a single, painless lesion. Chancroid, caused by Haemophilus ducreyi, is most common in developing regions and is rare in the United States. Behçet syndrome, most likely a form of vasculitis, is marked by recurrent oral aphthous ulcers, often with other systemic findings (eg, fever, uveitis, arthritis).
(Choice D) Granuloma inguinale is caused by Klebsiella granulomatis and is marked by extensive, progressive, and painless genital ulcers, usually without lymphadenopathy. In the United States, <100 infections occur annually, mostly in patients who have traveled internationally (eg, India, Guyana).
(Choice F) Vulvar carcinoma usually presents with a vulvar plaque, ulcer, or mass, often with significant pruritus. Vulvar cancer would evolve over weeks or months, not 2 days.
Educational objective:
Primary syphilis is marked by the formation of a single, painless chancre that begins as a papule and becomes a nonexudative ulcer with indurated borders. Mild to moderate, painless, bilateral lymphadenopathy is often present.