Hurry up!
: : Get The Offer
Unlimited Access Step ( one, two and three ).
Priority Access To New Features.
Free Lifetime Updates Facility.
Dedicated Support.
1
Question:

A 35-year-old woman comes to the office due to a vulvar lesion.  She has also experienced occasional headaches and memory loss recently.  The patient has had unprotected sexual intercourse with multiple partners.  Cardiovascular examination is notable for a diastolic murmur with a prominent second heart sound.  There is a painless indurated nodule on her vulva.  Cervical cultures are negative for gonorrhea, but a serum Venereal Disease Research Laboratory (VDRL) test is positive.  Chest x-ray reveals calcifications at the level of the ascending aortic arch.  Blood cultures are negative.  Lumbar puncture shows mild pleocytosis and a positive VDRL result.  HIV testing is negative.  Which of the following best describes this patient's vulvar lesion?

Hurry up!
: : Get The Offer
Unlimited Access Step ( one, two and three ).
Priority Access To New Features.
Free Lifetime Updates Facility.
Dedicated Support.


Explanation:

There are many explanatory sources, such as pictures, videos, and audio clips to explain these explanations and questions and explain the answers, but you must subscribe first so that you can enjoy all these advantages. We have many subscription plans at the lowest prices. Don't miss today's offer. Subscribe

This patient with neurosyphilis (headaches, memory loss, cerebrospinal fluid with Venereal Disease Research Laboratory positivity, pleocytosis) likely has cardiovascular syphilis (asymptomatic murmur with loud second heart sound [S2], ascending aortic arch calcification).  She therefore has late (tertiary) syphilis, and her vulvar lesion is most likely a gumma.  A chancre would be seen in primary syphilis (Choice A), and condylomata lata occur during secondary syphilis (Choice C).

The clinical presentation of syphilis occurs in well-defined stages:

  • Primary syphilis manifests as a painless ulceration with raised, indurated borders.  This chancre develops at the Treponema pallidum inoculation site (most commonly penis or vulva) 1-3 weeks after contact and resolves in 3-6 weeks.  The organism commonly disseminates systemically during this stage.
  • Secondary syphilis, a bacteremic stage that develops 5-10 weeks following chancre resolution, presents with a diffuse macular rash, as shown in the exhibit, encompassing the palms and soles.  Condylomata lata, large gray wartlike growths typically appearing in the genital/perineal region, are another typical manifestation.
  • Latent syphilis is an asymptomatic period divided into early latent (infection within past year) and late latent (infection >1 year ago).
  • Late (tertiary) syphilis develops many years after infection in untreated individuals.  Gummas are characteristic and often begin as painless, indurated granulomatous lesions that progress to white-gray rubbery lesions that may ulcerate.  They are most commonly cutaneous but also appear in the subcutaneous tissue, bones, liver, and other organs.  Tertiary syphilis can also manifest as cardiovascular involvement with ascending aortic aneurysms (with calcification seen on x-ray) and resultant aortic valve insufficiency (murmur, high-pitched tambour S2).

Neurosyphilis, which may be asymptomatic or cause subacute meningoencephalitis, tabes dorsalis, or other neurologic sequelae, is a common manifestation of late syphilis but can occur at any stage.

(Choice B)  Condylomata acuminata are anogenital warts due to human papillomavirus (HPV), the causative agent of cervical cancer.  Common strains associated with condylomata acuminata are HPV 6 and 11, which have low oncogenic potential.

(Choice D)  Patients with granuloma inguinale, a sexually transmitted disease caused by Klebsiella granulomatis (previously Calymmatobacterium granulomatis), can have inguinal swelling, ulcers, abscesses, and fistulas.  Gram staining of the lesions reveals cells with rod-shaped intracytoplasmic inclusions (Donovan bodies).

Educational objective:
The clinical presentation of tertiary syphilis includes cardiovascular involvement and gummas.  Gummas are necrotizing granulomas occurring on the skin, mucosa, subcutaneous tissue, and bones and within other organs.  Neurosyphilis can occur at any stage of infection.