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Painless Penile Ulcer and Tender Inguinal Lymphadenopathy

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Painless Penile Ulcer and Tender Inguinal Lymphadenopathy PHOTO ROUNDS Jeffrey Walden, MD; Raleigh Rumley, MD Painless penile ulcer and tender University of North Carolina, Chapel Hill (Dr. Walden); Cone Health Family Residency, inguinal lymphadenopathy Greensboro, NC (Drs. Walden and Rumley) Our patient had previously been treated for syphilis. But jeffrey.walden@conehealth. when his symptoms persisted, further testing revealed com DEPARTMENT EDITOR that he was being treated for the wrong STD. Richard P. Usatine, MD University of Texas Health at San Antonio The authors reported no potential conflict of interest relevant to this a 38-year-old man presented to our emer- signs. A genital examination revealed a non- article. gency department with a 2-day history of fever, tender, irregularly shaped 8-mm ulcer at the general malaise, and a painless genital ulcer. base of the glans penis (FIGURE). Tender uni- He denied having any abdominal pain, myal- lateral inguinal lymphadenopathy was noted gias, arthralgias, or other rashes. He had been on the right side. treated about a month earlier on an outpatient A chart review showed a normal CD4 basis with penicillin for a presumed diagnosis count (obtained 2 months earlier). We were un- of syphilis, but his symptoms did not resolve. able to access the results of his outpatient rapid His medical history included well-controlled plasma reagin test for syphilis. Due to the pa- human immunodeficiency virus (HIV), hepa- tient’s degree of pain from his lymphadenopa- titis B, hypertension, anxiety, and fibromyal- thy, fever, and general malaise, he was admitted gia for which he took lisinopril, emtricitabine/ to the hospital for overnight observation. tenofovir, metoprolol, and darunavir/cobici- stat. He smoked a half-pack of cigarettes a day ● WHAT IS YOUR DIAGNOSIS? and had unprotected sex with men. On physical examination, the patient was ● HOW WOULD YOU TREAT THIS febrile (103.1° F) with otherwise normal vital PATIENT? FIGURE Penile ulcer PHOTO COURTESY OF: CONE HEALTH HOSPITAL SYSTEM HOSPITAL OF: CONE HEALTH PHOTO COURTESY A nontender, irregularly shaped 8-mm ulcer at the base of the glans penis. MDEDGE.COM/JFPONLINE VOL 67, NO 6 | JUNE 2018 | THE JOURNAL OF FAMILY PRACTICE 381 PHOTO ROUNDS Diagnosis: ital ulcers (such as syphilis, chancroid, herpes Lymphogranuloma venereum simplex virus, and Behçet’s disease). Identifi- Based on the patient’s history and clinical pre- cation of the causal bacteria is often needed to sentation, we suspected lymphogranuloma make a definitive diagnosis. venereum (LGV). A positive nucleic acid am- ❚ Syphilis, caused by the spirochete plification test (NAAT) for Chlamydia tracho- Treponema pallidum, initially manifests as a matis confirmed the diagnosis. chancre (a single, well-demarcated, painless LGV is an infection caused by C tracho- ulcer). It is less commonly associated with matis—specifically serovars L1, L2, and L3— inguinal lymphadenopathy and can be diag- that is transmitted through unprotected sex.1-3 nosed via serologic testing.5,6 During intercourse, the serovars cross the epi- ❚ Chancroid is caused by Haemophilus thelial cells through breaks in the skin and ducreyi and manifests as a painful ulcer with enter the lymphatic system, often resulting in a friable base covered with a necrotic exudate. painful lymphadenopathy. LGV is more com- It can be associated with tender unilateral in- monly reported in men (primarily men who guinal lymphadenopathy.5 Due to the wide- have sex with men [MSM]), but can occur in spread availability of culture media to test for either gender.4 The true incidence and preva- H ducreyi, the diagnosis of chancroid is based lence of LGV are difficult to ascertain as the on the clinical exam plus a handful of clinical disease primarily occurs in tropical areas, but criteria: painful genital ulcers, no evidence of Lymphogranu- outbreaks in the United States occur predomi- T pallidum infection, and negative culture or loma venereum nantly in patients infected with HIV. polymerase chain reaction testing (PCR) for is more herpes simplex virus (HSV). commonly The 3 stages of infection ❚ HSV, the most common cause of genital reported Following an incubation period of 3 to 30 days, ulcers in the United States,5 typically manifests in men— LGV progresses through 3 stages. The first with multiple vesicular painful lesions, with primarily men stage involves a small, painless lesion at the or without lymphadenopathy. Constitutional who have sex inoculation site—usually the prepuce or glans symptoms, including fever, headache, mal- with men. of the penis or the vulva or vaginal wall. The aise, and myalgias, occur in 66% of females lesion typically heals in about one week.1,2,4 and 40% of males.5,7 Identification of HSV on Two to 6 weeks later, LGV enters the sec- culture or PCR can confirm the diagnosis.5 ond phase, characterized by painful unilat- ❚ Behçet’s disease is a noninfectious syn- eral inguinal or femoral lymphadenopathy or drome associated with intermittent arthritis, proctitis. Inguinal and femoral lymphadenop- recurrent painful oral and genital ulcers, uve- athy is more common in men.1,4 The “groove itis, and skin lesions. While most symptoms of sign”—lymphadenopathy occurring above Behçet’s are self-limited, recurrent uveitis can and below the inguinal ligament—is seen in result in blindness. A biopsy may be warranted 10% to 20% of men with LGV.1,3 In women, to diagnose Behçet’s disease; the results may lymphatic drainage occurs in the retroperito- show diffuse arteritis with venulitis.5,8 neal or intra-abdominal nodes and may result in abdominal or back pain.1,4 Proctitis is re- NAAT is recommended ported primarily in women and in MSM.1,4 to confirm the diagnosis Tertiary LGV (aka genitoanorectal syn- In the outpatient setting, diagnosis of LGV re- drome) is also more common in women and lies on physical exam, clinical presentation, MSM, due to the location of the involved lym- confirmation of infection, and exclusion of phatics. In this stage, chronic inflammation other causes of genital ulcer, lymphadenopa- causes scarring and destruction of tissue.1,4 thy, and proctitis.3 Diagnostic tests include Left untreated, LGV can lead to lymphatic ob- culture identification of C trachomatis, visual- struction, deep tissue abscesses, chronic pain, ization of inclusion bodies on immunofluores- strictures, or fistulas.1,3,4 cence of bubo aspirate, and positive serology for C trachomatis.1-3 (Serology to differentiate Other genital ulcers can mimic LGV LGV from non-LGV C trachomatis serovars is LGV can be confused with other causes of gen- difficult and not widely available.) 382 THE JOURNAL OF FAMILY PRACTICE | JUNE 2018 | VOL 67, NO 6 Visit us @ mdedge.com/fponline Recommendations regarding lab studies have shifted away from serologic testing and toward the use of NAAT. NAAT via PCR has a sensitivity and specificity comparable to in- vasive testing methods: 83% and 99.5% with USPSTF takes another stab at urine samples and 86% and 99.6% with cervi- cal samples, respectively.9 NAAT has a sensi- PSA screening recommendations tivity and specificity that is superior to culture Doug Campos-Outcalt, MD, MPA for detecting chlamydia in rectal specimens10 and is preferred by patients because it doesn’t require a pelvic exam or a urethral swab. USPSTF offers 3 recommendations for preventing falls in older adults Treat with antibiotics Doug Campos-Outcalt, MD, MPA Oral antibiotics are the treatment of choice for LGV. Standard treatment includes doxycycline 100 mg bid for 21 days. Women who are preg- nant or lactating may alternatively be treated with macrolides (eg, erythromycin).1,2,4 Buboes may be aspirated for pain relief and to prevent the development of ulcerations or fistulas.3,4 ❚ Our patient was started on oral doxy- cycline, which resolved his fever and reduced Residents’ the size of his ulcer. He was discharged on oral Rapid Review doxycycline and continued on the full 21-day Check out these quizzes, which are designed course. Two weeks later, the ulcer and lymph- to help physicians pass their family medicine adenopathy had completely resolved. On recertification—and certification—exam. follow-up in our office, the resident physician who treated the patient in the hospital dis- mdedge.com/jfponline cussed future use of safe sexual practices. JFP CORRESPONDENCE Jeffrey Walden, MD, Cone Health Family Medicine Residency, INSTANT POLL 1125 North Church Street, Greensboro, NC 27401; Jeffrey. [email protected]. What percentage of your patients (including parents of patients) express reticence or concerns about vaccinations? REFERENCES 1. Mabey D, Peeling RW. Lymphogranuloma venereum. Sex Transm Infect. 2002;78:90-92. ONLINE EXCLUSIVES 2. Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012;85:254-262. • APPLIED EVIDENCE 3. Stoner BP, Cohen SE. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis. Is the “breast is best” mantra an 2015;61:S865-S873. oversimplification? 4. Ceovic R, Gulin SJ. Lymphogranuloma venereum: diagnostic and treatment challenges. Infect Drug Resist. 2015;8:39-47. • CASE REPORT 5. Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012;85:254-262. History of posttraumatic stress disorder • 6. Mattei PL, Beachkofsky TM, Gilson RT, et al. Syphilis: a reemerging priapism • Dx? infection. Am Fam Physician. 2012;86:433-440. 7. Kimberlin DW, Rouse DJ. Genital herpes. N Engl J Med. PHOTO ROUNDS FRIDAY 2004;350:1970-1977. 8. Sakane T, Takeno M, Suzuki N, et al. Behçet’s disease. N Engl J Med. Test your diagnostic skills at www.jfponline.com/ 1999;341:1284-1291. 9. Cook RL, Hutchison SL, Østergaard L, et al. Systematic review: non- articles/photo-rounds-friday.html invasive testing for Chlamydia trachomatis and Neisseria gonor- rhea. Ann Intern Med. 2005;142:914-925. 10. Geisler WM. Diagnosis and management of uncomplicated Chla- GET UPDATES FROM US ON mydia trachomatis infections in adolescents and adults: summary of evidence reviewed for the 2010 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines.
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