Infectious Causes of Genital Ulcers and "Bumps"

Ulcers

Chancre

(Treponema pallidum)

A 18 year old male prostitute comes into the family practice clinic asking about a local, nontender ulcer (chancre) on penis. The ulcer is about 0.1 cm with a hard edge and clean, yellow base. Physical exam reveals slight lymphadenopathy.

Laboratory: Spirochete on darkfield and immunoflourescence microscopy. FTA-ABS positive. VDRL positive.

Discussion: The clinical presentation of a single chancre and labs indicate primary syphilis caused by Treponema pallidum. The lesions are usually found on genitalia and are frequently solitary, may be multiple and may have regional lymphadenopathy. It heals with scarring in 3 to 6 weeks with 75% of patients having no further symptoms. The primary and secondary form of syphilis are both highly infectious.

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Chancroid (soft chancre)

(Haemophilus ducreyi)

A 24 year old man who recently immigrated from Cuba comes into the family practice clinic complaining of soft, painful lesions. They are nonindurated with pus and erythema. Inguinal lymphadenopathy is present.

Labs: Gram-negative rods (isolated from pus aspirated from a lymph node or lesion) grow on blood agar supplemented with X (heme) factor but not V (NAD) factor.

Discussion: The diagnosis is Chancroid caused by Haemophilus ducreyi. It is a sexually transmitted disease. Diagnosis is made by isolating the organism. In addition to the clinical picture above, there may also be pus, suppuration, and a necrotic exudate present. Unlike Haemophilus influenzae, Haemophilus ducreyi does not require V factor. It is uncommon in the U.S.

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A 23 year old prostitute comes into the gynecological office for superficial ulcers on her labia majora. These ulcers are painless.

Laboratory: Cytoplasmic inclusions of obligate intracellular organisms seen with Giemsa stain and immunoflourescence.

Discussion: Diagnosis of Lymphogranuloma venereum by Chlamydia trachomatis (L1, L2, L3) is made by labs and clinical presentation. Three of fifteen known strains of C. trachomatis described as serovars L1, L2, and L3 are responsible for Lymphogranuloma venereum (LGV). While the strains of Chlamydia that cause urethritis appear to infect only squamocolumnar cells, LGV strains are more invasive and capable of replication in macrophages.

Genital Herpes

(Herpes Simplex Virus 2)

An 28 year old graduate student comes into the family practice clinic complaining of fever, inguinal adenopathy, and painful vesicular lesions on her genitalia. Physical exam reveals similar lesions on her anal area. She admits to being sexually active.

Laboratory: Isolation of an enveloped, linear dsDNA virus from the lesion by cell culture. Tzanck smear shows multinucleated giant cells with intranuclear inclusions.

Discussion: The diagnosis of genital herpes by Herpes Simplex Virus 2 (HSV-2) is made by both clinical presentation and labs. HSV-2 is transmitted by sexual contact. The number of infections by HSV-2 is on the rise. HSV-I is usually associated with infections "above the waist", while HSV-2 is associated with infections below the waist. HSV-2 is also assocated with cervical cancer.

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Granuloma inguinale

(Calymmatobacterium granulomatis)

A 28 year old male presents to the family practice clinic complaining of a painless ulcer on his penis. Physical exam also reveals inguinal lymphadenopathy and suppuration of the lymph node. He has recently traveled to Thailand and admits to having unprotected sex with a lady he met while vacationing there.

Labs: Donovan bodies present. Gram negative rods also seen with stain.

Discussion: The diagnosis of granuloma inguinale by Calymmatobacterium is made by seeing Donovan bodies within large macrophages from the lesion. It is also called Donovanosis and granuloma venereum. It is rare in the U.S. and presents as a painless ulcer on the penis with lymphadenopathy and swelling in the genitalia.

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Bumps

Condyloma Acuminata

(Papillomavirus-6 and Papillomavirus-11)

A 22 year old female presents to her gynecologist complaining of genital "bumps." She admits to being sexual active although she states that she only has one partner. Physical exam reveals brown, warty lesions.

Labs: Presence of koilocytes in the squamous epithelial cells.

Discussion: The diagnosis of genital warts is made by clinical presentation. Genital warts, also called condylomata acuminata are caused primarily by HPV-6 and HPV-11. When the papillomaviruses infect the cells, they produce a cytoplasmic vacuole. This process is called koilocytosis. The presences of koilocytes indicate an infection by HPV. Transmission occurs by sexual contact. This patient was infected by her partner.

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Condyloma lata

(Treponema pallidum)

A 19 year old female student comes into the student health clinic complaining of moist, flat, pink, peripheral warty lesions on her vulva. She also reports some hair loss on her scalp. She recalls that 2 weeks ago there was a local, nontender ulcer (chancre) on her labia that resolved spontaneously. She admits to being an IV drug user.

Laboratory: Spirochete on darkfield and immunoflourescence microscopy. FTA-ABS positive. VDRL positive.

Discussion: The clinical presentation of condyloma lata and labs diagnose secondary syphilis caused by Treponema pallidum. The primary and secondary stages are infectious. The moist lesions on genitalia are called condylomata lata. Secondary syphilis may also present with a maculopapular rash on the palms and soles. In secondary syphilis, alopecia of scalp, eyebrows and beard is common. Risk factors include multiple sexual partners, exposure to infected body fluids, IV drug use, and transplacental exposure.

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Molluscum contagiosum

(Poxvirus)

A 24 year old HIV positive male visits the family practice clinic complaining of "bumps" on his groin and genitalia area. On physical exam, the lesions are discrete pearly, firm papules. The diameter of the lesions range from 2 to 6 mm (rarely giant nodules up to 3 cm occur). They are centrally umbilicated with erythematous base.

Laboratory: Virus particles cannot be cultured.

Discussion: Diagnosis is made by clinical presentation. Lesions can be pruritic or tender. The lesion has an umbilicated center. Beneath the center is a white curd-like core. The lesions can be found anywhere but there is a predilection for face, trunk and extremities in children and groin and genitalia in adults.