LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 2 | Page : 189-191
Clinical approach to nonvenereal genital ulcer
Avani Modi, Yogesh S Marfatia
Department of Skin and VD, Medical College Baroda, Vadodara, Gujarat, India
|Date of Web Publication||23-Oct-2017|
Department of Skin and VD, Medical College Baroda, Vadodara, Gujarat - 390 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Modi A, Marfatia YS. Clinical approach to nonvenereal genital ulcer. Indian J Sex Transm Dis 2017;38:189-91
A 35-year-old married female presented to dermatology outpatient department with the complaints of high-grade fever of sudden onset. Genital ulcers were very painful due to which patient had complained of difficulty in walking and micturition. There was no complaint of oral ulcers. The patient had a similar history of multiple recurrent genital ulcers for 1 year. She was in monogamous relationship with her husband.
Clinical examination showed a single ulcer 2 cm in diameter on the inner aspect of the left side of labia majora and labia minora. The ulcer was well-defined with irregular margin and yellowish base with minimum slough [Figure 1].
It was tender. Inguinal lymph nodes were not palpable on either side. Oral mucosa was normal.
On her first visit, all routine investigations were done. Complete blood counts revealed neutrophilic leukocytosis and high erythrocyte sedimentation rate (60 mm/h). In urine, few pus cells were present. Her HIV, hepatitis B surface antigen, and venereal disease research laboratory were nonreactive. Herpes serology was not available. Tzanck smear taken from lesion revealed no multinucleated giant cells. Differential diagnosis such as herpes progenitalis, Behcet's disease, and aphthous ulcer was considered, and biopsy from genital lesion was advised. Tablet acyclovir (400 mg tds) was started for 7 days, but there was no response. To rule out nonvenereal causes of genital ulcers such as Behcet's disease, the patient was sent to ophthalmologist. There were no positive findings suggestive of eye involvement. Subsequently, tablet azithromycin (500 mg od) was given for 10 days to take care of it. Still, there was no response. An attempt was made to rule out tuberculosis, chest X–ray and ultrasonography abdomen were done which were normal. No acid–fast bacilli were seen in sputum. Mantoux test was also negative. Although motivated and counseled, the patient and her husband did not give consent for taking biopsy.
Then, in the absence of infectious etiology, probable diagnosis of Lipschutz ulcer was made, tablet prednisolone (30mg) and tablet dapsone (100 mg bd) were started. After 1 month of follow-up, genital ulcers started healing [Figure 2]. The dose of prednisolone was tapered to 20 mg for 1 month and 10 mg for another 1 month. Tablet dapsone (100 mg bd) was continued for 3 months, and external treatment (sitz bath) with potassium permanganate was advised. Ulcers have healed now with scarring [Figure 3].
- There was no positive serological marker suggestive of genital ulcer due to sexually transmitted disease. Moreover, there was no response with syndromic management for genital ulcer. The response to tablet dapsone and oral corticosteroid gives possible diagnosis of Lipschutz ulcer. It is also known as ulcus vulvae acutum or reactive nonsexually related acute genital ulcers and etiology – still unknown, although associated with several infectious causes, including paratyphoid, fever, cytomegalovirus, and Epstein–Barr virus infection ,
- In sexually active cases with genital ulcer, an attempt should always be made to rule out sexually transmitted disease, and therapeutic trial can be given for it. In nonresponsive cases, genital biopsy is helpful, and the patient should be motivated to take biopsy. In reluctant cases, therapeutic trial of corticosteroid can be given. In the present case, the patient responded well with corticosteroid and dapsone combination.
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| References|| |
Bhat RM, Furtado S. Lipschutz ulcer. Indian J Sex Transm Dis 2007;28:106-7. [Full text]
Berlin C. The pathogenesis of the so-called ulcus vulvae acutum. Acta Derm Venereol 1965;45:221-2.
Brinca A, Canelas MM, Carvalho MJ, Vieira R, Figueiredo A. Lipschütz ulcer (ulcus vulvae acutum): A rare cause of genital lesion. An Bras Dermatol 2012;87:622-4.
[Figure 1], [Figure 2], [Figure 3]