📚 Question Bank

This clinical scenario of an indurated, painless ulcer is suggestive of an extragenital syphilitic chancre. They can occur over fingers, hands, and the oral cavity.

The incubation period of syphilis is 9-90 days. The primary chancre is a painless, indurated, button-like ulcer, as seen below, with painless lymphadenopathy.

Option B: Chancroid or soft chancre presents with single or multiple painful ulcers.

Option C: Lymphogranuloma venereum presents with transient painful or painless ulcers later followed by painful lymphadenopathy.

Option D: Donovanosis presents with a beefy red, non-indurated painless ulcer that bleeds easily.

This clinical scenario of infertility and the finding of perihepatic adhesions on laparoscopy is characteristic of Fitz-Hugh-Curtis syndrome. It is not associated with syphilis.

It refers to perihepatitis that occurs as a complication of PID, due to:

• Gonorrhea
• Chlamydia
• Mixed infections
• Genital tuberculosis.

It results in fever, right upper quadrant pain, and tenderness mimicking acute cholecystitis. Fibrinous violin string adhesions can be seen on laparoscopy. It is also associated with extensive tubal scarring and adhesions.

A febrile reaction occurring within 24 hours of penicillin therapy for syphilis is suggestive of Jarisch-Herxheimer's reaction. Corticosteroids are only indicated in pregnant women and patients with neurosyphilis in whom the reaction can be more serious and lifethreatening sequelae.

Jarisch–Herxheimer reaction is self-limiting and is due to lipoprotein release from the dying treponemes, which trigger cytokine release.

The patient presents with flu-like symptoms and exacerbation of skin lesions. Fever rarely lasts more than 8 hours. Symptoms may be controlled by antipyretics. It is not a contraindication for penicillin use in the future.

Penicillin allergy is a contraindication for further use. JH reactions must be differentiated from penicillin allergy. Allergic reactions can be early or late as follows:

• Early type- anaphylaxis within 1 hour of the first dose.
• Late type- rash after several doses of penicillin

The given image shows Donovan bodies, which points to a diagnosis of granuloma inguinale.

Donovan bodies refer to the Gram-negative rod-shaped or oval organisms that show bipolar staining or safetypin appearance, present intracellularly in the cytoplasm of large mononuclear cells.

Option B: Neisseria gonorrhoeae appears on microscopy as Gramnegative intracellular diplococci within phagocytes as seen below.

Option C: Microscopy of chancroid lesions shows H. ducreyi in a sheet-like or school of fish railroad pattern as seen below.

Option D: In LGV, an increased number of polymorphonuclear leukocytes are noted on microscopy.

The clinical picture of a painless, beefy red, foul-smelling ulcer with no lymphadenopathy points to a diagnosis of granuloma inguinale. It is caused by Calymmatobacterium granulomatis also known as Klebsiella granulomatis.

The incubation period varies from 8-80 days, the average being 50 days. Four types of lesions have been described in this condition:

• Ulcerogranulomatous - most common type with painless beefy red ulcers. They are also highly vascular and bleed on touch.
• Hypertrophic - usually with a raised irregular edge
• Necrotic - offensive smelling ulcer that causes tissue destruction
• Sclerotic or cicatricial - with fibrous or scar tissue

Primary lesions can occur on genital and extragenital sites. Untreated genital ulcers are followed by genital disfigurement and have the potential for malignant change.

Donovan bodies are characteristic of donovanosis or granuloma inguinale. The primary ulcer, if left untreated, heals spontaneously with scarring or persists and spreads.

Granuloma inguinale is a sexually transmitted infection caused by Calymmatobacterium granulomatis / Klebsiella granulomatis. The incubation period varies from 8-80 days, the average

being 50 days.

Four types of lesions have been described in this condition:

• Ulcerogranulomatous - most common type with painless beefy red ulcers. They are also highly vascular and bleed on touch.
• Hypertrophic - usually with a raised irregular edge
• Necrotic - offensive smelling ulcer that causes tissue destruction
• Sclerotic or cicatricial - with fibrous or scar tissue

Primary lesions can occur on genital and extragenital sites. Untreated genital ulcers are followed by genital disfigurement and have the potential for malignant change.

This man with a painless, vascular ulcer and no lymphadenopathy has granuloma inguinale. The first-line treatment is azithromycin 1 g orally once weekly or 500 mg daily for 3 weeks.

In this condition, prolonged antibiotic therapy is required. Antibiotics must be given for 3-6 weeks and until the ulcer has completely healed. The second-line drugs are as follows:

• Doxycycline 100 mg orally BD
• Erythromycin base 500 mg orally QID
• Trimethoprim-sulfamethoxazole 160 mg/800 mg orally BD

Pseudobubo is a feature of donovanosis.

It refers to granulomatous lesions that may extend into subcutaneous tissue and mimic lymphadenopathy. The presence of these lesions both above and below the inguinal ligament results in a pseudo-groove sign, similar to the groove sign of Greenblatt seen in lymphogranuloma venereum.

The given image shows colpitis macularis or strawberry cervix, which is a characteristic finding of trichomoniasis. It results from microscopic, punctate hemorrhages of the cervix.

It is caused by Trichomonas vaginalis and is one of the most common causes of vaginal discharge. It is transmitted by sexual intercourse, with an incubation period of 4–21 days.

In females, it characteristically causes a copious, frothy, yellow-green discharge with pH gt; 4.5, along with vaginal soreness and urinary frequency. Males can be asymptomatic or develop

non-specific urethritis.

Diagnosis in females is usually easily confirmed by the presence of motile organisms on a wet film. Culture in Feinberg–Whittington medium is the most reliable method but is not routinely done.

Standard treatment is metronidazole 2g PO single dose. Regardless of treatment given, patients should avoid sexual contact for 7 days since the last antibiotic dose.

The clinical picture of multiple, grouped painful ulcers with tender lymphadenopathy in this patient points to a diagnosis of herpes genitalis infection by HSV-2. It is treated with a red kit.

The red kit or kit 5 is meant for genital ulcer disease - herpetic. It contains acyclovir 400 mg tablets to be taken TDS for 7 days.

Chancroid is a close differential diagnosis, which presents with multiple, soft painful ulcers and unilateral tender lymphadenopathy. However, vesicles are not seen in chancroid and the ulcers are deeper with ragged undermined edges.

History of drug allergy to penicillin is relevant only when the patient presents with the primary chancre of syphilis. In such a case, they would need to be treated with a blue kit instead of a white kit.

The red kit is used for the treatment of herpetic genital ulcer disease, in which treatment of asymptomatic partners is not required.

Option A: Grey kit used in men for urethral discharge and scrotal swelling requires all recent partners to be treated. But, when used for cervical discharge in women, only symptomatic male

partners need to be treated.

Option B: Blue kit is used for non-herpetic genital ulcer disease when the patient is allergic to penicillin. All partners in the last 3 months must be treated.

Option D: Black kit is used for inguinal buboes. All partners in the last 3 weeks must be treated.

This patient with painful, deep ulcers with tender lymphadenopathy has chancroid. It is caused by Haemophilus ducreyi.

The incubation period is 3-10 days. The primary lesion begins as a painful papule that undergoes central necrosis to form painful, non-indurated ulcers with undermined edges. Kissing ulcers due to autoinoculation may also be present.

It is associated with painful lymphadenopathy, which later progresses to form suppurating buboes and sinuses.

Option B: HSV-2 infection presents with multiple vesicles, which develop into shallow ulcers, along with painful lymphadenopathy.

Option C: LGV presents with a painless or painful ulcer later followed by painful lymphadenopathy. The incubation period is 3-30 days.

Option D: Granuloma inguinale or donovanosis presents with a painless papule that forms a beefy red ulcer with no lymphadenopathy. The incubation period is 8-80 days (average 50 days).

This clinical scenario is suggestive of chancroid. First-line treatment is azithromycin 1g orally as a single dose or ceftriaxone 250 mg IM as a single dose.

The second-line options for chancroid are as follows:

•

Ciprofloxacin 500 mg orally twice a day for 3 days (OR)

•

Erythromycin base 500 mg orally four times a day for 7 days

Chlamydial urethritis is the likely diagnosis in this patient as it has an incubation period of 1-3 weeks. Nucleic acid amplification test (NAAT) is the only diagnostic test recommended for detecting Chlamydia.

The samples used are:

• Men - first void urine
• Women - vaginal or endocervical swabs

NAAT can only detect Chlamydia species, but cannot differentiate between LGV and non-LGV types. Genotyping of Chlamydiapositive samples is needed to specifically diagnose LGV infection.

Serology, cell culture, and microscopy have no role in routine screening or diagnosis.

A single dose of azithromycin 1g is the drug of choice in pregnant women with uncomplicated chlamydial infection.

The drug of choice for chlamydia infection in adults and adolescents is doxycycline 100 mg orally BD for 7 days. It is contraindicated in pregnancy.

Alternative regimens are:

• Azithromycin 1g orally, single dose
• Levofloxacin 500mg OD for 7 days

Azithromycin is preferred due to its greater effectiveness and lower cost.

Option A: Doxycycline is contraindicated in pregnancy as it causes depression of bone growth and enamel hypoplasia in the fetus.

Option B: Ceftriaxone is used for the treatment of gonococcal infections. Option D: Amoxicillin is used as an alternative regimen as it is less effective.

The symptoms of this patient occurring 3 days after unprotected sex point to urethritis caused by Neisseria gonorrhoeae, as its incubation period is 1-5 days.

The most common presentation of gonococcal infection in men is acute urethritis with dysuria and profuse purulent discharge. Pharyngeal and rectal infections can also occur depending on the type of sexual contact.

The primary site of infection in women is the cervix but the urethra, rectum, and pharynx may be involved. Symptoms include excessive vaginal discharge, dysuria, deep dyspareunia, postcoital and intermenstrual bleeding.

The most common cause of non-gonococcal urethritis (NGU) is Chlamydia, which has an incubation period of 1-3 weeks. It usually presents with dysuria alone, but mucopurulent discharge can occur. Other causes of NGU are Mycoplasma genitalium and Trichomonas vaginalis.

This clinical scenario of a patient with a positive blood culture is suggestive of disseminated gonococcal infection, which is due to hematogenous spread.

It is seen in 0.5–3 of patients. Risk factors include:

• Female sex
• Men who have sex with men
• Pregnancy
• Menstruation
• Systemic lupus erythematosus
• Complement deficiency
• Intravenous drug use
• HIV infection

The classic presentation is dermatitis–arthritis syndrome with mild fever. The skin lesions are small, tender, and initially maculopapular. Later a central vesicle or pustule appears and is followed by hemorrhage and necrosis. These lesions are commonly seen near affected joints.

Joint or tendon pain is the most common accompanying feature. Tenosynovitis often affects the hands and fingers. 1/3rd of the patients may proceed to suppurative arthritis, most commonly of the knee.

Other manifestations like endocarditis, pericarditis, osteomyelitis, and meningitis are extremely rare.

This image shows the pathognomonic groove sign of Greenblatt, which is suggestive of lymphogranuloma venereum. It is caused by Chlamydia trachomatis serovars L1-L3.

Groove sign is seen in of the cases. It refers to the depression between the enlarged femoral and inguinal lymph nodes on either side of the inguinal ligament.

Option B: H. ducreyi causes chancroid.

Option C: C. trachomatis D-K causes non-gonococcal urethritis. Option D: K. granulomatis causes granuloma inguinale.

This clinical scenario along with the microscopic findings of Gramnegative intracellular diplococci indicates infection with Neisseria gonorrhoeae. As it has not been confirmed by NAAT testing, this patient must also be treated for concurrent chlamydial infection.

Single-agent therapy with ceftriaxone is preferred for the treatment of gonococcal infections. According to CDC guidelines (2021), treatment of uncomplicated gonococcal infections is as follows:

• Weight lt;150 kg – Ceftriaxone 500 mg intramuscular (IM) in a single dose
• Weight ≥150 kg – Ceftriaxone 1 g IM in a single dose

The doses of ceftriaxone are higher than the previous guidelines as the gonococcal minimum inhibitory concentrations (MICs) are rising worldwide. The British BASHH guidelines also recommend a high dose of 1g.

Concurrent chlamydial infection must also be treated unless it has been excluded by molecular testing. First-line drug administered is:

• Oral doxycycline 100 mg BD for 7 days Partner treatment is also required.

The image shows bilateral painful masses of lymph nodes called buboes, that occurred in this patient following a painless genital ulcer. This is typically seen in lymphogranuloma venereum.

The incubation period of this condition is 3-30 days. It occurs in three stages.

Primary stage: Begins with painless papules or ulcers at the site of inoculation, which may go unnoticed. The classical ulcer is single, shallow, non-indurated, and may be painful or painless. The common site is the coronal sulcus in men and the posterior vaginal wall in women. It heals without scarring.

Secondary stage: Develops 2-6 weeks later and presents as tender femoral and/ or inguinal lymphadenopathy. The nodes may coalesce to form buboes or abscesses, which later rupture to form fistulae and sinus tracts.

Tertiary stage: Occurs several years later and is characterized by lymphatic obstruction and disfiguring conditions such as elephantiasis and esthiomene.

Option A: Chancroid presents with multiple painful ulcers with painful lymphadenopathy. The incubation period 3-10 days.

Option B: Syphilis presents with painless indurated ulcers with painless lymphadenopathy. The incubation period is 9-90 days.

Option D: Granuloma inguinale presents as a painless beefy red ulcer with no lymphadenopathy. The incubation period is 8-80 days (average 50 days).

The given image shows esthiomene, a feature of lymphogranuloma venereum.

In the tertiary stage of LGV, there is lymphatic obstruction due to chronic inflammation and fibrosis. This results in genital lymphoedema and inflammation which causes ulceration and chronic granulomatous fibrosis, resulting in esthiomene in women and elephantiasis in men.

The deformity shown in the above image depicts a penis that is twisted along its long axis, which is called saxophone penis. It is a late complication of lymphogranuloma venereum, penile tuberculosis, and primary lymphedema. It does not occur in donovanosis.

It occurs as a complication of long-standing inflammation, which causes fibrosis of lymphatics and connective tissue. The dorsal surface of the penis has a poor blood supply compared to the ventral surface and undergoes more fibrosis. This leads to a dorsal bend of the penis.

Gonococcal urethritis can lead to periurethral abscesses, which result in urethral strictures. In males, this may cause a saxophone penis deformity.

Acidic pH is not a feature of the Amsel criteria, which are used for the diagnosis of bacterial vaginosis.

3 out of 4 of the following criteria are needed for a positive diagnosis:

• Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls.
• Vaginal pH gt; 4.5.
• Positive whiff-amine test - Fishy odor when a drop of 10 KOH is added to vaginal discharge.
• Clue cells on saline wet mount: Vaginal epithelial cells studded with adherent coccobacilli at the edge of the cell.

Bacterial vaginosis is caused by a reduction in lactobacilli, and an increase in anaerobic organisms such as Gardnerella vaginalis, Mycoplasma hominis and Prevotella species.

Nugent scoring system is highly sensitive and is considered the gold standard for bacterial vaginosis. It is calculated using Gram-stained smear findings and observing the number of lactobacilli and morphology of anaerobes. High scores of 7–10 indicate bacterial vaginosis.

Xeroderma pigmentosa is an autosomal recessive genodermal disease that occurs due to defective DNA repair as a result of defective nucleotide excision and repair pathway.

It is characterized by severe photosensitivity, UV-induced skin and mucous membrane cancers, and neurodegeneration.

The characteristic finding of hyperpigmentation along Blaschko's lines is suggestive of incontinentia pigmenti, an X linked dominant disorder. Blaschko's lines are the lines of normal embryological development of skin.

It occurs due to loss-of-function mutation in IKBKG gene which encodes the nuclear factor kappa B essential modulator (NEMO), which is essential for protection against tumor necrosis factors.

It usually affects females, as it is believed to be lethal in males in utero leading to miscarriage of the affected male conceptuses.

It is characterized by erythematous vesicular rash following Blaschko's lines, malformed cone-shaped teeth, onychodystrophy, and alopecia.

The image given below shows cone-shaped teeth.