A 46-year-old man comes to the urgent care clinic due to genital lesions. Three days ago, the patient noticed a papule on the shaft of his penis, which has since evolved into an ulcer. Two similar lesions have developed on the glans penis in the last 24 hours. The patient has had multiple female sexual partners in the last 3 months and uses condoms inconsistently. He has no other symptoms. Examination reveals a 2-cm, nonpainful, ulcerated lesion on the shaft of the penis with indurated borders and no purulent drainage. There are 2 smaller, similar lesions on the glans penis. Mild, bilateral, nontender inguinal lymphadenopathy is present. Which of the following is the most likely diagnosis?
Infectious genital ulcers | ||
Painful | Herpes simplex virus |
|
Haemophilus ducreyi (chancroid) |
| |
Painless | Treponema pallidum (syphilis) |
|
Chlamydia trachomatis serovars L1-L3 (lymphogranuloma venereum) |
| |
Genital ulcers are typically caused by sexually transmitted infection. Although diagnostic confirmation requires testing, the causative etiology is often inferred based on patient history, the presence or absence of pain, and visual inspection of the lesions, as follows:
History: Genital ulcers due to infectious organisms are most common in those who have unprotected sex with multiple partners. Genital ulcers in the United States are usually caused by herpes simplex virus (HSV) or syphilis, whereas patients who have recently returned from travel overseas are at increased risk for tropical and subtropical infections such as chancroid or lymphogranuloma venereum (LGV).
Pain: Painless ulcers usually indicate syphilis or LGV whereas pain is typically seen with HSV or chancroid.
Appearance: The number and size of lesions, the presence/absence of painful lymphadenopathy, and the presence/absence of purulence informs the likely diagnosis.
This patient's painless ulcer with indurated borders, a nonpurulent base, and bilateral, painless lymphadenopathy is consistent with syphilis (chancre). Although patients with primary syphilis typically have a single chancre at the site of inoculation, multiple chancres occasionally occur, particularly in those with underlying HIV.
(Choice A) Behçet disease is marked by recurrent mucocutaneous ulcers; oral ulcers are most common, but genital ulcers can occur. However, the ulcers are painful, round, and have a white-yellow necrotic base with surrounding erythema. In addition, men usually develop Behçet ulcers on the scrotum.
(Choice B) Chancroid is caused by Haemophilus ducreyi and is marked by one or more painful ulcers with purulence and an erythematous base. Painful inguinal lymphadenitis may occur, leading to buboes. Most cases arise in the developing world; it is very uncommon in the United States.
(Choice C) HSV can cause multiple small, painful ulcers with an erythematous base. Most patients with initial infection have systemic, nonspecific symptoms and tender lymphadenopathy.
(Choice D) LGV is an infection with serovars L1-L3 of Chlamydia trachomatis. Although it causes multiple painless ulcers, they tend to be very small (<6 mm) and disappear within a few days. In addition, LGV is very uncommon in the United States.
Educational objective:
In the United States, genital ulcers are most often due to herpes simplex virus or syphilis. In developing regions, ulcers can also be caused by chancroid or lymphogranuloma venereum. Painless ulcers with indurated borders and a clean base are most often due to primary syphilis (chancre); although most cases are marked by a single chancre, multiple chancres can occur, particularly in those with HIV.