Man With Painful Genital Lesions

THE CASE: A 30-year-old man has had painful genital lesions for the past several days. He recently returned from a business trip during which he had several unprotected sexual encounters.

What is the most likely cause of the patient’s lesions?

•Syphilis
•Chancroid
•Herpes simplex virus (HSV) infection
•Lymphogranuloma venereum

Discussion: The patient has chancroid, a sexually transmitted disease caused by the gram-negative bacillus Haemophilus ducreyi. Typically seen in poor urban areas and developing countries, chancroid is endemic in Latin America, Africa, Southeast Asia, and the Caribbean, and is thought to be endemic in southern Florida and New York City.

The male-to-female ratio of chancroid is about 13:1. The disease predominantly affects uncircumcised heterosexual men. Asymptomatic female prostitutes are the primary source of infection.

Following an incubation period of 3 to 5 days, painful erythematous papules develop at the site of contact. The papules subsequently become pustular and then rupture, forming ulcerations. Autoinoculation produces multiple sites of infection. The ulcers usually have a soft edge with deep, ragged borders and are extremely painful. In men, the ulcers erupt on the prepuce, coronal sulcus, or glans; in women, they are found most commonly on the labia, although they sometimes appear on the cervix or vaginal wall and thighs.

Unilateral lymphadenopathy develops in 30% to 60% of patients 7 to 14 days after ulcer formation. The fluctuant abscess (bubo) is highly specific for chancroid.

Male patients often present with inguinal discomfort or painful genital lesions. Women may report nonspecific symptoms of dysuria, vaginal discharge, dyspareunia, or rectal bleeding.

Clinical diagnosis based on the ulcer’s appearance is accurate in only 30% to 50% of cases. As many as 10% of patients have coexisting HSV infection or syphilis. Gram staining has a low sensitivity and specificity but may show gram-negative coccobacilli in a “school of fish” pattern, singly or in clusters. Cultural isolation can definitively establish the diagnosis, but this method is difficult and the sensitivity is only 60% to 80%. Aspiration and culture of the buboes is not routinely recommended; the results are usually sterile. Tests to rule out other conditions—especially syphilis, HIV infection, herpesvirus infection, chlamydial disease, and gonorrhea—are recommended if there is concern about coinfection or if the diagnosis is unclear.

Local therapy includes soaks and topical cleansing. Incision and drainage of fluctuant buboes is controversial. Most strains of H ducreyi are resistant to penicillin and tetracycline. The current CDC-recommended therapy includes azithromycin, ceftriaxone, and ciprofloxacin. Contacts must be treated, and patients must be advised to refrain from sexual contact until the ulcerations are completely healed. Most immunocompetent patients respond well; patients with HIV infection may be slow to heal. Secondary complications include scarring, phimosis, balanoposthitis, fistula formation, and rupture of the buboes. Approximately 5% of patients may experience relapse; another round of antibiotic therapy is usually successful.

Syphilis is caused by the spirochete Treponema pallidum. Primary syphilis develops at the site of transmission following an incubation period of 10 to 90 days. The chancre is usually a single painless papule that, in most cases, rapidly becomes an ulcer with a firm edge and base. Chancres usually occur on the penis in heterosexual men and may also be found in the oral or external genital region in homosexual men. The lesions tend to occur on the cervix and labia in women. Regional lymphadenopathy may be unilateral or bilateral. The nodes are firm, discrete, mobile, and painless; there are no overlying skin changes.

The diagnosis is confirmed by dark-field microscopy, serology, or immunofluorescent staining. Treatment consists of benzathine penicillin G, 2.4 million U IM. Patients allergic to penicillin may be given a 2-week course of doxycycline or erythromycin.

Infection with HSV-1, which usually causes oral lesions, may be contracted by direct exposure to infected saliva or spread via respiratory droplets. Infection with HSV-2, which primarily causes genital lesions, is transmitted by genital contact. Prodromal symptoms include general malaise and anorexia. Patients may complain of tenesmus, dysuria, dysesthesia, and pruritus.

Genital herpetic lesions are usually painful vesicular or ulcerative lesions that may be indistinguishable from those of syphilis or chancroid. Inguinal lymphadenopathy may be present. The diagnosis is frequently suggested by the patient’s history, but it should be confirmed or ruled out by serology, viral culture, or monoclonal antibody testing. Tzanck smears that demonstrate intranuclear inclusions and multinuclear giant cells support the diagnosis. Acyclovir is effective for initial, recurrent, and suppressive treatment. Recurrences may also be treated with famciclovir or valacyclovir. Analgesics are added if needed.

Lymphogranuloma venereum, a sexually transmitted disease caused by Chlamydia trachomatis, principally affects the lymph nodes. Abrasions or breaks in the skin allow subsequent access of the organism to the lymphatics. Primary lesions form at the site of inoculation as shallow erosions or ulcers or painless herpetiform ulcerations. In men, these lesions affect the frenulum, prepuce, scrotum, or coronal sulcus; in women, the cervix, vulva, and posterior vaginal wall are commonly involved. The lesions are mainly asymptomatic and are noticed in only a third of infected men.

After an incubation period of 10 to 30 days, the secondary stage of this disease manifests as enlarged, tender regional lymph nodes (buboes). The location of these lesions depends on the initial site of inoculation and may include the inguinal, perirectal, pelvic, and cervical regions. Myalgia, fever, and malaise may be present. Proctocolitis develops in the third stage of the disease. Manifestations include tenesmus, rectal pruritus, and bloody, purulent rectal discharge.

The diagnosis is usually based on clinical findings. Microimmunofluorescence is the most sensitive and specific test. Aspiration and culture of a bubo helps establish the diagnosis in 30% of cases. The disease is treated with doxycycline, erythromycin, or trimethoprimsulfamethoxazole; analgesics; and drainage of the buboes. Most patients recover fully with treatment; relapses may occur. Complications include fistulae or sinuses, cervicitis or salpingitis in women, complete bowel obstruction, conjunctivitis, arthritis, and hepatomegaly.