Infectious Disease [GENITAL ULCERS]

Intro
Genital ulcers can be easily separated from one another based on
the number of ulcers, the presence of pain, and the presence of
affected lymph nodes. Getting to the right answer should be easy;
knowing the details of each disease becomes harder (as does
keeping them straight). Give lots of attention to syphilis as the
others are often distractors against it.

1) Syphilis
Primary Syphilis presents as a painless ulcer called a chancre. It
represents the entry point of the Treponema Pallidum organism,
a spirochete. There may be associated painless
lymphadenopathy. It’s too early to use serology so we have to
look for the organisms themselves with a Darkfield Microscopy.
At this point IM PenG will be curative. If the patient is penicillin
allergic, doxycycline can be used instead.

Secondary syphilis is a disseminated targetoid or

maculopapular rash that involves the palms and soles. The rash
is infectious. By this time serology is positive. Screen for syphilis
with a non-treponemal test such as RPR (or VDRL) and confirm
with a treponemal test such as FTA-Antibodies. If FTA-Abs ,
treat with IM PenG.

Tertiary syphilis penetrates the CSF. Look for the Argyll-

Robertson pupil, Tabes Dorsalis, and any neuro symptom. Do
serology, only this time the “serology” should be on the CSF fluid
following a lumbar puncture. In tertiary syphilis the patient Tests for Syphilis
needs IV Penicillin x 7-14 days. If allergic AND pregnant they RPR Good sensitivity requires > 1 month to be positive
have to be desensitized and given the penicillin anyway; doxy is VDRL Decent sensitivity, False with Lupus
contraindicated. FTA-abs Good specificity, confirmatory for RPR
Darkfield Excellent specificity, only means of diagnosis for primary
If the patient has a positive RPR but no symptoms, it’s said to
Microscopy chancre, can be used on 2o lesions
be latent syphilis. If it’s within one year of contraction, it’s early
Treatment for Syphilis
latent syphilis and is treated as secondary. If the time is unknown
Pen G IM Mainstay of therapy, x1 time primary and secondary
or it’s > 1 year from contraction, it’s considered late latent
Doxy If Pen Allergic x7 days for primary and secondary
syphilis and is treated with PenG IM qWeek x 3 weeks.
PenV IV Best treatment for 3o disease x 14 days, or for penicillin
allergic pregnant patients (desensitize)
2) Haemophilus ducreyi
Types of Syphilis
You “do cry with ducreyi” presenting as a syphilitic chancroid
Primary Painless chancre with Inguinal Lymphadenopathy
that hurts. It will have the ulcer, erythematous base, and inguinal
Secondary Maculopapular Rash on hands and soles (infectious)
lymphadenopathy of syphilis, but this will hurt - syphilis doesn’t.
Tertiary Any neurologic complaint (Argyll-Robertson Pupil)
Do a simple gram stain and culture, then treat with antibiotics.
Azithromycin or Cipro will do the job. Early Positive RPR and
Latent < 1 year from contraction
3) Herpes Late Latent Asymptomatic Positive RPRP and
Herpes Hurts like ducreyi, but are often multiple roofed > 1 year from contraction, or unknown
vesicles, each on an erythematous base, whose eruption is
preceded by a painful prodrome. If this classic picture is seen
just treat with acyclovir as the diagnosis is clinical. At times, Dz Presentation Test Treatment
however, vesicles can unroof and become confluent. This makes Syphilis Painless but firm 1o=Dark Field PenG IM or Doxy
clinical diagnosis difficult. Diagnose definitively with an HSV ulcer (singular) 2o RPR à Abs PenG IM or Doxy
PCR. The Tzanck prep is no longer recommended given the + Lymphadenopathy 3o LP of 2o Pen IV x 14 days
absence of specificity and sensitivity. Ducreyi Painful (singular) Gram Stain + Azithromycin or
+ Lymphadenopathy culture Ciprofloxacin
4) Lymphogranuloma Venereum Herpes Roofed vesicle on HSV PCR Acyclovir
It is caused by C. trachomatis. It presents as a painless singular an erythematous Valacyclovir
ulcer (much like Syphilis), but has painful lymphadenopathy base after a painful
that’s often supportive (pus). While a nucleic acid amplification prodrome
assay will confirm the diagnosis, treatment is often supportive or LGV Painless singular Ø needed Doxy
with simple antibiotics such as doxycycline. ulcer, Pussy LN

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