GENITAL ULCER DISEASES

Rebeka , Nishanth
Genital Ulcer Diseases
● Syphilis
● Chancroid
● Lymphogranuloma Venereum
● Granuloma Inguinale
● Herpes Genitalis
Syphilis
● Causative organism -Treponema Palladium
● Majority of infections are acquired by direct sexual
contact with an infected person in early stages .
● Secondary syphilis is most contagious due to greater
amount and variety of lesions.
● Incubation period: 9-90 days
Acquired Syphilis
Primary Syphilis
● Painless chancre(primary chancre,Hunterdon
chancre,Hard chancre) -single,clean based,indurated,
doesn't bleed on touch.
● Inguinal lymph nodes-indolent bubo ,bilateral
enlargement , nontender ,non supportive, firm, shotty.
● Heals with scarring in 3-6 weeks without treatment.
● Chancre redux is rare.
Secondary Syphilis
● Due to hematogenous dissemination.
● Appear after 3- 12 weeks of primary lesion.
● Constitutional symptoms-fever, arthralgia,myalgia.
● Rash-symmetric,polymorphous, non pruritic.
● All types of morphology is seen except vehicles and
bullae-The great imitator
● Examination of palms and soles is characteristic.
● Bushcke Olendorff Sign-deep dermal pain on
pressing lesion With blunt end of pin.
● Greyish white mucous patches ,snail track ulcers.
● Condylomata lata-flat topped moist plaques in
intertrigenous areas.
● Generalized lymphadenopathy -inguinal ,
posterior cervical , epitrochlear are characteristic.
● Moth eaten ,non scarring alopecia.
Tertiary syphilis
● Gummatous :nontender pink to dusky red
nodules,vary in size .
● Cardiovascular :Aortic aneurysm , regurgitation.
● Neuro syphilis:Taber dorsalis , general paresis of
insane.
Congenital Syphilis
● Treponema cross placenta and infect fetus.
● Kassowitz’s law :ability of mother to infect fetus
diminishes but never disappears in latent , late
stages.
● Early - < 2yrs
● Late - > 2yrs
Early congenital syphilis
● Snuffles - persistent rhinitis
● Cutaneous lesions
● Furuncle of Barlow
● Hepatosplenomegaly
● Pseudoparalysis of parrot
● Sawtooth metaphysis
● Salt and pepper fundus -syphilitic chorioretinitis
Late congenital syphilis
● Hotcross bun deformity of skull,saddle nose
● Mulberry molars /notched molars/moon’s molars.
● Hutchinson’s teeth + interstitial keratitis + 8th nerve
deaf ness- Hutchinsons’s triad.
● Rhagades, Clutton’s joints(Painless joint swellings).
● Sabre tibia,palate perforation ,
neurosyphilis,paroxysmal cold hemoglobinuria.
Diagnosis
● Dark field microscopy( most sensitive,specific)-cork
screw motility.
● Nonspecific tests -VDRL , RPR .Significant titre is
>/=1:8.
● Treponemal tests - Treponemal pallidum
hemeagglutination assay(TPHA) ,
Microhaemagglutination assay (MHA-TP) ,Fluoroscent
treponemal antibody absorption test (FTA-ABT).
● Silver staining.
● CSF examination , chest X ray for tertiary syphilis.
● Skin biopsy-Endarteritis obliterans ,perivascular
infiltration of lymphoid cells and plasma cells.
Treatment
● Injection Benzathine Penicillin 2.4 million
units ,deep IM.
● Single dose for early syphilis
● 3 doses for late syphilis once weekly.
● Neurosyphilis:inj Aqeous crystalline penicillin ,18-
24 million units per day,IV ,10-14 days.
● If allergic to penicillin -Doxycycline 100 mg BD
Chancroid
● Soft sore,soft chancre , ulcus molle.
● Haemophilus ducreyi(gram negative bacillus)
● 1-5 days is incubation period.
● Lesion erodes to form extremely painful ,deep ulcer-
soft,friable ,non indurated, ragged undermined
margins,foul smelling, yellow grey erudite, surrounding
erythema.
● Inflammatory bubo-Unilateral ,painful inguinal
lymphnodes.May rupture to form ulcer.
Diagnosis
● Gram stain:gram negative coccobacilli ,school of
fish appearance.
● Ito-Reenstierna test:Intradermal test with vaccine
containing killed H.ducreyi in
suspension ,producing inflammatory papule after
48 hours.
Treatment
● Azithromycin 1g orally single dose (or)
● Ceftriaxone 250 mg IM stat. (or)
● Ciprofloxacin 500 mg orally BD for 3 days (or)
● Erythromycin base 500 mg orally TDS for 7 days.
Herpes Genitalis
• Caused by HSV 1 (20%) and HSV 2 (80%).

• Incubation period is between 3 to 14 days.

• Primary lesion: small grouped vesicles.

(2-4 days)

Ulcerative lesions( Superficial and tiny)

• The floor is erythematous and covered with serous exudates.
 Diagnosis
• Tzanck smear – multi-nucleate giant cells

• Definitive diagnosis is done by viral culture of the lesion which

can differentiate between HSV 1 and HSV 2

• Direct immunofluorescence

• Specific monoclonal antibodies directed against HSV 1 and HSV 2

 Treatment
• Tab Acyclovir 400 mg thrice daily for 7 to 10 days.

• Syndromic management- kit no 5 (red)

• Recurrent episodes – tab acyclovir 400 mg thrice daily for 5

days.

• Famciclovir and Valacyclovir can also be used.

 Lymphogranuloma Venerum
• Causative organism – Chlamydia trachomatis immunotypes L1, L2, L3

• Incubation period 3 to 30 days

• First stage – small painless papule or pustule that erodes to form an

asymptomatic herpetiform ulcer this heals without scarring in 1 week

• Second stage begins within 2-6 weeks and consists of painful inflammation
and infection of inguinal and femoral lymph nodes
Diagnosis

• Nuclei acid amplification test

• ELISA

• Direct immunofluorescence

• Frei test
 Treatment
• Doxycycline 100 mg twice daily for 21 days

• Erythromycin 500 mg four times daily for 21 days

Donovanosis :

• Causative agent : Klebsiella granulomatis.

• Incubation period : 8 to 12 days.
• Site of inoculation: Single or multiple subcutaneous nodules
or papules( thigh, genitalia, groin, perineum).
• These enlarge and erode to form painless, soft, beefy, red,
exuberant ulcerations with clean friable based and distinct
raised rolled margins.
Diagnosis:

• Bipolar staining.
• Biopsy and histopathological examination.

Treatment :
• Doxycycline 100 mg BD for atleast 3 weeks.
• Alternate regimens: Azithromycin 1g OD or Ciprofloxacin 750
mg BD or Erythromycin base 500 mg QID or Cotrimoxazole(DS)