Vulvar ulcers in young females: a manifestation of aphthosis

COVID 19 vaccination as a trigger of acute genital ulcers in an immunocompromised adolescent-case study and literature review

Acute genital ulcers can affect females of all ages. In children, they often appear as an emergency and remain a diagnostic challenge for pediatricians, gynecologists and dermatologists. Prompt diagnosis and identification of disease- related factors help to implement appropriate treatment. Firstly, it is crucial to properly compile the past medical history of the patient. Past infectious, autoimmune, malignant or traumatic conditions, as well as vaccinations may contribute to the occurrence of acute genital ulcers. Moreover, new infectious agents, such as severe acute respiratory syndrome coronavirus 2 and vaccinations against Coronavirus disease of 2019, may play a significant role in the development of atypical clinical symptoms. Here we present a case of a 12-year-old girl with acute genital ulcers. Additional symptoms accompanying the ulcer included: abdominal pain, nausea, vomiting, dysuria, vulvar pain and fever. Blood test showed leukocytosis, especially neutrophilia and monocytosis and increased levels of c-reactive protein and procalcitonin. Serological tests for the most common infections were negative. Moreover, the patient had a history of autoimmune diseases. She had periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, and IgA vasculitis, also known as Henoch-Schönlein purpura in her past medical history. Additionally, she was vaccinated against SARS-CoV-2 shortly before the lesions appeared.

Ulcus Vulvae Acutum Lipschütz-UVAL: case series at a Swiss university hospital emergency room

Background

Ulcus Vulvae Acutum Lipschütz (UVAL) is a largely unknown disease with a broad and complex differential diagnosis.

Objectives

To provide a description of the main characteristics of UVAL, determine the most appropriate diagnostic process and describe the current therapeutic approach.

Methods

We designed a retrospective, descriptive cohort study using the gynecological-ER database of our institution. Inclusion criteria: female patients aged between 10 and 20 years old with suspicion of a UVAL diagnosis at CHUV's gynecological ER. Data extraction: epidemiological characteristics, clinical presentation, laboratory tests, established diagnostics, treatment, and ulcer outcomes.

Results

15 patients were included for the analysis; average age: 15 years old; 60% of patients were virgo at the time of ulcer onset; all patients had at least one flu-like symptom concomitant with the vulvar lesion; the most-performed serology was for EBV and acute disease was present in only one patient; for diagnostic purposes two biopsies were performed with both inconclusive histopathology analysis; the main prescribed treatments were: oral NSAIDs, Paracetamol, and Lidocaine gel; 93% of cases presented signs of regression; the average follow-up time was 10 days. The diagnostic algorithm of Sadoghi et al: 10 out of 15 cases were retrospectively diagnosed with UVAL by the algorithm; half were diagnosed with UVAL, and the other half received a diagnosis of "ulcers of unknown origin" at the time of the gynecological ER visit.

Conclusions

We highly recommend the diagnostic and therapeutic algorithms developed by Sadoghi et al. as valuable tools to guide clinical reasoning and, consequently, improve acute vulvar ulcers management.

Acute Genital Ulcers in a Woman Secondary to COVID-19 Infection: A Case Report

Acute genital ulcers (AGU) have been associated with various pathogens, such as Epstein-Barr virus (EBV) and cytomegalovirus (CMV). However, cases of AGU associated with coronavirus disease 2019 (COVID-19) are rare, and this disease significantly impairs human quality of life. In this case, we report a 37-year-old woman who presented with a five-day history of a painful genital ulcer and fever. A month earlier, she had experienced a COVID-19 infection that resolved without medical therapy. Physical examination revealed that multiple asymmetric ulcers presented on labia minora covered with whitish exudates. The patient, without any high-risk sexual behavior, or a personal or family history of autoimmune disorders or inflammatory bowel disease, was diagnosed with COVID-19-related AGU after ruling out other infectious and immune diseases. Following a two-week treatment of oral prednisone, her vulvar edema, ulcers, and fever improved significantly. This case suggests that AGU may be triggered by a COVID-19 infection.

Vulvar Ulcers: An Algorithm to Assist With Diagnosis and Treatment

OBJECTIVES

Vulvar ulcers can be challenging to diagnose, manage, and treat. Ulcers can be nonspecific in appearance and have many etiologies. Description of the lesion is very important.

METHODS

An interactive vulvar ulcer algorithm was created to aid in the evaluation, diagnosis, and treatment of vulvar ulcers.

RESULTS

The algorithm flowchart begins with careful history and physical examination. Pending these, specific tests can be obtained to aid in diagnosis. The algorithm also links to appropriate treatments. The algorithm can be accessed on the International Society for the Study of Vulvovaginal Disease Web site ( issvd.org ). Each underlined word in the algorithm is a hyperlink that leads to a wealth of information on the topic that providers can use to direct testing and aid in diagnosis and treatment.

CONCLUSIONS

The vulvar ulcer algorithm can help clinicians with diagnosis and treatment plans.

Nonsexual Acute Genital Ulcerations as a Rare Presentation of Disseminated Lyme Disease in a Pediatric Patient

Nonsexual acute genital ulcerations (NAGU), also known as Lipschütz ulcers, are vulvar ulcers occurring predominantly in adolescent females. While the pathogenesis is unknown, NAGU are commonly associated with systemic infections. Here we present a female child with NAGU along with disseminated Lyme disease. We believe this is the first reported pediatric case of this phenomenon.

Management of acute genital ulcers; a survey of North American Pediatric and Adolescent Gynecology care providers

INTRODUCTION

Acute genital ulcers (AGU) are painful ulcerations of the lower vagina and vulva, with limited data to guide management. We aim to survey care providers to understand the work up and management of AGU across North America.

METHODS

A cross-sectional survey was distributed to members of NASPAG. Data is presented descriptively, and management practices between care providers are compared using Fisher's Exact test.

RESULTS

Responses from 100 NASPAG members were included. Common diagnostic tests performed were HSV PCR (82%), EBV virus serology (56%) and CMV serology (47%). Topical steroids were considered by 67% based on the degree of accompanying inflammation. There was no difference in corticosteroid prescriptions between types or location of providers (p > 0.05).

DISCUSSION

Collaboration between pediatric and adolescent gynecology care providers is needed to prospectively evaluate the effectiveness of treatment modalities, and develop evidence-based guidelines.

Vulvar Aphthous Ulcers in Perimenarchal Adolescents after COVID-19 Vaccination: A Multicenter Case Series

This case series from 3 academic hospital-based pediatric and adolescent gynecology services outlines the temporal association between vulvar ulcers in female adolescents and COVID-19 vaccination. We identified 8 cases and describe each patient's presentation, differential diagnosis, diagnostic workup, complications, treatment modalities, and overall course of illness. All cases seek to illustrate the clinical experiences of patients and providers interfacing with vulvar aphthous ulcers and contribute to the emerging literature exploring the novel association between vulvar aphthous ulcers and COVID-19 vaccination. To date, this is the largest described case series of this association in the literature. Key Words: COVID-19, Vaccine, Aphthous ulcers, Vulva, Adolescent.

Pediatric and Adolescent Gynecologic Emergencies

Diagnosis of gynecologic emergencies in the pediatric and adolescent population requires a high index of suspicion to avoid delayed or incorrect diagnoses. This article aims to dispel common misunderstandings and aid with diagnosis and management of 3 common pediatric and adolescent gynecologic emergencies: adnexal torsion, vulvovaginal lacerations, and nonsexually acquired genital ulcers.

Vulvar Aphthous Ulcers in an Adolescent After Coronavirus Disease 2019 (COVID-19) Vaccination

BACKGROUND

Nonsexually acquired genital ulcers have been described among girls who are prepubertal after various viral illnesses due to mucosal inflammation from an immunologic response. Until recently, nonsexually acquired genital ulcers have only been associated with viral infections.

CASE

We present a case of an adolescent girl developing nonsexually acquired genital ulcers after both her first and second coronavirus disease 2019 (COVID-19) vaccine doses. Her course followed an expected timeline for severity and resolution of ulcers.

CONCLUSIONS

Aphthous ulcers may arise from inflammatory effects of COVID-19 vaccination. Clinical monitoring after COVID-19 vaccination from all formulations should include assessment for nonsexually acquired genital ulcers if vaginal pain is reported.

Vulvar Aphthous Ulcer in an Adolescent After Pfizer-BioNTech (BNT162b2) COVID-19 Vaccination

BACKGROUND

Vulvar aphthous ulcers are a rare type of genital lesion most common in non-sexually active adolescents. Vulvar aphthous ulcers are typically associated with viral infections. To date, there have been several cases reported in patients infected with COVID-19. Vulvar aphthous ulcers following vaccination have not been previously reported in the literature.

CASE

We present the case of a 16-year-old adolescent who developed vulvar aphthous ulceration following Pfizer-BioNTech (BNT162b2) vaccination.

SUMMARY AND CONCLUSION

Through an extensive literature search, we found no previous reports of vulvar aphthous ulcer following vaccination. Our case highlights a potential novel side effect of Pfizer-BioNTech COVID-19 vaccination and a new etiology for vulvar aphthous ulcers. This case suggests that vulvar aphthous ulcers might be associated with COVID-19 vaccination through a yet undetermined mechanism that requires further investigation.

Vulvar Aphthous Ulcer in an Adolescent With COVID-19

BACKGROUND

Vulvar aphthous ulcers have been associated with various prodromal viral illnesses. We describe the case of an adolescent girl who developed vulvar aphthous ulcers during infection with Coronavirus, SARS-CoV-2.

CASE

A 19-year-old girl presented to the emergency department with cough, sore throat, fevers, and rash, and tested positive for COVID-19. She re-presented 2 days later with vulvar pain and was found to have a vulvar aphthous ulcer. She was admitted for pain control and treated with oral steroids. Improvement in her vulvar pain was noted, along with resolution of fevers, cough, and rash.

SUMMARY AND CONCLUSION

This case illustrates the novel association of COVID-19 with vulvar aphthous ulcers in adolescents. Use of oral steroids for symptomatic management of COVID-19 led to rapid clinical improvement.

Reactive non-sexually related acute genital ulcers associated with COVID-19

Acute genital ulcers (AGU), known as Lipschütz ulcers, are painful vulvar ulcers typically affecting non-sexually active girls and women. AGU have been associated with viral infections, namely, Epstein-Barr virus (EBV). Here, we describe a case of AGU in the setting of SARS-CoV-2 in a non-sexually active adolescent girl hospitalised for pain control and urinary retention, who failed a course of oral corticosteroids and then improved with colchicine. Testing for herpes simplex virus, EBV and Behcet's syndrome were all negative. Testing for SARS-CoV-2 was positive. COVID-19 increases cytokines such as tumour necrosis factor alpha, which has been shown to affect endothelial cell adhesion and neutrophil chemotaxis, leading to aphthosis.

Herpetiform aphthous genital ulcers misdiagnosed as herpes genitalis in a young male and their effective response to colchicine therapy

Genital ulceration can be a source of tremendous stress to the patient, as well as to the family members, and poses a difficult and sensitive diagnostic conundrum for the clinician. Cultural taboos and social stigmas related with the disease often result in the clinician not believing the patient’s version of history and basing the diagnosis entirely upon the clinical picture, aided by diagnostic tests. The clinicians should keep in mind that sexually transmitted infections (STIs), which can cause genital ulceration are very common, but there is a long list of non-sexually acquired causes of genital ulceration, which can lead to a diagnostic dilemma, and these should be considered before labelling the patient as suffering from a STI. We present a rare case of herpetiform genital aphthous ulcers mimicking herpes genitalis and chancroid, which was misdiagnosed repeatedly, and their effective response to treatment with colchicine on subsequent identification of the correct diagnosis.

Nonsexually Transmitted Genital Ulcer Secondary to Hand, Foot, and Mouth Disease

BACKGROUND

Genital ulcers that are not the result of sexually transmitted infections (STIs) are uncommon, and case reports predominantly feature pubertal girls.

CASE

A 38-year-old monogamous, nulliparous woman acutely developed painful vaginal ulcers 7 days after babysitting a child who was subsequently diagnosed with hand, foot, and mouth disease. The patient developed nonspecific systemic symptoms followed by painful and rapidly expanding genital ulcers. Laboratory test results for herpes, syphilis, human immunodeficiency virus, gonorrhea, chlamydia, and Epstein-Barr virus were all negative. The patient was treated with brief inpatient observation, oral prednisone, meticulous wound care, and debridement. The ulcers resolved over a 3-week period.

CONCLUSION

Although typically associated with pubertal girls, genital ulcers that are not the result of STIs can affect adults as well. The cornerstone of management regardless of age is supportive care, debridement and wound care, and treatment with steroids.

Lipschütz ulcer and group A streptococcal tonsillitis

Lipschütz ulcers (LU) are non-sexually related genital ulcers, rarely reported. We describe a healthy 11-year-old girl, who presented with fever and a painful vulvar ulcer associated with erythematous tonsillitis. Throat swab test for Group A Streptococcus (GAS) was positive. She was treated with amoxicillin. Further investigation was negative, including Herpes Simplex virus DNA from ulcer swab and serology for Epstein-Barr virus, cytomegalovirus and Mycoplasma pneumoniae Antistreptolysin O titre was high. The ulcer healed in 2 weeks, with no recurrence in a 1 year follow-up period. The association of LU with GAS tonsillitis is very rare.

Should Female Partners of Men With Non-Gonococcal Urethritis, Negative for Chlamydia trachomatis and Mycoplasma genitalium, Be Informed and Treated? Clinical Outcomes From a Partner Study of Heterosexual Men With NGU

BACKGROUND

To determine if female partners of men with pathogen-negative non-gonococcal urethritis (NGU) are at risk of genital infection.

METHODS

Secondary data analysis using health records from a large sexually transmitted disease clinic in Melbourne of 1710 men and their female partners attending on the same day from January 2006 to April 2015. Proportions of female partners with symptoms suggesting genital infection or pelvic inflammatory disease (PID) were determined for: (1) men with NGU and no Chlamydia trachomatis or Mycoplasma genitalium (referred to as pathogen-negative NGU) (n = 91); 2) men with urethral C. trachomatis (n = 176); 3) men with urethral M. genitalium (n = 26); and 4) asymptomatic men (n = 652).

RESULTS

Female partners of men with pathogen-negative NGU experienced deep pelvic pain (adjusted odds ratio [AOR], 2.2; 95% confidence interval [CI], 1.1-4.4), post coital bleeding (AOR, 2.4; 95% CI, 1.2-4.9), and dysuria (AOR, 3.7; 95% CI, 1.6-8.6) more commonly and were diagnosed with PID more commonly (AOR, 4.8; 95% CI, 2.1-11.3) than the female partners of asymptomatic men. Pelvic inflammatory disease was not more likely to be diagnosed in the female partners of men with genital warts (AOR, 1.4; 95% CI, 0.5-4.4) or candidiasis (AOR, 1.2; 95% CI, 0.4-3.5) than the female partners of asymptomatic men. The female partners of men with chlamydia experienced post coital bleeding more (AOR, 1.9; 95% CI, 1.0-3.6) and were more likely to be diagnosed with PID (AOR, 3.6; 95% CI, 1.6-8.0).

CONCLUSIONS

The female partners of men with pathogen-negative NGU may be at increased risk of genital infection, even if a recognised pathogen is not identified in the man.

Lymphocytic Arteritis in Epstein-Barr Virus Vulvar Ulceration (Lipschütz Disease): A Report of 7 Cases

Epstein-Barr virus (EBV) infection can rarely present as painful genital ulcers, mostly in young female adolescents. Typically diagnosed by clinical findings, EBV vulvar ulceration (EBVVU) is rarely biopsied. Herein, the authors report the histopathology in 8 biopsies from 7 EBVVU patients, all serologically confirmed for acute (4/7) or reactivated-chronic (3/7) EBV infection. The 7 women all presented with 1 or more painful, punched-out vulvar ulcers. Only patients with acute EBV infection showed other clinical findings: fever and/or atypical lymphocytosis affected 75% (3/4); lymphadenopathy in 50%; and malaise/fatigue, dysuria and/or hepatomegaly in 25%. All reactivated-chronic EBVVU had a solitary ulcer, and 2 had history of a similar episode of vulvar ulceration (aphthosis). Histopathologically, lymphocytic arteritis was identified in 88% (7/8); a submucosal scar was found in the eighth specimen. Other histopathologies included venulitis (62%), endarteritis obliterans (38%), thrombosis (25%), neutrophilic sebaceous adenitis (25%), and mucosal lymphoid hyperplasia (12%). Dense angiocentric CD3 CD4 T-cell lymphocyte-predominant infiltrates were found, regionally or diffusely. In 2 specimens, neutrophils compromised half of the infiltrate. Minor components of CD8, CD20, and CD30 lymphocytes, CD123 plasmacytoid monocytes, CD68 macrophages, and plasma cells were present. Small-vessel endothelium and smooth muscle adjacent to the ulcers faintly expressed cytoplasmic EBV latent membrane protein-1 (LMP1). In situ hybridization for early EBV mRNA (EBER) identified rare solitary or scattered clustered positive lymphocytes in 38%. Polymerase chain reaction for EBV DNA was positive in one EBER positive biopsy. EBV infection has been documented in muscular vessel vasculitis. Based on the aforementioned, EBVVU appears to be the consequence of localized lymphocytic arteritis.

Ulcus vulvae acutum - A case of genital ulcers in adolescent girl

Ulcus vulvae acutum is a rare clinical condition characterized by the presence of multiple acute painful genital ulcers of non-venereal origin associated with systemic symptoms in young women. The aetiopathogenesis of the disease is not fully understood, although recent reports have associated it with the Epstein–Barr virus. Diagnosis is difficult and generally made by exclusion after venereal diseases, and autoimmune, inflammatory, traumatic, and neoplastic causes. We describe a case of adolescent female with an episode of ulcus vulvae acutum associated with infectious mononucleosis. The diagnosis was supported by the clinical symptoms, elevated circulating levels of liver enzymes, positive EBV serology, cervical and inguinal lymphadenomegaly, and hepatosplenomegaly. The patient presented a history of aphthous stomatitis. Negative Pathergy test and the absence of any other related symptoms allowed us to exclude the Behçhet syndrome. Lesions healed with no sequelae or recurrences.

Lipschütz ulcers: should we rethink this? An analysis of 33 cases

OBJECTIVES

To describe the presentation and characteristics of patients with Lipschütz ulcers (LU) and to evaluate the role of a standard protocol in the aetiological diagnosis.

STUDY DESIGN

Retrospective analysis of all cases of diagnosis of LU at our Vulvar Clinic during a five-year period.

RESULTS

Of 110 women with vulvar ulcers, 33 (30.0%) had a diagnosis of LU. The mean age was 29.1±15.14 years (10-79 years). Nine (27.3%) were 35 years old or more. The majority had had their sexual debut (28, 84.8%). Ten patients (30.3%) referred had at least one previous similar episode. Twenty-five (75.7%) had non-gynecological symptoms in the week before. The ulcers were located most frequently on the vestibule (19, 57.6%) and the labia minora (10, 30.3%). Isolated lesions on the left side were uncommon (3, 9.1%). Most had multiple (22, 66.7%) lesions. The mean time to full healing of the lesions was 15.6±6.20 days. A microbiological possible cause was identified in 9 (27.3%) patients: CMV (3 cases), Mycoplasma pneumoniae (3 cases), EBV (2 cases) and PVB19 (1 case). The protocol did not include systematic biopsies, blood count differentials, C-reactive protein and liver enzymes, which may have lead to some missed diagnosis.

CONCLUSIONS

LU can be found in women of any age, most of them sexually active. In most cases the lesions are preceded by non-gynecological symptoms and recurrence is common. Most lesions occur on the vestibule and labia minora, being rarely found isolated on the left side. Viruses seem to be the most frequent associated agents but Mycoplasma pneumoniae serology should be considered. In one case there was a possible role for PVB19. A standard protocol can effectively exclude sexually transmitted diseases and lead to a diagnosis in up to a third of cases.

A Review of Lesions of the Posterior Fourchette, Posterior Vestibule (Fossa Navicularis), and Hymen

Lesions specific to the posterior fourchette, posterior vestibule (fossa navicularis), and hymen are reviewed. Knowledge of these regional lesions will be helpful if such a patient is encountered.

Epstein-Barr virus: dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders

Epstein-Barr virus (EBV) is a ubiquitous virus that has been implicated in a wide range of human diseases, many of which have mucocutaneous manifestations. As a member of the herpesviridae family, EBV causes lifelong infection by establishing latency in B lymphocytes. An intact immune response is critical in preventing progression of EBV disease, and the clinical manifestations of infection are dependent on the intricate relationship between virus and host immune system. This review provides a comprehensive overview of the epidemiology, pathophysiology, and diagnostic testing in EBV infection. In part I of this continuing medical education article, the mucocutaneous manifestations of EBV infection are reviewed with an emphasis on pathophysiology and management.

Genital ulcers: it is not always simplex …

Patients with vulval aphthae, also termed Lipschütz ulcers, often present to genitourinary medicine clinics. Typically, these ulcers present as acute, painful, vulval ulcers in young women and adolescents. The aetiology is unknown, and often these ulcers are accompanied by flu-like symptoms. Previous case reports have linked such lesions to acute viral infections such as Epstein-Barr virus, cytomegalovirus and influenza A. We report the first case of influenza B virus and adenovirus infections associated with this presentation.

Acute genital ulcers

Acute genital ulcers, also known as acute vulvar ulcers, ulcus vulvae acutum or Lipschütz ulcers, refer to an ulceration of the vulva or lower vagina of non-venereal origin that usually presents in young women, predominantly virgins. Although its incidence is unknown, it seems a rare entity, with few cases reported in the literature. Their aetiology and pathogenesis are still unknown. The disease is characterised by an acute onset of flu-like symptoms with single or multiple painful ulcers on the vulva. Diagnosis is mainly clinical, after exclusion of other causes of vulvar ulcers. The treatment is mainly symptomatic, with spontaneous resolution in 2 weeks and without recurrences in most cases. We present a case report of a 13-year-old girl with two episodes of acute ulcers that fit the clinical criteria for Lipschütz ulcers.

Mycoplasma pneumoniae: a rare cause of vulvar ulcers or an undiagnosed one?

OBJECTIVES

Acute vulvar ulcers are quite common, and often, an etiological diagnosis cannot be achieved. This article reports 3 cases of vulvar ulcers in adult women infected with Mycoplasma pneumoniae. The authors were able to find only one similar report in the literature.

MATERIAL AND METHODS

Two women in their third decade of life and 1 in the fourth presented to the hospital with acute and intense vulvar pain. Two of them reported oropharyngeal symptoms in the preceding days. All 3 presented with extensive, painful, and destructive vulvar ulcers. A standard protocol was applied, including samples taken from the ulcer (microbiology and polymerase chain reaction) and blood drawn for serological examination and liver function testing. All 3 had the remarkable finding of a positive immunoglobulin G (IgG) and IgM for M. pneumonia (in one of the cases, IgM was initially inconclusive but turned to positive when repeated 2 weeks later). One patient had an extensive destruction of one labium minus, requiring surgical reconstruction.

RESULTS

Two of them were treated with antibiotics, and one was not. However, in fact, all 3 healed in a similar period, making it probable that this kind of medication is not helpful.

CONCLUSIONS

M. pneumoniae might be associated with some cases of vulvar ulcers and should always be tested in this context. Probably, antibiotic treatment is not helpful, even when this agent is identified as the possible causal agent of vulvar ulcers.

Fournier's Gangrene Associated with Local Cutaneous HPV Lesions in a Previously Healthy Girl

A case of an 11-year-old prepubertal girl with Fournier's gangrene is presented. The diagnosis was posed after the disease had progressed to the typical clinical picture of frank gangrene. A benign viral infection, common warts, possibly represents the initiating event of the development of this necrotizing soft tissue infection. The development of childhood Fournier's gangrene in association with viral infections has been reported in the past. An optimal outcome was achieved by aggressive antibiotic and surgical treatment despite the late diagnosis. In children, Fournier's gangrene develops in previously healthy individuals with benign diseases often representing the initiating events; thus, high index of suspicion is necessary for an early diagnosis that will lead to the optimal outcome.

Paucibacillary tubercular vulval ulcer in a sexually inactive pubertal girl: role of therapeutic trial

BACKGROUND

Genital ulcers in adolescent girls present a complex diagnostic dilemma. Of all the causes of painful vulval ulcer in a virgin girl, tuberculosis is an extremely rare possibility with no case reported in literature.

CASE

We are reporting a case of tubercular vulval ulcer in a sexually inactive pubertal girl. She had a close contact with active tuberculosis, positive tuberculin skin test, and chronic granulomatous inflammation on vulval biopsy. Therapeutic trial was offered and on follow up visit after 4 weeks, lesion had completely resolved.

SUMMARY AND CONCLUSION

Unlike previous case reports that describe tubercular vulval ulcers in sexually active or post menopausal women our patient was sexually inactive. In endemic areas tuberculosis should be considered in differential diagnosis of vulval ulcers irrespective of sexual history of the patient.

Acute genital ulcers in nonsexually active young girls: case series, review of the literature, and evaluation and management recommendations

Acute genital ulcers rarely occur in nonsexually active young girls. When present, they can cause significant physical and emotional distress for the patient and her parents, and prompt an evaluation for sexual abuse and sexually transmitted diseases. With this review, we aim to further characterize acute genital ulcers in nonsexually active young girls by reviewing the medical records of patients with this disorder and to offer an approach to the diagnosis, evaluation, and treatment of acute genital ulcers based on our understanding and knowledge of this condition. We retrospectively review our understanding and knowledge of acute genital ulcers in nonsexually active girls at a pediatric hospital. A review of the recent literature on acute genital ulcers and a multidisciplinary approach to the diagnosis, evaluation, and treatment of acute genital ulcers are also presented. Twelve patients presented with acute genital ulcers, 11 of which were hospitalized for evaluation and pain management. Extensive work-up failed to reveal a specific infectious or autoimmune etiology in all but one patient, who was diagnosed with acute mycoplasma pneumonia. Acute genital ulcers in nonsexually active young girls likely represent a form of idiopathic vulvar aphthosis. Evaluation of a first episode of acute genital ulcers with mild prodromal symptoms should be limited. Treatment consists primarily of supportive care and symptom relief.

Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.

Diagnosis and management of vulvar ulcers

The diagnosis and management of the following non-infectious vulvar ulcers are reviewed: vulvar aphthae in adult and pediatric patients, aphthae associated with Behçet's disease, vulvar ulcers resulting from Crohn's disease, and vulvar ulcers associated with human immunodeficiency virus infection. There are many resources providing excellent reviews of infectious ulcers; therefore this topic will not be covered here.

American Academy of Pediatrics. Clinical report--gynecologic examination for adolescents in the pediatric office setting

The American Academy of Pediatrics promotes the inclusion of the gynecologic examination in the primary care setting within the medical home. Gynecologic issues are commonly seen by clinicians who provide primary care to adolescents. Some of the most common concerns include questions related to pubertal development; menstrual disorders such as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uterine bleeding; contraception; and sexually transmitted and non-sexually transmitted infections. The gynecologic examination is a key element in assessing pubertal status and documenting physical findings. Most adolescents do not need an internal examination involving a speculum or bimanual examination. However, for cases in which more extensive examination is needed, the primary care office with the primary care clinician who has established rapport and trust with the patient is often the best setting for pelvic examination. This report reviews the gynecologic examination, including indications for the pelvic examination in adolescents and the approach to this examination in the office setting. Indications for referral to a gynecologist are included. The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women's health care.

Genitourinary manifestations of epstein-barr virus infections

Epstein-Barr virus (EBV) is best known as the organism responsible for the syndrome of acute infectious mononucleosis. Transmission of EBV most commonly occurs through oral secretions. EBV has also been isolated from the female genital tract, where its role is poorly understood. This article reviews the available literature and data regarding EBV in the female genital tract and discusses areas of consensus and controversy. The primary manifestation of EBV seems to be vulvar ulcers, which are underrecognized. Diagnosis relies on appropriate serologic testing. Management includes local care and may require pain and corticosteroid medications. Although EBV is present elsewhere in the female genital tract, its pathogenic role in the cervix, uterus, fallopian tubes, and ovaries is poorly understood.

Aphthous vulvar ulcers in adolescent girls: case report and review of the literature

BACKGROUND

Aphthous vulvar ulcers are painful ulcerations on the genital mucosa frequently accompanied by systemic symptoms. They are most commonly reported in young women and adolescents without a history of sexual contact. Diagnosis is made by exclusion of more common causes, and treatment for this self-limited condition is mainly symptomatic.

OBJECTIVE

Clinicians should be aware of this rare condition to avoid misdiagnoses and unwarranted investigations into sexual abuse or false accusations of sexual activity.

METHODS

We report a case of an 11-year-old girl with systemic symptoms and vulvar ulcers of unknown etiology.

RESULTS

The patient's illness was consistent with previous reports that vulvar ulcers can occur without sexual transmission or a documented infectious cause.

CONCLUSION

A lack of general knowledge regarding this entity may lead to its exclusion from the differential diagnosis of vulvar ulcers in this patient population. Aphthous ulcers should be strongly considered in any adolescent with vulvar ulcers.

Premenarchal vulvar ulceration: is chronic irritation a causative factor?

OBJECTIVE

To study the common features of the young girls with vulvar ulcerations, and to help guide physicians caring for girls with this unusual condition.

METHODS

In this retrospective study, ten patients who developed vulvar ulcerations and denied any kind of sexual contact or sexual abuse were identified. Patient information was collated from detailed history, physical, and laboratory examinations including age, menarchal status, type of clothing worn, whether history of oral aphthosis or previous vulvar ulcers had occurred, symptoms at the time of presentation, description of ulcer, laboratory studies including serologies, blood count, erythrocyte sedimentation rate, C-reactive protein, and biopsy results.

RESULTS

Despite multiple evaluations, no patient had a specific medical cause identified to account for their vulvar ulcerations. None were diagnosed with Behcet's syndrome. Seven had bilateral vulvar ulcerations, which we attribute to the practice of wearing tightly fitted pants or polyester underwear frequently. No recurrences were documented in 6 months follow-up.

CONCLUSION

Girls with vulvar ulcerations who have deny being sexually active should be thoroughly evaluated for infections, Behcet's disease, and other health problems, but, in addition, should be questioned about use of tight-fitting clothing in the perineal area. We hypothesize that chronic irritation because of tight clothing may play a role in causing vulvar ulcerations in this setting.