Venerology Practice Questions

Q: A 40-year-old man presents with a 2-week history of a non-tender penile ulcer. Dark field microscopy is negative, and initial VDRL is non-reactive. What is the most appropriate next step?

Repeat VDRL in 1-2 weeks. ***Repeat VDRL in 1-2 weeks*** - This is the most appropriate next step because **serologic tests for syphilis** (like VDRL) can be negative early in the disease course, especially within the first few weeks of chancre appearance, known as the **"window period."** - Repeating the VDRL allows time for **antibodies to develop** and become detectable, confirming or ruling out primary syphilis. *Perform biopsy of the lesion* - A biopsy might be considered if the diagnosis remains uncertain after further serological testing or if there are atypical features, but it's not the **initial test** of choice given the typical presentation of a syphilitic chancre. - Doing a biopsy prematurely can delay definitive diagnosis and treatment if the ulcer is indeed a syphilitic chancre. *Treat empirically with benzathine penicillin* - While penicillin is the treatment for syphilis, **empirical treatment** without a confirmed diagnosis is generally discouraged to prevent unnecessary antibiotic use and potential delayed diagnosis of other conditions. - A definitive diagnosis is crucial, especially in cases where the initial tests were negative. *Test for herpes simplex virus* - HSV causes **tender, painful, vesicular lesions** that often recur, which is inconsistent with the description of a non-tender penile ulcer. - While HSV testing can be done, it's less likely given the **non-tender nature** of the lesion, and syphilis remains a primary concern that needs to be definitively ruled out first.

Q: Which of the following is a defining characteristic of Lymphogranuloma venereum (LGV)?

Pronounced lymphadenopathy often with suppuration. Pronounced lymphadenopathy often with suppuration - **Lymphogranuloma venereum** (LGV) is characterized by a transient, often unnoticed, primary lesion followed by significant **regional lymphadenopathy** [1]. - The swollen lymph nodes (buboes) can become **fluctuant** and **suppurate**, forming draining fistulas [1]. *Painful genital ulcers with undermined edges* - This description is more characteristic of **chancroid**, caused by *Haemophilus ducreyi* [1]. - LGV's initial lesions are typically **painless vesicles** or small ulcers that heal quickly and are often missed. *Painless, clean-based ulcers with induration* - This accurately describes the **chancre** of **primary syphilis**, caused by *Treponema pallidum*. - Unlike syphilis, LGV's primary lesion is generally not indurated and is less distinct. *Beefy red granulation tissue in the genital area* - This presentation is typical of **donovanosis** (granuloma inguinale), caused by *Klebsiella granulomatis* [1]. - Donovanosis is characterized by **progressive, destructive lesions** with extensive granulation tissue, which differs from LGV's lymphatic involvement.

Q: A 23-year-old woman presents with recurrent genital herpes despite continuous suppressive therapy with valacyclovir 1g daily for 6 months. She reports adherence to medication. HIV test is negative. What is the most appropriate next step in management?

Perform viral culture with acyclovir sensitivity testing. ***Perform viral culture with acyclovir sensitivity testing*** - **Recurrent genial herpes** despite **continuous suppressive therapy** with 1g daily valacyclovir is suggestive of possible **antiviral resistance**. - A **viral culture with sensitivity testing** is crucial to confirm resistance and guide appropriate treatment [1]. *Increase valacyclovir to 1g twice daily* - While increasing the dose might be considered in some cases of treatment failure, it is not the most appropriate first step here given the **recurrent infections** despite an already high dose and excellent adherence. - Doing so without first checking for **resistance** might delay appropriate management. *Add topical foscarnet to current regimen* - Topical foscarnet is generally reserved for **acyclovir-resistant herpes simplex virus (HSV)** infections, especially in immunocompromised patients, and is typically used as monotherapy or an alternative systemic treatment. - It would be premature to add an alternative agent without confirming **resistance** and the HSV strain. *Switch to famciclovir suppressive therapy* - Famciclovir and valacyclovir have similar mechanisms of action and **cross-resistance** is common, particularly if the resistance is due to a **thymidine kinase (TK) mutation**. - Switching medications without determining the cause of **treatment failure** is unlikely to be effective [1].

Q: A 35-year-old HIV-positive woman (CD4 count 320/μL) presents with extensive genital warts not responding to conventional treatments. Which of the following is the most appropriate management?

Intralesional interferon. **Intralesional interferon** - In **immunocompromised** patients, such as those with HIV, **genital warts** can be extensive and resistant to conventional therapies. **Intralesional interferon** can enhance the local immune response against the **human papillomavirus (HPV)**. - It is particularly useful for **recalcitrant** or large warts that have not responded to topical or destructive methods, by directly addressing the viral replication and host immunity at the site. *Surgical excision* - While surgical excision can remove large or bothersome warts, it carries a higher risk of **recurrence** and **scarring**, especially with extensive lesions in an immunocompromised patient. - It provides immediate removal but does not prevent the growth of new lesions from existing **subclinical HPV infection**, which is common in HIV-positive individuals. *Podophyllin resin application* - **Podophyllin resin** is a **cytotoxic agent** that inhibits cell mitosis and is commonly used for genital warts in immunocompetent individuals. - However, it can be quite **toxic** and irritating, and its efficacy is often diminished in immunocompromised patients, leading to poor response or severe side effects without clearing the extensive lesions. *Oral isotretinoin* - **Oral isotretinoin** is primarily used for severe **acne** and certain other dermatological conditions, but it is **not a standard treatment** for genital warts. - While it has some immune-modulating effects, its role in treating **HPV-induced warts** is not well-established, and it has potential for significant adverse effects, making it an inappropriate first-line choice for this condition.

Q: A male presents with urethral discharge as shown in the figure. What is the most likely cause?

Gonorrhea. ***Gonorrhea*** - The image depicts **purulent urethral discharge**, a classic symptom frequently seen in **gonococcal urethritis**. - **Neisseria gonorrhoeae** commonly causes urethritis with a thick, yellowish, or greenish discharge. *HIV* - HIV primarily affects the immune system and does not typically present with **gonorrhea-like urethral discharge** as a direct symptom. - While HIV can increase susceptibility to other STIs, the discharge itself is not a direct manifestation of HIV infection. *Haemophilus ducreyi* - This bacterium is the causative agent of **chancroid**, which presents as painful genital ulcers, not urethral discharge. - **Chancroid ulcers** are typically soft, ragged, and associated with tender inguinal lymphadenopathy. *Syphilis* - Syphilis, caused by **Treponema pallidum**, presents with a **painless chancre** in its primary stage, not urethral discharge. - Later stages of syphilis involve rashes, neurological symptoms, or gummas, which are distinct from the penile discharge shown.

Q: A 28-year-old man presents with painless anal ulcer. Dark-field microscopy shows spirochetes. He is allergic to penicillin with history of anaphylaxis. Which of the following is the most appropriate treatment?

Doxycycline 100 mg orally twice daily for 14 days. **Doxycycline 100 mg orally twice daily for 14 days** - **Doxycycline** is the recommended alternative for treating **primary syphilis** in patients with a **penicillin allergy**, especially with a history of anaphylaxis. - The 14-day duration for doxycycline is appropriate for treating early syphilis, including primary syphilis. *Erythromycin 500 mg four times daily for 14 days* - While erythromycin is an alternative, its efficacy for syphilis is **lower than doxycycline**, and it requires a longer duration of treatment. - It is generally considered a less preferred option than doxycycline for penicillin-allergic patients due to adherence issues and potential for gastrointestinal side effects. *Penicillin desensitization followed by benzathine penicillin* - **Penicillin desensitization** is typically reserved for situations where penicillin is the **only truly effective treatment** and alternatives are not suitable, such as in neurosyphilis or syphilis in pregnancy. - For primary syphilis in a non-pregnant patient with a clear anaphylactic allergy, an effective alternative like doxycycline is preferred over the risks associated with desensitization. *Azithromycin 2 g orally once* - **Azithromycin** resistance in *Treponema pallidum* is increasingly prevalent, making it an unreliable treatment for syphilis. - A single dose is insufficient for effective treatment and carries a higher risk of treatment failure. *Ceftriaxone 250 mg IM* - **Ceftriaxone** is an alternative in some cases of syphilis, but the recommended dose for primary syphilis is typically higher and given for a longer duration (e.g., 1-2 g IM or IV daily for 10-14 days). - A single 250 mg IM dose is insufficient for the treatment of syphilis and is more commonly used for gonorrhea.

Q: A 42-year-old man presents with painless penile ulcer and rash on palms and soles. VDRL is positive at 1:64. CSF examination shows: WBC 35/μL (lymphocytes), protein 65 mg/dL, VDRL positive. Which of the following is the most appropriate treatment?

Aqueous crystalline penicillin G IV for 14 days. ***Aqueous crystalline penicillin G IV for 14 days*** - This patient presents with symptoms indicating **secondary syphilis** (painless penile ulcer, rash on palms/soles, positive VDRL) and **neurosyphilis** (positive VDRL in CSF, elevated CSF WBC and protein) [1]. - **Aqueous crystalline penicillin G IV** is the recommended treatment for neurosyphilis due to its excellent penetration into the central nervous system, administered for **10-14 days**. *Benzathine penicillin G IM weekly for 3 weeks* - This regimen is typically used for **late latent syphilis** or **tertiary syphilis** without neurological involvement [1]. - While it's a form of penicillin, it does not achieve adequate CNS levels to effectively treat neurosyphilis. *Benzathine penicillin G IM once* - A single dose of **benzathine penicillin G IM** is the standard treatment for **primary, secondary, and early latent syphilis** [1]. - However, it is insufficient for neurosyphilis as it does not reliably achieve treponemicidal concentrations in the CSF. *Ceftriaxone IV for 10 days* - **Ceftriaxone** can be an alternative treatment for syphilis in **penicillin-allergic patients** and has some CNS penetration. - However, for neurosyphilis, penicillin is still universally considered the **most effective first-line agent**, and ceftriaxone efficacy is less established. *Doxycycline for 28 days* - **Doxycycline** is an alternative treatment for **early syphilis** in penicillin-allergic patients (usually 14 days) or **late latent syphilis** (28 days). - It does not achieve adequate CNS concentrations and is therefore **not recommended for neurosyphilis**.

Q: Which diagnostic test is most appropriate for detecting early congenital syphilis?

IgM testing. ***IgM testing*** - **IgM antibodies** are the first antibodies produced in response to a **Treponema pallidum infection** and do not cross the placenta, making them specific for actual fetal infection. [1] - A positive IgM test in a neonate indicates a **recent or active infection**, differentiating it from passively acquired maternal IgG antibodies. [1] *VDRL* - The **VDRL test** (Venereal Disease Research Laboratory) detects **non-treponemal antibodies** and can be used in newborns, but it may also be positive due to passive transfer of maternal antibodies, leading to false positives. [1] - While useful for screening, it doesn't definitively distinguish between passive maternal transfer and active congenital infection without additional follow-up or comparison to maternal titers. *TPHA* - **TPHA** (Treponema Pallidum Hemagglutination Assay) detects **treponemal antibodies**, which are highly specific for syphilis but also cross the placenta. - A positive TPHA in a neonate could simply reflect the mother's previous exposure to syphilis rather than an active fetal infection. *Dark field microscopy* - **Dark field microscopy** directly visualizes **Treponema pallidum spirochetes** from lesions or body fluids, but it requires accessible lesions (which might not be present at birth or in early stages) and skilled personnel. - It's not a general screening test for early congenital syphilis but rather a diagnostic tool for active lesions in symptomatic cases.

Q: What is the most common cause of genital ulcers globally?

Herpes simplex virus. ***Herpes simplex virus*** - **HSV-2** (primarily) and **HSV-1** are the leading causes of **genital ulcers** worldwide, characterized by painful vesicles that rupture and form ulcers. - Its high prevalence and recurrent nature make it the most common etiological agent for genital ulcer disease. *Chlamydia trachomatis* - While *Chlamydia trachomatis* is the most common bacterial sexually transmitted infection, it typically causes **urethritis** or **cervicitis**, not genital ulcers. - Certain serovars (L1, L2, L3) can cause **lymphogranuloma venereum (LGV)**, which involves lymphadenopathy and sometimes ulcers, but is less common globally. *Treponema pallidum* - *Treponema pallidum* causes **syphilis**, which presents with a characteristic **painless chancre** (a type of ulcer). - Although significant, syphilis is not as prevalent globally as HSV as a cause of genital ulcers. *Haemophilus ducreyi* - *Haemophilus ducreyi* is the causative agent of **chancroid**, which is characterized by **painful, friable genital ulcers** with ragged borders. - While common in some regions, its global incidence is lower than that of herpes simplex virus.

Q: A 40-year-old female with multiple sexual partners presented with fever, rash, and articular symptoms. Migratory arthritis and tenosynovitis of knees, hands, wrists, feet, and ankles were noticed during clinical examination. Synovial fluid leukocyte count was 12,000/ml and culture was sterile. The patient has been successfully treated with injection ceftriaxone 1 g Q24 hours for 7 days. What was the diagnosis in this setting?

Disseminated gonococcal infection. ***Disseminated gonococcal infection*** - The classic triad of **fever**, **rash**, and **articular symptoms (migratory polyarthralgia or tenosynovitis)** in a sexually active individual strongly suggests disseminated gonococcal infection (**DGI**). - The positive response to **ceftriaxone**, an antibiotic effective against *Neisseria gonorrhoeae*, further supports this diagnosis. *Gonococcal septic arthritis* - While *N. gonorrhoeae* can cause septic arthritis, it typically presents as a **monoarticular** joint infection with severe pain and swelling, not **migratory polyarthritis** and tenosynovitis. - The synovial fluid in septic arthritis would show a significantly **higher leukocyte count** (often >50,000 cells/mm³) and frequently a positive culture if bacteria are adequately cultured. *Syphilitic arthritis* - Syphilitic arthritis is uncommon and often presents in **secondary or tertiary syphilis**, characterized by chronic inflammation and unique bone lesions, not acute migratory polyarthritis or tenosynovitis. - The rash of secondary syphilis is typically **macropapular and non-pruritic**, often involving the palms and soles, which differs from the rash seen in DGI. *Arthritis due to Pseudomonas aeruginosa* - *Pseudomonas aeruginosa* arthritis is rare and typically occurs in individuals with **immunocompromise**, **intravenous drug use**, or following **puncture wounds**, none of which are mentioned here. - The clinical picture of **migratory polyarthralgia and tenosynovitis** is not characteristic of *Pseudomonas* arthritis, which is usually purulent and monoarticular.

Question 1

A 40-year-old man presents with a 2-week history of a non-tender penile ulcer. Dark field microscopy is negative, and initial VDRL is non-reactive. What is the most appropriate next step?

Accepted Answer

Repeat VDRL in 1-2 weeks

Answer

Perform biopsy of the lesion

Answer

Treat empirically with benzathine penicillin

Answer

Test for herpes simplex virus

Question 2

Which of the following is a defining characteristic of Lymphogranuloma venereum (LGV)?

Accepted Answer

Pronounced lymphadenopathy often with suppuration

Answer

Painful genital ulcers with undermined edges

Answer

Painless, clean-based ulcers with induration

Answer

Beefy red granulation tissue in the genital area

Question 3

A 23-year-old woman presents with recurrent genital herpes despite continuous suppressive therapy with valacyclovir 1g daily for 6 months. She reports adherence to medication. HIV test is negative. What is the most appropriate next step in management?

Accepted Answer

Perform viral culture with acyclovir sensitivity testing

Answer

Increase valacyclovir to 1g twice daily

Answer

Add topical foscarnet to current regimen

Answer

Switch to famciclovir suppressive therapy

Question 4

A 35-year-old HIV-positive woman (CD4 count 320/μL) presents with extensive genital warts not responding to conventional treatments. Which of the following is the most appropriate management?

Accepted Answer

Intralesional interferon

Answer

Surgical excision

Answer

Podophyllin resin application

Answer

Oral isotretinoin

Question 5

A male presents with urethral discharge as shown in the figure. What is the most likely cause?

Accepted Answer

Gonorrhea

Answer

HIV

Answer

Haemophilus ducreyi

Answer

Syphilis

Question 6

A 28-year-old man presents with painless anal ulcer. Dark-field microscopy shows spirochetes. He is allergic to penicillin with history of anaphylaxis. Which of the following is the most appropriate treatment?

Accepted Answer

Doxycycline 100 mg orally twice daily for 14 days

Answer

Erythromycin 500 mg four times daily for 14 days

Answer

Penicillin desensitization followed by benzathine penicillin

Answer

Azithromycin 2 g orally once

Answer

Ceftriaxone 250 mg IM

Question 7

A 42-year-old man presents with painless penile ulcer and rash on palms and soles. VDRL is positive at 1:64. CSF examination shows: WBC 35/μL (lymphocytes), protein 65 mg/dL, VDRL positive. Which of the following is the most appropriate treatment?

Accepted Answer

Aqueous crystalline penicillin G IV for 14 days

Answer

Benzathine penicillin G IM weekly for 3 weeks

Answer

Benzathine penicillin G IM once

Answer

Ceftriaxone IV for 10 days

Answer

Doxycycline for 28 days

Question 8

Which diagnostic test is most appropriate for detecting early congenital syphilis?

Accepted Answer

IgM testing

Answer

VDRL

Answer

TPHA

Answer

Dark field microscopy

Question 9

What is the most common cause of genital ulcers globally?

Accepted Answer

Herpes simplex virus

Answer

Chlamydia trachomatis

Answer

Treponema pallidum

Answer

Haemophilus ducreyi

Question 10

A 40-year-old female with multiple sexual partners presented with fever, rash, and articular symptoms. Migratory arthritis and tenosynovitis of knees, hands, wrists, feet, and ankles were noticed during clinical examination. Synovial fluid leukocyte count was 12,000/ml and culture was sterile. The patient has been successfully treated with injection ceftriaxone 1 g Q24 hours for 7 days. What was the diagnosis in this setting?

Accepted Answer

Disseminated gonococcal infection

Answer

Gonococcal septic arthritis

Answer

Syphilitic arthritis

Answer

Arthritis due to Pseudomonas aeruginosa

Venerology — MCQs

Venerology — MCQs

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