Venerology Practice Questions

Q: A 45-year-old female with a history of genital herpes presents with painful vesicular lesions on her vulva, fever, and malaise. She has experienced multiple recurrences despite suppressive therapy. What is the most appropriate change in her treatment regimen?

Increase dose of valacyclovir for suppressive therapy. **Increase dose of valacyclovir for suppressive therapy** - For patients with **frequent recurrent genital herpes** despite suppressive therapy, increasing the dose of daily oral antiviral medication is often recommended to achieve better control. - In this case, **valacyclovir** is a prodrug of acyclovir, offering improved bioavailability and simplified dosing which is effective for both episodic treatment and suppression [1]. *Discontinue antiviral therapy and manage symptoms* - Discontinuing antiviral therapy would likely lead to **more frequent and severe recurrences**, as she is already experiencing multiple recurrences on suppressive therapy. - Management of symptoms alone would not address the underlying **viral replication** or prevent future outbreaks. *Use topical acyclovir as needed* - **Topical acyclovir** is generally less effective than oral antiviral therapy for managing genital herpes outbreaks and is not recommended for recurrent episodes, especially when systemic symptoms like fever and malaise are present [1]. - It does not prevent recurrences and its efficacy for acute treatment of established lesions is limited. *Switch to famciclovir for suppressive therapy to improve control of recurrences.* - While **famciclovir** is an alternative antiviral agent for herpes suppression, there is no strong evidence to suggest it would be significantly more effective than a higher dose of valacyclovir in a patient already failing standard suppressive therapy [1]. - The most straightforward and often effective approach is to first try **optimizing the current effective therapy** (valacyclovir) by increasing its dosage.

Q: A 31-year-old male presents with dysuria and urethral discharge. NAAT confirms gonorrhea. Which additional infection should be treated empirically?

Chlamydia trachomatis. ***Chlamydia trachomatis*** - Due to the high rate of **coinfection** with *Neisseria gonorrhoeae*, empirical treatment for *Chlamydia trachomatis* is recommended when gonorrhea is diagnosed. - This approach ensures comprehensive treatment for common sexually transmitted infections, even if NAAT results for Chlamydia are pending. *Treponema pallidum* - This bacterium causes **syphilis**, which typically presents with a **chancre** in its primary stage or a rash in its secondary stage. - While syphilis is also an STI, its presentation is distinct from the patient's symptoms of dysuria and urethral discharge, and routine empirical treatment alongside gonorrhea is not standard unless there's clinical suspicion. *Herpes simplex virus* - This virus causes **genital herpes**, characterized by **painful genital ulcers or vesicles**. - The patient's symptoms of dysuria and urethral discharge are not typical for a primary HSV infection, and empirical treatment is not indicated in this scenario. *Trichomonas vaginalis* - This protozoan causes **trichomoniasis**, which can present with dysuria and discharge, often described as frothy and odorous. - While it causes similar symptoms, it is less frequently co-infected with gonorrhea compared to Chlamydia, and current guidelines prioritize empirical treatment for Chlamydia.

Q: Which sexually transmitted infection is associated with a painless, indurated ulcer?

Primary syphilis. Primary syphilis - **Primary syphilis** is classically characterized by a **chancre**, which is a **painless, indurated ulcer** that develops at the site of infection [1]. - The chancre typically appears 10 to 90 days after exposure and usually resolves spontaneously within 3 to 6 weeks, even without treatment. *Genital herpes* - Genital herpes typically presents with **painful, vesicular lesions** that often rupture to form shallow ulcers, which is distinct from a painless, indurated ulcer [1]. - The vesicles are usually preceded by itching or tingling and can recur. *Chancroid* - Chancroid is characterized by **painful, ragged-edged ulcers** with a gray or yellow exudate, often accompanied by tender inguinal lymphadenopathy. - Unlike syphilis, the ulcers of chancroid are noticeably painful and often **purulent**. *Lymphogranuloma venereum* - **Lymphogranuloma venereum (LGV)** often begins with a small, **painless ulcer or papule** that might go unnoticed, but its hallmark is severe, often unilateral, **inguinal lymphadenopathy** (buboes) that can rupture. - The initial lesion is typically transient and not the primary defining feature of the disease's progression.

Q: A patient presents with flu-like symptoms and a maculopapular rash on the palms and soles. What is the most likely diagnosis?

Secondary syphilis. ### Secondary syphilis - **Maculopapular rash on the palms and soles** is a classic and highly characteristic feature of secondary syphilis [1]. - **Flu-like symptoms** (fever, malaise, headache) frequently precede or accompany the rash in secondary syphilis [1]. *Rocky Mountain spotted fever* - While it causes a **maculopapular rash**, it typically starts on the ankles and wrists and spreads centrally, not initially on the palms and soles. - The rash can become **petechial**, a feature not mentioned, and patients often have a history of **tick bite**. *Measles* - The characteristic rash of measles is **maculopapular** but typically starts on the **face** and behind the ears, spreading downwards, not on the palms and soles. - It's usually associated with **Koplik spots** (small white spots with red halos on the buccal mucosa) and **cough, coryza, and conjunctivitis**. *Hand, foot, and mouth disease* - Caused by **coxsackievirus**, it primarily affects young children and causes tender, papulovesicular lesions [2]. - The rash involves the **hands, feet, and oral cavity**, but is typically vesicular, not primarily maculopapular, and less commonly affects the palms and soles as a sole presentation without other characteristic findings [2].

Q: A 42-year-old female presents with a painless, indurated ulcer on her labia that has been present for 3 weeks. She has bilateral non-tender inguinal lymphadenopathy. Darkfield microscopy of the ulcer is positive for spirochetes. Analyze and determine the best treatment approach.

Single dose of intramuscular penicillin G. ***Single dose of intramuscular penicillin G*** - The clinical presentation of a **painless, indurated labial ulcer** (chancre) with **inguinal lymphadenopathy**, along with **positive darkfield microscopy for spirochetes**, is characteristic of **primary syphilis** [1]. - **Penicillin G benzathine** is the **first-line and most effective treatment** for all stages of syphilis, particularly effective as a single intramuscular dose for primary syphilis. *Oral doxycycline for 14 days* - **Doxycycline** is an alternative treatment for primary syphilis, especially in patients with a **penicillin allergy**. - However, it requires a **14-day course of oral therapy**, which may lead to compliance issues, making it less ideal than a single-dose injection if penicillin is tolerated. *Ceftriaxone 250mg IM once* - **Ceftriaxone** is typically used for the treatment of **gonorrhea** and is not considered a first-line agent for syphilis [2]. - While it has some efficacy against *Treponema pallidum*, **penicillin** remains the superior and recommended treatment. *Azithromycin 2g orally once* - **Azithromycin** is used to treat various bacterial infections, including **chlamydia** and some cases of **gonorrhea and chancroid**. - It is **not effective** against syphilis due to widespread resistance and is therefore not recommended for its treatment.

Q: A 29-year-old male presents with a painless ulcer on his genitalia and a maculopapular rash on his palms and soles. What is the causative organism?

Treponema pallidum. ***Treponema pallidum*** - The presentation of a **painless genital ulcer (chancre)** followed by a **maculopapular rash on the palms and soles** is highly characteristic of **secondary syphilis**, caused by *Treponema pallidum* [1]. - *Treponema pallidum* is a **spirochete** that causes syphilis, which progresses through distinct stages with varied clinical manifestations [1]. *Chlamydia trachomatis* - **Chlamydia trachomatis** is a common cause of **urethritis**, **cervicitis**, and **lymphogranuloma venereum**, but it does not typically cause a painless chancre followed by a widespread maculopapular rash on palms and soles. - Genital ulcers caused by *Chlamydia trachomatis* in **lymphogranuloma venereum** are usually transient and small, followed by significant **lymphadenopathy**. *Haemophilus ducreyi* - *Haemophilus ducreyi* causes **chancroid**, which is characterized by **painful genital ulcers** with irregular, undermined borders and frequently associated with **inguinal lymphadenopathy**. - The ulcers are typically **painful**, which contrasts with the patient's painless ulcer. *Herpes simplex virus* - **Herpes simplex virus (HSV)** causes **genital herpes**, which presents as painful, vesicular lesions that ulcerate, often accompanied by **flu-like symptoms** during the primary infection [2]. - The lesions are typically **painful vesicles** and ulcers, not a painless, indurated ulcer (chancre), and the maculopapular rash on palms and soles is not a typical manifestation of HSV infection [2].

Q: A 58-year-old male presents with chronic genital ulceration, inguinal lymphadenopathy, and foul-smelling discharge. A biopsy shows granulomatous inflammation with Donovan bodies. Analyze and determine the most appropriate treatment.

Doxycycline 100mg orally BID for 21 days. ***Doxycycline 100mg orally BID for 21 days*** - This regimen is the **recommended treatment** for **donovanosis (granuloma inguinale)**, characterized by chronic genital ulcers and the presence of **Donovan bodies**. - **Doxycycline** targets the causative organism, *Klebsiella granulomatis*, effectively resolving the infection. *Azithromycin 1g orally once a week for 3 weeks* - While azithromycin is used for some sexually transmitted infections, the **weekly dosing** for donovanosis is typically **1g once weekly for at least 3 weeks**, but **doxycycline** is generally preferred for initial treatment. - This regimen is sometimes used as an alternative, but continuous daily dosing of **doxycycline** is often more effective in achieving sustained therapeutic levels. *Ceftriaxone 250mg IM once* - **Ceftriaxone** [1] is the standard treatment for **gonorrhea** and is often used in combination with azithromycin for suspected chlamydial coinfection. - It is **not effective** against *Klebsiella granulomatis* and therefore would not treat donovanosis. *Penicillin G 2.4 million units IM once* - This is the standard treatment for primary, secondary, and early latent **syphilis**. - **Penicillin G** does not have activity against *Klebsiella granulomatis* and would be ineffective for donovanosis.

Q: Which of the following conditions is not a typical feature of secondary syphilis?

Gummas. Self-Correction: Gummas are a characteristic feature of tertiary syphilis, not secondary syphilis, representing chronic granulomatous lesions. They can affect various organs, including skin, bones, and internal organs, appearing years after the initial infection. *Maculopapular rash* - A diffuse maculopapular rash, often involving the palms and soles, is a classic presentation of secondary syphilis [1]. - This rash is typically non-itchy and can vary in appearance, sometimes becoming papulosquamous [1]. *Condyloma lata* - Condyloma lata are moist, wart-like lesions that appear in intertriginous areas (e.g., genital, perianal) during secondary syphilis [1]. - These lesions are highly infectious and result from widespread spirochetemia. *Alopecia* - Patchy alopecia, often described as a "moth-eaten" appearance, can occur during secondary syphilis. - This type of hair loss is temporary and usually resolves with treatment.

Q: A neonate is diagnosed with congenital syphilis. Which serological test is the most specific for confirming the diagnosis in the mother?

TPHA. PH (Treponema Pallidum Hemagglutination Assay) - **TPHA** is a **treponemal-specific test** that directly detects antibodies against *Treponema pallidum*, making it highly reliable for confirming syphilis, particularly in cases of suspected congenital syphilis in the mother. - It remains positive even after treatment, indicating past or present infection, and provides a definitive confirmation absent in non-treponemal tests. *VDRL (Venereal Disease Research Laboratory)* - **VDRL** is a **non-treponemal test** that detects antibodies to cardiolipin, a lipid-like substance released from damaged host cells, and is primarily used for screening and monitoring treatment response. [1] - While useful for initial screening and assessing disease activity, it lacks the specificity for definitive confirmation since biological false positives can occur due to other conditions such as pregnancy. [1] *RPR (Rapid Plasma Reagin)* - **RPR** is also a **non-treponemal test** similar to VDRL, detecting antibodies to cardiolipin and is widely used for screening due to its ease of performance. [1] - Like VDRL, it is not specific enough for confirmation due to potential **false positives** and is mainly used for screening and monitoring treatment effectiveness. [1] *EIA (Enzyme Immunoassay)* - **EIA** can be used as either a **treponemal-specific** or **non-treponemal** test, depending on the antigens used in the assay. [1] - While some **EIAs** are highly sensitive and specific for detecting treponemal antibodies, the term "EIA" itself is too broad, and its specificity for confirmation depends entirely on the type of antigen used, requiring further clarification for definitive diagnosis over **TPHA**.

Question 1

A 45-year-old female with a history of genital herpes presents with painful vesicular lesions on her vulva, fever, and malaise. She has experienced multiple recurrences despite suppressive therapy. What is the most appropriate change in her treatment regimen?

Accepted Answer

Increase dose of valacyclovir for suppressive therapy

Answer

Discontinue antiviral therapy and manage symptoms

Answer

Use topical acyclovir as needed

Answer

Switch to famciclovir for suppressive therapy to improve control of recurrences.

Question 2

A 31-year-old male presents with dysuria and urethral discharge. NAAT confirms gonorrhea. Which additional infection should be treated empirically?

Accepted Answer

Chlamydia trachomatis

Answer

Treponema pallidum

Answer

Herpes simplex virus

Answer

Trichomonas vaginalis

Question 3

Which sexually transmitted infection is associated with a painless, indurated ulcer?

Accepted Answer

Primary syphilis

Answer

Genital herpes

Answer

Chancroid

Answer

Lymphogranuloma venereum

Question 4

A patient presents with flu-like symptoms and a maculopapular rash on the palms and soles. What is the most likely diagnosis?

Accepted Answer

Secondary syphilis

Answer

Rocky Mountain spotted fever

Answer

Measles

Answer

Hand, foot, and mouth disease

Question 5

A 42-year-old female presents with a painless, indurated ulcer on her labia that has been present for 3 weeks. She has bilateral non-tender inguinal lymphadenopathy. Darkfield microscopy of the ulcer is positive for spirochetes. Analyze and determine the best treatment approach.

Accepted Answer

Single dose of intramuscular penicillin G

Answer

Oral doxycycline for 14 days

Answer

Ceftriaxone 250mg IM once

Answer

Azithromycin 2g orally once

Question 6

A 29-year-old male presents with a painless ulcer on his genitalia and a maculopapular rash on his palms and soles. What is the causative organism?

Accepted Answer

Treponema pallidum

Answer

Chlamydia trachomatis

Answer

Haemophilus ducreyi

Answer

Herpes simplex virus

Question 7

A 58-year-old male presents with chronic genital ulceration, inguinal lymphadenopathy, and foul-smelling discharge. A biopsy shows granulomatous inflammation with Donovan bodies. Analyze and determine the most appropriate treatment.

Accepted Answer

Doxycycline 100mg orally BID for 21 days

Answer

Azithromycin 1g orally once a week for 3 weeks

Answer

Ceftriaxone 250mg IM once

Answer

Penicillin G 2.4 million units IM once

Question 8

A 25-year-old male with a history of unprotected sex presents with dysuria, urethral discharge, and conjunctivitis. Laboratory results show a negative gram stain, and NAAT is pending. What is the next best step in management?

Accepted Answer

Empiric treatment with ceftriaxone and azithromycin for suspected gonococcal and chlamydial infections

Answer

Delay treatment until NAAT results are available

Answer

Topical antibiotics for conjunctivitis only

Answer

Penicillin G intramuscularly for suspected gonorrhea

Question 9

Which of the following conditions is not a typical feature of secondary syphilis?

Accepted Answer

Gummas

Answer

Condyloma lata

Answer

Alopecia

Answer

Maculopapular rash

Question 10

A neonate is diagnosed with congenital syphilis. Which serological test is the most specific for confirming the diagnosis in the mother?

Accepted Answer

TPHA

Answer

VDRL

Answer

RPR

Answer

EIA

Venerology — MCQs

Venerology — MCQs

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