Challenges in diagnosis of genital ulcers: a genital leishmaniasis case series

Abstract Leishmaniasis is a tropical infectious disease caused by Leishmania spp. protozoa and is transmitted by insects from the Phlebotominae subfamily. It can manifest as cutaneous leishmaniasis, a painless ulcer that can develop into a more serious systemic affliction as the protozoa spreads lymphatically or hematogenously, depending on the host's immunity. In this case series, the authors present a rare form of genital mucocutaneous leishmaniasis, with consideration of epidemiologic characteristics, clinical presentation, differential diagnosis, and treatments offered.

Hansen's Disease“ Clinically Atypical Presentation with Atypical Histopathology

Type II Lepra reaction is a Th2 mediated hypersensitivity reaction characterized by involvement of skin and nerves. Herein we report an unusual leprosy case that had a rheumatic mode of onset of Type II Lepra reaction. This case also had livedoid plaques, ulcers on the genitalia, extremities as the initial manifestation of Hansen's Disease and atypical histopathology. His symptoms had started 1 year back as polyarthralgia of both knees and small joints of hands and feet for which he was on immunosuppressant by a Rheumatologist who made a diagnosis of rheumatoid arthritis. After 6 months, patient developed red painful lesions; initially on arms, chest and trunk followed by legs. Subsequently, painful ulcerations developed on feet, knees and genitalia and a dermatology referral was made. Histopathology and slit skin smears led to diagnosis of Lepromatous leprosy in Type II Lepra reaction. Hansen's disease is a great imitator. Rheumatic manifestations can be the initial presentation of Type II Lepra reaction. Rheumatic manifestations thus can be the initial presentation of Type II Lepra reaction even before starting Multi drug therapy. High index of suspicion and routine slit skin smears in small peripheral settings can be helpful in diagnosing and treating such cases.

Síndrome de Behcet / Síndrome de Behcet

El síndrome de Behcet, también conocido como enfermedad de Behcet es un proceso autoinflamatorio crónico de baja frecuencia y etiología desconocida. Es una vasculitis que afecta arterias y venas de todos los calibres, provoca una alteración de la función endotelial y se expresa clínicamente con lesiones orgánicas en varios niveles. Tiene una mayor incidencia en los países localizados en la antigua ruta de la seda (mediterraneo del este, oriente medio y este de Asia). En su fisiopatogenia intervienen factores genéticos, microbianos e inmunológicos. Los síntomas varían de persona a persona y de acuerdo a las regiones geográficas, pero los más comunes son las úlceras orales y genitales, inflamaciones oculares (uveítis, retinitis e iritis), lesiones de piel y artritis. En algunos casos pueden presentarse alteraciones del sistema nervioso central, del tracto digestivo y renal. Como guía para el diagnóstico se emplean los criterios del grupo internacional de estudio de la enfermedad de Behcet. El tratamiento incluye medicamentos de uso tópico y sistémico, entre estos los más empleados son los esteroides, los inhibidores del factor de necrosis tumoral y los inmunosupresores(AU)

Behcet's syndrome, also known as Behcet's disease is a chronic autoinflammatory process of low frequency and unknown etiology. It is a vasculitis affecting arteries and veins of all sizes that causes an alteration of endothelial function and is expressed clinically by organ damage at various levels. It has a higher incidence in countries located in the ancient Silk Road (East Mediterranean, Middle East and East Asia). Its pathogenesis involves genetic, microbial and immunological factors.Symptoms vary from person to person and according to geographical regions, but the most common are oral and genital ulcers, eye inflammation (uveitis, iritis and retinitis), skin lesions and arthritis. In some cases they can present central nervous system, gastrointestinal tract and kidney. As a guide to the diagnosis criteria of International Study Group of Behcet's disease are used. Treatment includes topical and systemic drugs. The most commonly used are steroids, tumor necrosis factor inhibitors and immunosuppressants(AU)

Trombosis de senos venosos cerebrales en la enfermedad de Behçet / Cerebral venous sinus thrombosis in Behcet's disease

La enfermedad de Behçet es una vasculitis sistémica inmunomediada que afecta los pequeños vasos sanguíneos y se presenta frecuentemente con ulceraciones de las membranas mucosas y síntomas oculares. Se presentó un paciente masculino de 25 años de edad, con antecedentes de úlceras bucales y genitales recurrentes, foliculitis, eritema nudoso, lesiones papulo-pustulosas, el cual tenía, desde 3 meses antes de su presentación en nuestro servicio, manifestaciones clínicas compatibles con un síndrome de hipertensión endocraneana benigna que no logra una evolución favorable con el tratamiento. Mediante la angio-TAC de cráneo se identificó una trombosis de senos venosos cerebrales. Los hallazgos clínicos y radiológicos son compatibles con una enfermedad de Behçet(AU)

Behcet's disease is an immune-mediated systemic vasculitis that affects small blood vessels and it frequently presents with ulceration of the mucous membranes and eye symptoms. A 25 year-old male patient is presented with history of recurrent cold sores and genital folliculitis, erythema nodosum, papular-pustular lesions. For three months before submission to our service, this patient had clinical manifestations compatible with benign intracranial hypertension syndrome that fails favorable evolution with treatment. By skull venuos CTA, venous sinus cerebral thrombosis was identified. Clinical and radiological findings are compatible with Behcet's disease(AU)

Tuberculosis vulvar: Una rara localización / Vulvar Tuberculosis: A Rare Localization

La tuberculosis vulvar es una rara localización de la enfermedad, que debe incluirse en los diagnósticos diferenciales de lesiones ulcerosas o exofíticas dolorosas a ese nivel. Se presenta el caso de una mujer joven, VIH negativa, con grave compromiso del estado general debido a una tuberculosis diseminada con múltiples localizaciones: pulmonar, renal, genital, intestinal y peritoneal. La cepa de Mycobacterium tuberculosis aislada del esputo, orina y tracto genital fue pansensible y la paciente respondió al tratamiento con drogas de primera línea.

The vulvar tuberculosis is an uncommon localization of tuberculosis, which has to be included in the differential diagnosis of painful vulvar ulcerative or exophytic lesions. This report presents a case of an HIV negative young woman with severe compromise of her health status, due to disseminated tuberculosis with multiple localizations: pulmonary, renal, genital, intestinal and peritoneal manifestations. The strain of Mycobacterium tuberculosis isolated from sputum, urine and the genital tract was susceptible to all the antituberculosis medicaments and the patient responded to treatment with first-line drugs.

Diagnosis and Management of Genital Ulcers.

Herpes simplex virus infection and syphilis are the most common causes of genital ulcers in the United States. Other infectious causes include chancroid, lymphogranuloma venereum, granuloma inguinale (donovanosis), secondary bacterial infections, and fungi. Noninfectious etiologies, including sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions, can also lead to genital ulcers. Although initial treatment of genital ulcers is generally based on clinical presentation, the following tests should be considered in all patients: serologic tests for syphilis and darkfield microscopy or direct fluorescent antibody testing for Treponema pallidum, culture or polymerase chain reaction test for herpes simplex virus, and culture for Haemophilus ducreyi in settings with a high prevalence of chancroid. No pathogen is identified in up to 25 percent of patients with genital ulcers. The first episode of herpes simplex virus infection is usually treated with seven to 10 days of oral acyclovir (five days for recurrent episodes). Famciclovir and valacyclovir are alternative therapies. One dose of intramuscular penicillin G benzathine is recommended to treat genital ulcers caused by primary syphilis. Treatment options for chancroid include a single dose of intramuscular ceftriaxone or oral azithromycin, ciprofloxacin, or erythromycin. Lymphogranuloma venereum and donovanosis are treated with 21 days of oral doxycycline. Treatment of noninfectious causes of genital ulcers varies by etiology, and ranges from topical wound care for ulcers caused by sexual trauma to consideration of subcutaneous pegylated interferon alfa-2a for ulcers caused by Behçet syndrome.