COVID-19 related acute genital ulcer: a case report

ABSTRACT Acute vulvar ulcer (Lipschütz's ulcer) is a rare lesion with local hyperimmunoreactivity triggered by infection, which is characterized by acute, painful, and necrotic ulcerations. This condition is usually found in non-sexually active adolescents, and it resolves spontaneously. We report a case of a 35-year-old woman who was diagnosed with COVID-19 who did not have severe symptoms, but had high levels of D-dimer for 9 days. The COVID-19 diagnosis was followed by the appearance of an acute, necrotic, extremely painful vulvar ulcer, although symptoms caused by COVID-19 had improved. We emphasize the importance of the differential diagnosis to exclude diseases such as Behçet's syndrome, Sexually Transmitted Infections, as well as the presence of viruses that generally trigger Lipschütz's ulcer, such as Epstein-Barr virus and cytomegalovirus. No treatment is usually necessary, however, in the present report due to the pain experienced by the patient, we successfully used oral prednisone.

Forma necrótica de úlcera de Lipschütz / Necrotic type of Lipschütz ulcer

Resumen INTRODUCCIÓN: Las úlceras de Lipschütz son una causa infrecuente de úlcera genital, de alivio espontáneo y casi siempre benignas, aunque en algunas pacientes pueden dejar cicatrices genitales. Lo común es que aparezcan en mujeres jóvenes, antes del inicio de la vida sexual activa, en coincidencia con un cuadro catarral o pseudogripal. CASO CLÍNICO: Paciente de 18 años con una úlcera vulvar dolorosa, coincidente con un episodio de amigdalitis aguda y fiebre de 38 ºC. La paciente negó haber tenido relaciones sexuales. La úlcera alcanzó 3 a 4 cm, profunda, purulenta, con apertura del labio menor derecho y con importante componente necrótico. Para el control del dolor se le indicaron: corticoides, doxiciclina oral, crema con lidocaína y antiinflamatorios. Los análisis de laboratorio descartaron que se tratara de infección de trasmisión sexual. Al término del esquema terapéutico prescrito la evolución fue favorable, con desaparición de los síntomas, pero con una secuela: apertura del labio mayor derecho. CONCLUSIONES: La úlcera de Lipschütz es una causa infrecuente de úlcera vulvar. Su tratamiento consiste en el control de los síntomas y casi siempre se cura en el transcurso de 4 a 6 semanas, sin dejar lesiones. El diagnóstico solo puede establecerse luego de excluir otras causas más frecuentes de úlcera vulvar.

Abstract INTRODUCTION: Lipschütz ulcers are an infrequent cause of genital ulcer, of spontaneous relief and almost always benign, although in some patients they may leave genital scars. They usually appear in young women, before the onset of active sexual life, coinciding with a catarrhal or flu-like condition. CLINICAL CASE: 18-year-old female patient with a painful vulvar ulcer, coinciding with an episode of acute tonsillitis and fever of 38 ºC. The patient denied having had sexual intercourse. The ulcer was 3 to 4 cm, deep, purulent, with opening of the right labium minora and with a significant necrotic component. For pain control she was prescribed corticosteroids, oral doxycycline, lidocaine cream and anti-inflammatory drugs. Laboratory tests ruled out sexually transmitted infection. At the end of the prescribed therapeutic scheme the evolution was favorable, with disappearance of symptoms, but with a sequel: opening of the right labium majus. CONCLUSIONS: Lipschütz ulcer is a rare cause of vulvar ulcer. Its treatment consists of symptom control and it almost always heals within 4 to 6 weeks, leaving no lesions. The diagnosis can only be established after other more frequent causes of vulvar ulceration have been excluded.

Lipschütz ulcer and Epstein-Barr virus infection: a case report / Úlcera de Lipschütz e infecção pelo vírus Epstein-Barr: um relato de caso

Aims: Lipschütz ulcer (LU), also known as acute vulvar ulcer, is a rare cause of vulvar ulcerations of nonvenereal origin. Our aim is to alert about this manifestation of the disease and to prevent unnecessary treatment. Case description: we present a 15 years old female, without relevant family and past history, admitted in the emergency room with a painful vulvar ulcer, preceded by five days of fever and sore throat. On physical examination, she had enlarged, and erythematous tonsils and bilateral anterior cervical lymphadenopathy and the genital examination revealed vulvar oedema and a deep ulcer with necrotic plaques in labium minus. The exclusion of transmitted sexual disease led to a diagnosis of Lipschütz ulcer. She started symptomatic treatment, oral antibiotic and corticoid therapy. She was discharged from the hospital after 6 days of admission and returned to a consult one month later when it was observed an almost complete resolution of the lesions. No recurrences occurred until 3 months. Conclusion: LU is a misdiagnosed pathology, probably because doctors, in general, are not familiarized with that, and since the diagnosis is made by exclusion. Infectious, such as Epstein-Barr Virus infections, are proposed etiologies.

Objetivo: a úlcera de Lipschütz, ou úlcera vulvar aguda, é uma causa rara de ulceração de origem não venérea. O nosso objetivo é alertar para essa manifestação da doença e prevenir tratamentos desnecessários. Descrição: adolescente, sexo feminino, 15 anos, sem história pessoal ou antecedentes familiares de relevo. Recorreu ao Serviço de Urgência por febre e odinofagia, com cinco dias de evolução, associada a uma úlcera vulvar dolorosa, que surgiu no próprio dia. O exame clínico revelou amígdalas hipertrofiadas e eritematosas, linfadenopatia cervical anterior, e o exame ginecológico apresentou edema da vulva e uma úlcera profunda, com placas necróticas nos lábios menores. A exclusão de uma doença sexualmente transmissível levou ao diagnóstico de úlcera de Lipschütz. Ficou internada no Serviço de Pediatria e iniciou tratamento sintomático, antibioterapia por sobreinfeção da úlcera e corticoterapia tópica. Teve alta após seis dias de hospitalização e foi reavaliada em consulta um mês depois, com resolução completa do caso. Não apresentou recorrência da úlcera até aos três meses seguintes. Conclusão: a úlcera de Lipschütz é uma doença subdiagnosticada, muito provavelmente porque os médicos não estão familiarizados com ela e por ser um diagnóstico de exclusão. A infeção pelo vírus Epstein-Barr é uma das etiologias propostas.

Úlceras vulvares agudas en adolescentes, reporte de una serie de casos clínicos / Severe vulvar ulcers in adolescents, a report of clinical cases series / Úlceras vulvares agudas em adolescentes, informe de uma série de casos clínicos

Introducción: las úlceras genitales se caracterizan por su gran heterogeneidad clínica y etiológica. Pueden corresponder a entidades patológicas cutáneas o sistémicas de naturaleza infecciosa o no infecciosa. Dentro de estas últimas, se destacan las úlceras de Lipschütz y la enfermedad de Behcet. Objetivo: describir cuatro casos clínicos de adolescentes con úlceras vulvares agudas de causa no infecciosa hospitalizadas en dos prestadores del Sistema Nacional Integrado de Salud de Montevideo con el objetivo de brindar herramientas a profesionales para el correcto abordaje diagnóstico y terapéutico. Discusión: la realización de una anamnesis detallada y un examen físico minucioso son esenciales para realizar un adecuado abordaje diagnóstico y terapéutico. En el análisis clínico es importante considerar la edad de la paciente, el inicio de relaciones sexuales, el número, topografía y características de las úlceras incluyendo la presencia o no de dolor, así como la asociación de manifestaciones sistémicas. Resulta necesario el conocimiento de esta patología poco frecuente en niñas y adolescentes cuyo abordaje diagnóstico y terapéutico depende de la orientación etiológica basada en criterios epidemiológicos y clínicos bien definidos. Ello contribuirá a mejorar la calidad de la asistencia y a minimizar las repercu¬siones biológicas y psicológicas.

Introduction: genital ulcers are characterized by great clinical and etiological heterogeneity. They may correspond to infectious or non-infectious skin or systemic pathologies. Lipschütz ulcer and Behcet disease stand out among non-infectious conditions. Objective: to describe four clinical cases of adolescents with non-infectious severe vulvar ulcers hospitalized in two institutions of the national integrated health system in Montevideo, with the purpose of providing professionals with tools for the adequate diagnostic and therapeutic approach. Discussion: a detailed anamnesis questionnaire and a thorough physical examination are of the essence for an adequate diagnostic and therapeutic approach. The clinical analysis should include considering the patient's age, initiation of sexual intercourse, the number, topography and characteristics of the ulcers including finding out whether there is pain or not, as well as the association of systemic manifestations. It is important to learn about this rather unusual condition in girls and adolescents, whose diagnostic and therapeutic approach depends on the etiological orientation based on well-defined epidemiological and clinical criteria. This will contribute to improving the quality of assistance and minimizing biological and psychological effects.

Introdução: as úlceras genitais se caracterizam por uma grande heterogeneidade clínica e etiológica. Podem ser causadas por patologias cutâneas ou sistémicas tanto infecciosas como não infecciosas. Entre as últimas, destacam-se as úlceras de Lipschütz e a doença de Behçet. Objetivo: descrever quatro casos clínicos de adolescentes com úlceras vulvares agudas de causa não infecciosa hospitalizadas em duas unidades de saúde do sistema nacional integrado de saúde de Montevidéu buscando oferecer ferramentas para uma correta abordagem diagnóstica e terapêutica. Discussão: é fundamental realizar uma anamnese detalhada e um exame físico minucioso para uma abordagem diagnóstica e terapêutica adequada. O exame clínico deve incluir a idade da paciente, o inicio das relações sexuais, o número, topografia e características das úlceras incluindo a presencia ou não de dor, bem como a associação com manifestações sistémicas. É necessário conhecer esta patologia pouco frequente em meninas e adolescentes cuja abordagem diagnóstica e terapêutica depende da orientação etiológica baseada em critérios epidemiológicos e clínicos bem definidos. Isso contribuirá para melhorar a qualidade da assistência e a minimizar as repercussões biológicas e psicológicas.

Úlcera de Lipschütz, un diagnóstico para considerar en la población pediátrica / Ulcer of Lipschütz, a diagnosis to consider in the pediatric population

La úlcera vulvar aguda o úlcera de Lipschütz corresponde a una entidad poco frecuente, por lo general, subdiagnosticada. Se caracteriza por la aparición súbita o aguda de lesiones ulcerosas y dolorosas en la vulva, la vagina y/o el periné, sin antecedente de contacto sexual en niñas y adolescentes. Su etiología permanece desconocida en la mayoría de los casos, aunque se ha asociado a agentes infecciosos. Para su estudio, se deben sospechar infecciones de transmisión sexual, reacciones adversas a medicamentos, enfermedades autoinmunes e inmunosupresión. Las lesiones ulcerosas desaparecen espontáneamente, de manera habitual, sin secuelas ni recurrencias a largo plazo. Se presenta el caso de una paciente adolescente de 11 años, sin inicio de actividad sexual ni menarquia y que consultó por un cuadro prodrómico de cuatro días, seguido del desarrollo agudo de úlceras genitales. Se discuten sus causas, presentación clínica, diagnósticos diferenciales y tratamiento.

Acute vulvar ulcer or ulcer of Lipschütz corresponds to a rare disease, being usually underdiagnosed. It is characterized by a sudden or acute development of ulcerous and painful lesions in the vulva, vagina and/or perineum, without a previous history of sexual contact in girls and teenagers. Its etiology remains unknown in most cases, although they have been associated with infectious agents. Their study includes the suspicion of sexually transmitted infections, adverse drug reactions, autoimmune diseases and immunosuppression. The ulcerative lesions disappear spontaneously, usually without sequelae or recurrences in the long term. We present the case of an 11-year-old adolescent patient, without sexual initiation, or menarche and who consulted due to a four-day prodromal condition, followed by the acute development of genital ulcers. Its causes, clinical presentation, differential diagnosis and treatment are discussed.

Úlcera vulvar aguda de Lipschütz / Acute vulvar ulcer of Lipschütz

RESUMEN La úlcera de Lipschütz es una entidad poco frecuente e infradiagnosticada. Se presenta el caso de una paciente de 24 años sin antecedente de contacto sexual que consultó por aparición súbita de úlceras vulvares dolorosas, en el contexto de un cuadro pseudogripal. Se discuten los principales diagnósticos diferenciales, dado que es una enfermedad no relacionada con enfermedades de transmisión sexual y poco reconocida por los profesionales de la salud, que precisa de manejo conservador.

ABSTRACT Lipschütz ulcer is a rare underdiagnosed entity. We present the case of a 24-year-old patient without history of sexual contact who consulted for sudden occurrence of painful vulvar ulcers, in the context of flu-like symptoms. The main differential diagnoses are discussed, as it is a disease unrelated to sexually transmitted diseases and little recognized by health professionals, which requires conservative management.

Úlceras genitales de Lipschütz: reporte de un caso pediátrico / Lipschütz ulcers: a pediatric case report

Las úlceras genitales son una patología poco frecuente en las consultas de pediatría, pero que generan gran ansiedad familiar. Las úlceras de Lipschütz son úlceras vulvares agudas, dolorosas y autolimitadas de causa desconocida. Aparecen en mujeres jóvenes que no han tenido relaciones sexuales previas o tras un período de abstinencia. Paciente de 10 años con úlceras vulvares dolorosas que, tres días antes de la aparición de las lesiones, había presentado un cuadro de deposiciones diarreicas y fiebre. Se realizó una anamnesis y exploración física detallada y se llevaron a cabo diferentes pruebas complementarias para descartar enfermedades infecciosas de origen venéreo y no venéreo, todas ellas negativas. Se indicó tratamiento sintomático, y se observó, al mes, una completa resolución del cuadro, por lo que se confirmó el diagnóstico de úlceras de Lipschütz.

Genital ulcers are a rare entity in pediatric consultation, but they generate great family anxiety. Lipschütz ulcers are acute, painful, and self-limiting vulvar ulcers of unknown cause. These ulcers appear in young women who have not had previous sexual intercourse or after a period of sexual abstinence. We present a 10-year-old girl with painful vulvar ulcers with a 3-day history of diarrhea and fever before the onset of the lesions. A complete anamnesis and detailed physical examination were carried out and complementary tests were performed to investigate sexually and non-sexually transmitted disease; the results were negative. Symptomatic treatment was started; at one-month follow-up a complete resolution of ulcers confirmed the diagnosis of ulcer of Lipschütz.

Nonsexually Acquired Genital Ulceration on the Perianal Area in an Elderly Man / 대한피부과학회지

Nonsexually acquired genital ulceration (NSAGU) is characterized by the abrupt appearance of painful genital ulcers, most often in young women. The onset may be preceded by an acute systemic illness such as fever or malaise, and many of the patients have a history of oral aphthosis. Its pathogenesis is not fully understood. In our case, a 72-year-old male visited with multiple painful erythematous ulcers on the perianal area. By history taking, laboratory tests, and skin biopsy, we excluded etiologies such as herpes simplex virus infection, syphilis, chancroid, and Behcet's disease. Thus, we diagnosed the patient with NSAGU and treated him with systemic steroids, nonsteroidal anti-inflammatory drugs, antibiotics, cyclosporine, and triamcinolone injection. Approximately 13 months after resolution, there had been no relapse. NSAGU is an uncommon condition and underrecognized by physicians. There have been no documentarily reported cases of NSAGU in Korea. Therefore, we present a case of NSAGU on the perianal area in an elderly man.

Úlcera genital aguda de Lipschütz: caso clínico / Lipschütz acute genital ulcer: case report

La úlcera genital aguda (UGA) o úlcera de Lipschütz constituye una infrecuente entidad clínica caracterizada por la aparición de úlceras genitales en niñas y adolescentes que no han iniciado su actividad sexual. El cuadro es de inicio agudo, con formación de úlceras dolorosas habitualmente precedidas en su aparición por manifestaciones sistémicas tales como fiebre, cefalea, astenia, adinamia, mialgias y adenopatías inguinales, y donde el estudio microbiológico de la lesión descarta un posible origen infeccioso. A pesar de presentar un cuadro clínico característico, esta enfermedad constituye una entidad poco conocida y por tanto subdiagnosticada, motivo por el cual presentamos el caso de una paciente de 10 años con diagnóstico de UGA realizado en el Departamento de Dermatología de la Pontificia Universidad Católica de Chile.

Acute genital ulcer (AGU) or Lipschütz ulcer is a rare clinical entity characterized by the appearance of genital ulcers in children and adolescents who have not initiated sexual activity. The picture is of acute onset, with formation of painful ulcers on their occurrence usually preceded by systemic manifestations such as fever, headache, fatigue, weakness, muscle pain and inguinal lymphadenopathy, and where the microbiological study of injury rule out a possible infectious origin. Despite presenting a characteristic clinical picture, this disease is a little known entity and under diagnosed, we present the case of a 10 years old girl diagnosed with UGA conducted at the Department of Dermatology, Catholic University of Chile.

Úlcera genital aguda en paciente adolescente / Acute genital ulcer in an adolescent patient

La úlcera vulvar aguda o úlcera de Lipschütz es una entidad poco frecuente y habitualmente subdiagnosticada. Es reconocida por la aparición súbita de lesiones ulcerosas y dolorosas en vulva, vagina y/o periné, sin antecedente de contacto sexual previo. La etiología es desconocida. El diagnóstico diferencial debe incluir causa infecciosa venérea o no, síntoma de cuadro autoinmune u otra enfermedad sistémica, o efecto secundario a la administración de fármacos. Las lesiones desaparecen espontáneamente, habitualmente sin secuelas y sin recurrencias a largo plazo.

Acute genital ulcer or Lipschütz ulcer is a rare and underdiagnosed, entity that usually presents an acute and painful ulcer in the vulva, lower vagina and/or perineum of nonvenereal origin. The etiology is unknown but the differential diagnosis must include sexually and nonsexually transmitted infections, autoimmune conditions, local manifestations of systemic illness and drug reactions. The lesions heal spontaneously and most patients have no recurrence and no long-term sequelae.