Lipshutz's acute vulvar ulceration and SARS-CoV-2: possible correlation?

ABSTRACT

Background Vulvar ulcers are mostly caused by sexually transmitted microorganisms, like T. pallidum, HSV and, occasionally, HIV. When genital ulcers occur in not sexually active women and girls, Lipschutz's acute vulvar ulceration is the leading cause. This benign and self-remitting condition is a non-sex-ually acquired condition, generally related to flu-like infections or mono-nucleosis syndrome. A concurrent EBV infection occurs in nearly 50% of cases. Local hygiene, ulcers care and pain control are the mainstay of man-agement of this condition. Case study A 14-year-old-girl, not sexually active, arrives to the emergency referring since four days severe pain in the genital area, enhanced during voiding and associated with vulvar ulcers. No other symptoms are referred. A two days therapy with acyclovir has shown to be ineffective. Local inspection of external genitalia shows 4 ulcerated lesions <5 mm, with no active bleeding and a slight oedema of the right labium minus. Hymen shows to be intact. A diagnosis of Lipschutz ulcers is hypothesize. Some tests are thus performed microbiological cultures of the lesions are negative for HSV and VZV. Blood panel shows mild isolated lymphopenia and CRP is 2 mg/L. Serologies for CMV, HBV, HCV, HIV, Toxoplasmosis and T. pallidum are negative. Serologies for EBV turn out positive for past infection. PCR for SARS-Cov-2 is otherwise positive. We set home symptomatic therapy with ibuprofen alternating with co-paracetamol, and cold-water vulvar ir-rigation for voiding. A spontaneous resolution takes place in ten days. Due to her moving to Italy and to problems related to non-recognition of swiss immunity documents, the girl had to take the third dose of vaccine (BioN-Tech/Pfizer) one month after healing. Four days later the ulcers recur in the same place, although with eased symptoms. Conclusion According with other literature cases, Covid-19 infection could represent a likely explanation for this clinical situation. The recurrence after vaccine represents a strong evidence for this hypothesis. We therefore suggest to always include Covid-19 infection in the lab tests from now on, while screening for Lipschutz ulcers. Although benign, this clinical picture is con-firmed to be highly invalidating and do not respond to any specific ther-apy. The treatment of pain is critical. It is always important to consider whether pain management can be carried out at home, if hospitalization and eventual catheterization can be avoided.