A 23-year-old woman presents to your office complaining of a growth around her vaginal opening. Recently, the growth has been itching and bleeding. On physical examination, she has a broad-based lesion measuring 2 cm in diameter on the posterior fourchette. Although there is no active bleeding, the lesion has some crusted blood along the right lateral margin.
Which of the following is the best way to treat this patient?
The lesions are most likely condyloma acuminata, also known as venereal warts. Condyloma acuminata are squamous lesions caused by a HPV, most commonly HPV 6 and 11. Treatment options include chemical or physical destruction, immune therapy, and surgical therapy. Self treatment with imiquimod, an immune modulator, is considered first line treatment for most simple condyloma. Other options for chemical destruction include in-office application of podophyllin or trichloroacetic acid. Surgical therapy could include laser therapy or excision. Podophyllum is not recommended for extensive disease because of toxicity (peripheral neuropathy). As this patient has large, bleeding lesions, local excision is the best treatment option.
At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive.
Without treatment, the next stage of this disease is clinically characterized by which of the following?
Syphilis is a chronic disease produced by the spirochete Treponema pallidum. Because of the spirochete’s extreme thinness, it is difficult to detect by light microscopy; therefore, spirochetes in the lesion exudate or tissue are diagnosed by use of a specially adapted technique known as dark-field microscopy. Clinically, syphilis is divided into primary, secondary, and tertiary (or late) stages. In primary syphilis a chancre develops. This is a painless ulcer with raised edges and an indurated base that is usually found on the vulva, vagina, or cervix. Secondary syphilis is the result of hematogenous dissemination of the spirochetes and thus is a systemic disease. There are a number of systemic symptoms depending on the major organs involved. The classic rash of secondary syphilis is red macules and papules over the palms of the hands and the soles of the feet. Secondary syphilis may also be manifest by mucocutaneous lesions or lymphadenopathy. The manifestations of tertiary, or late, syphilis include optic atrophy, tabes dorsalis, generalized paresis, aortic aneurysm, and gummas of the skin and bones.
A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV).
The diagnosis can be established by which of the following?
LGV is a chronic infection produced by C trachomatis. It is most commonly found in the tropics. The primary infection begins as a painless ulcer on the labia or vaginal vestibule; the patient usually consults the physician several weeks after the development of painful adenopathy in the inguinal and perirectal areas. Diagnosis can be established by culture or by demonstrating the presence of serum antibodies to C trachomatis. The differential diagnosis includes syphilis, chancroid, granuloma inguinale, carcinoma, and herpes. Chancroid is a sexually transmitted disease caused by H ducreyi that produces a painful, tender ulceration of the vulva. Donovan bodies are present in patients with granuloma inguinale, which is caused by C granulomatis. Therapy for both granuloma inguinale and LGV is administration of doxycycline. Chancroid is successfully treated with either azithromycin or ceftriaxone.
One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. An HIV antibody titer is obtained and is negative.
To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?
Persons at high risk for infection by HIV include homosexuals, bisexual males, women having sex with a bisexual or homosexual male partner, intravenous drug users, and hemophiliacs. African Americans are the racial/ethnic group most affected by HIV in the United States. Gay, bisexual, and other men who have sex with men account for the majority of new infections despite making up only 2% of the population. The virus can be transmitted through sexual contact, use of contaminated needles or blood products, and perinatal transmission from mother to child. The antibody titer usually becomes positive 2 to 8 weeks after exposure, and the presence of the antibody provides no protection against AIDS. Because of occasional delayed appearance of the antibody after initial exposure, if the initial test is negative, a repeat HIV screening test should be repeated at least 3 months after the likely exposure.
A 32-year-old G3P0030 obese woman comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at the age of 15 years. She has had three first-trimester pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms. She has a history of genital warts, but has never had an abnormal Pap smear. The patient says she does not use illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. Three weeks later, you receive the results of her Pap smear, which was reported as a HSIL.
Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?
The occurrence of cervical squamous dysplasia/carcinoma is caused by infection with the HPV, which is sexually transmitted. HPV causes genital warts as well. Women who begin sexual activity at a young age, have multiple sexual partners, do not use condoms, and have a history of sexually transmitted diseases are at an increased risk for cervical neoplasia. Alterations in immune function (such as in patients with HIV or on immunosuppressive therapy) place a patient at an increased risk of cervical neoplasia. Women who smoke tobacco have an increased risk of developing cervical dysplasia. There is no known increased risk of cervical dysplasia caused by the use of Depo-Provera.
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