Venerology Practice Questions

Q: A female presents with a 3 cm painless ulcer with raised edges on the labia majora. What is the most common cause?

Syphilis. **Explanation:** The clinical presentation of a **painless, indurated ulcer with raised edges** (often described as a "button-like" consistency) is the classic hallmark of a **Chancre**, which is the primary lesion of **Syphilis**, caused by *Treponema pallidum*. **Why Syphilis is correct:** Primary syphilis typically manifests as a single, firm, painless ulcer at the site of inoculation. The "raised edges" and lack of tenderness are key diagnostic features [1]. In females, these are often found on the labia majora, labia minora, or cervix. **Why the other options are incorrect:** * **Gonorrhea:** Typically presents as a purulent vaginal or urethral discharge (cervicitis/urethritis) rather than a discrete ulcer [2]. * **Herpes (HSV-2):** Characterized by **painful**, multiple, shallow, vesicular or ulcerative lesions on an erythematous base [1]. They are rarely painless or indurated. * **Chlamydia trachomatis:** While Serotypes L1-L3 cause *Lymphogranuloma Venereum (LGV)*, the initial ulcer is usually small, transient, and often goes unnoticed. The dominant feature of LGV is painful inguinal lymphadenopathy (Buboes) [3]. **NEET-PG High-Yield Pearls:** * **Painful vs. Painless Ulcers:** Remember the mnemonic **"H is for Hurt"** (Herpes and Hemophilus ducreyi/Chancroid are painful). Syphilis and LGV are generally painless. * **Donovanosis (Granuloma Inguinale):** Caused by *Klebsiella granulomatis*; presents as a painless, beefy-red, velvety ulcer that bleeds on touch (Donovan bodies on biopsy) [3]. * **Investigation of Choice:** Dark-field microscopy is the gold standard for primary syphilis; VDRL/RPR are screening tests (may be negative in early primary stage). * **Treatment:** Benzathine Penicillin G (2.4 million units IM) remains the drug of choice.

Q: Which of the following is characteristic of Granuloma inguinale?

Beefy red ulcers that bleed easily. **Granuloma Inguinale (Donovanosis)** is a chronic, progressive bacterial infection caused by the Gram-negative intracellular bacterium ***Klebsiella granulomatis*** (formerly *Calymmatobacterium granulomatis*). ### **Explanation of Options** * **Correct Answer (B):** The hallmark of Donovanosis is the presence of **beefy red, velvety, painless ulcers**. These lesions are highly vascular due to extensive granulation tissue, which causes them to **bleed easily on contact**. Despite the extensive tissue destruction, the ulcers remain painless unless secondarily infected. * **Option A:** *Gardnerella vaginalis* is the causative agent of Bacterial Vaginosis (associated with Clue cells and a fishy odor), not Granuloma inguinale. * **Option C:** Painful inflammatory nodules are characteristic of **Chancroid** (*Haemophilus ducreyi*) or **Lymphogranuloma Venereum (LGV)** during the bubo stage. Donovanosis typically presents with "pseudobuboes"—firm, painless swellings in the groin that are actually subcutaneous granulomas rather than true lymphadenopathy. * **Option D:** Donovanosis has a relatively **long and variable incubation period**, typically ranging from **1 to 12 weeks** (average 50 days). A short incubation period of 1–3 days is more characteristic of Chancroid. ### **High-Yield Clinical Pearls for NEET-PG** * **Pathognomonic Sign:** **Donovan Bodies** (safety-pin appearance) seen within large mononuclear cells (macrophages) on Giemsa or Wright stain. * **Clinical Presentation:** Painless, beefy red ulcers; **absence of true inguinal lymphadenopathy** (Pseudobuboes). * **Treatment of Choice:** **Azithromycin** (1g orally once weekly or 500mg daily) for at least 3 weeks or until lesions have completely healed. * **Differential Diagnosis:** Must be distinguished from Syphilis (painless but clean-based ulcer) and Chancroid (painful, dirty-based ulcer).

Q: A 34-year-old HIV-positive male, a truck driver, presented with small painless nodules and a sexual history 15 days prior. Subsequently, the nodules ruptured, forming open, fleshy, oozing lesions that developed into beefy red ulcers in the genital region. What is the most likely diagnosis?

Klebsiella granulomatis. **Explanation:** The clinical presentation of **beefy red, painless, fleshy ulcers** in the genital region is the hallmark of **Granuloma Inguinale (Donovanosis)**, caused by **Klebsiella granulomatis** (formerly *Calymmatobacterium granulomatis*). [1] **Why Option A is correct:** The incubation period (typically 1–4 weeks) and the progression from painless nodules to highly vascular, "beefy red" ulcers that bleed easily on contact (friable) are classic features. [1] Unlike many other STIs, Donovanosis is characterized by the **absence of significant inguinal lymphadenopathy** (though "pseudobuboes"—subcutaneous granulation tissue—may occur). [1] **Why other options are incorrect:** * **B. Chlamydia trachomatis (L1-L3):** Causes Lymphogranuloma Venereum (LGV). It typically presents with a transient, small, painless papule followed by painful, massive inguinal lymphadenopathy (the "Groove sign"). [1] * **C. Neisseria gonorrhea:** Primarily causes urethritis (purulent discharge) rather than genital ulcers. [2] * **D. Haemophilus ducreyi:** Causes Chancroid. These ulcers are characteristically **painful**, soft, and often associated with painful inflammatory inguinal buboes. [1] **NEET-PG High-Yield Pearls:** * **Pathognomonic Finding:** Presence of **Donovan Bodies** (safety-pin appearance) within macrophages on Giemsa or Wright stain. * **Clinical Appearance:** Often described as "velvety" or "serpiginous" ulcers. * **Treatment of Choice:** Azithromycin (1g once weekly or 500mg daily) for at least 3 weeks or until lesions heal. * **Risk Group:** Frequently seen in tropical regions and among individuals with high-risk sexual behavior (e.g., long-distance truck drivers).

Q: What is the recommended treatment for penicillin-resistant gonorrhea?

Ceftriaxone. **Explanation:** The correct answer is **Ceftriaxone**. **Why Ceftriaxone is correct:** *Neisseria gonorrhoeae* has developed widespread resistance to penicillin due to the production of **plasmid-mediated beta-lactamase (PPNG)** and chromosomal mutations. Consequently, third-generation cephalosporins, specifically **Ceftriaxone**, have become the first-line treatment [1]. Ceftriaxone is highly bactericidal, has a long half-life, and provides high cure rates for mucosal gonorrhea (urethral, cervical, and pharyngeal) [1]. **Why the other options are incorrect:** * **Ciprofloxacin:** Once a standard treatment, fluoroquinolone resistance (QRNG) is now globally prevalent, making it unreliable for empirical therapy [1]. * **Streptomycin:** This aminoglycoside is not effective against *N. gonorrhoeae* and is primarily used in the treatment of tuberculosis or plague. * **Erythromycin:** While used for neonatal prophylaxis (ophthalmia neonatorum), it is not the drug of choice for adult gonorrhea due to poor efficacy and gastrointestinal side effects. **High-Yield Clinical Pearls for NEET-PG:** 1. **Dual Therapy Concept:** To cover potential co-infection with *Chlamydia trachomatis*, the current CDC/WHO guidelines often recommend combining Ceftriaxone with **Azithromycin** (though some recent guidelines suggest Ceftriaxone monotherapy at higher doses, e.g., 500mg IM, if Chlamydia is ruled out) [1]. 2. **Disseminated Gonococcal Infection (DGI):** Ceftriaxone remains the drug of choice for systemic manifestations like arthritis-dermatitis syndrome. 3. **Spectinomycin:** This is an alternative for patients who are allergic to cephalosporins. 4. **Culture Media:** Remember **Thayer-Martin medium** (VPN: Vancomycin, Polymyxin, Nystatin) is the selective medium for *N. gonorrhoeae*.

Q: Schirmer test is done for?

Facial nerve. Explanation: The **Schirmer test** is a clinical diagnostic tool used to measure tear production (lacrimation). It is primarily used to evaluate dry eye syndrome or conditions like Sjögren’s syndrome. **Why Facial Nerve is the Correct Answer:** The **Facial nerve (CN VII)** provides parasympathetic innervation to the **lacrimal gland** via the Greater Petrosal Nerve. In cases of proximal facial nerve palsy (e.g., Bell’s palsy or lesions at the geniculate ganglion), tear production is significantly reduced. The Schirmer test is used topographically to determine the level of the facial nerve lesion; if lacrimation is absent, the lesion is at or proximal to the geniculate ganglion. **Why Other Options are Incorrect:** * **Oculomotor Nerve (CN III):** This nerve controls most extraocular muscles, the levator palpebrae superioris (eyelid elevation), and pupillary constriction. It does not control lacrimation. * **Optic Nerve (CN II):** This is a purely sensory nerve responsible for vision and the afferent limb of the pupillary light reflex. It has no motor or secretomotor function. **High-Yield Clinical Pearls for NEET-PG:** * **Procedure:** A filter paper (Whatman No. 41) is placed in the lower conjunctival fornix for 5 minutes. * **Interpretation:** Normal wetting is >15 mm. Wetting <5 mm is diagnostic of **Keratoconjunctivitis Sicca (Dry Eye)**. * **Topographic Diagnosis:** In Facial Nerve palsy, the Schirmer test helps differentiate a lesion in the Internal Auditory Meatus/Geniculate ganglion (abnormal test) from a lesion in the Stylomastoid foramen (normal test). * **Sjögren’s Syndrome:** Often presents with a positive Schirmer test along with xerostomia (dry mouth).

Q: Which of the following features is NOT associated with Chancroid?

Painless lymphadenopathy. Everything is painful in Chancroid, a sexually transmitted infection caused by **_Haemophilus ducreyi_** [1]. 1. **Why Option B is correct:** In Chancroid, the inguinal lymphadenopathy (buboes) is characteristically **exceedingly painful**, inflammatory, and often unilateral [1]. These buboes may become fluctuant and spontaneously rupture. Painless lymphadenopathy is instead a feature of Primary Syphilis or Lymphogranuloma Venereum. 2. **Analysis of other options:** * **Option A (Painful ulcer):** Unlike the painless chancre of syphilis, the ulcer in Chancroid is soft, friable, and very painful [1]. * **Option C (School of fish appearance):** On Gram stain of the discharge, the organisms arrange themselves in parallel rows or chains, described as a "school of fish" appearance. * **Option D (Azithromycin):** According to CDC guidelines, a single 1g oral dose of Azithromycin is a first-line treatment for Chancroid. **Clinical Pearls for NEET-PG:** * **The "H" Rule:** _**H**. ducreyi_ causes a **H**eavy (large), **H**orrible (painful) ulcer that makes you **"cry"** (ducreyi). * **Syphilis vs. Chancroid:** Syphilis (Chancre) is painless with painless nodes; Chancroid is painful with painful nodes [1]. * **Autoinoculation:** Chancroid ulcers often show "kissing lesions" on opposing skin surfaces due to autoinoculation [1].

Q: What is the most common cause of nongonococcal urethritis?

Chlamydia. **Explanation:** **Nongonococcal Urethritis (NGU)** refers to inflammation of the urethra not caused by *Neisseria gonorrhoeae*. It is the most common sexually transmitted syndrome in men [1]. **Why Chlamydia is Correct:** * **Chlamydia trachomatis** (Serovars D-K) is the most common cause of NGU worldwide, accounting for approximately **30% to 50%** of cases [1]. It is an obligate intracellular bacterium. Clinically, NGU typically presents with a longer incubation period (7–14 days) and a more mucoid, scant discharge compared to the purulent discharge of gonorrhea [1]. **Analysis of Incorrect Options:** * **B. Mycoplasma:** *Mycoplasma genitalium* is the second most common cause of NGU (approx. 15–25%). It is increasingly recognized due to its association with persistent or recurrent urethritis and its resistance to azithromycin [1]. * **C. Trichomonas:** *Trichomonas vaginalis* is a protozoan cause of NGU. While significant in certain populations, it is much less common than Chlamydia [1]. * **D. Gram-negative rod:** While *E. coli* can cause urinary tract infections (UTIs), it is an uncommon cause of primary urethritis in sexually active young men unless associated with insertive anal intercourse. **High-Yield Clinical Pearls for NEET-PG:** 1. **Dual Infection:** Up to 30% of patients with gonorrhea are co-infected with *C. trachomatis*. Therefore, treatment usually covers both (e.g., Ceftriaxone + Azithromycin/Doxycycline). 2. **Diagnosis:** The gold standard for diagnosing Chlamydia is **Nucleic Acid Amplification Testing (NAAT)** using a first-void urine sample or urethral swab. 3. **Complications:** Untreated NGU can lead to epididymitis in men and Pelvic Inflammatory Disease (PID) or infertility in women. 4. **Reiter’s Syndrome:** NGU is a classic trigger for Reactive Arthritis (triad of urethritis, conjunctivitis, and arthritis).

Q: Which of the following infections is not sexually transmitted?

Bacterial vaginosis. **Explanation:** The correct answer is **Bacterial Vaginosis (BV)**. While BV is associated with sexual activity and is more common in sexually active individuals, it is not classified as a **Sexually Transmitted Infection (STI)** [1]. **1. Why Bacterial Vaginosis is the correct answer:** BV is a **dysbiosis** (imbalance) of the normal vaginal flora, characterized by a reduction in hydrogen peroxide-producing *Lactobacillus* and an overgrowth of anaerobic bacteria like *Gardnerella vaginalis*, *Mobiluncus*, and *Atopobium vaginae*. It is considered a "sexually associated" condition rather than an infection transmitted from person to person via coitus. Treatment of the male partner does not prevent recurrence, further confirming it is not a traditional STI. **2. Why the other options are incorrect:** * **Lymphogranuloma venereum (LGV):** Caused by *Chlamydia trachomatis* (serovars L1, L2, L3). It is a classic STI presenting with painless ulcers followed by painful inguinal lymphadenopathy (Buboes) [2]. * **Genital Herpes:** Caused by Herpes Simplex Virus (HSV-2 > HSV-1). It is one of the most common STIs worldwide, characterized by painful, fluid-filled vesicles [3]. * **Syphilis:** Caused by the spirochete *Treponema pallidum*. It is a systemic STI transmitted through direct contact with an infectious lesion (chancre). **Clinical Pearls for NEET-PG:** * **Amsel’s Criteria for BV (3 out of 4 required):** 1. Homogeneous white-grey discharge. 2. Vaginal pH > 4.5. 3. Positive **Whiff test** (fishy odor with 10% KOH). 4. Presence of **Clue cells** on saline microscopy (Gold Standard). * **Nugent Scoring:** The diagnostic gold standard for BV based on Gram stain. * **Drug of Choice:** Oral or topical **Metronidazole**. [4] * **Note:** BV increases the risk of acquiring other STIs (like HIV) due to the loss of protective lactobacilli.

Question 1

A female presents with a 3 cm painless ulcer with raised edges on the labia majora. What is the most common cause?

Accepted Answer

Syphilis

Answer

Gonorrhea

Answer

Herpes

Answer

Chlamydia trachomatis

Question 2

Which of the following is characteristic of Granuloma inguinale?

Accepted Answer

Beefy red ulcers that bleed easily

Answer

Is caused by Gardnerella vaginalis

Answer

Painful inflammatory nodules

Answer

Short incubation period of 3 days

Question 3

A 34-year-old HIV-positive male, a truck driver, presented with small painless nodules and a sexual history 15 days prior. Subsequently, the nodules ruptured, forming open, fleshy, oozing lesions that developed into beefy red ulcers in the genital region. What is the most likely diagnosis?

Accepted Answer

Klebsiella granulomatis

Answer

Chlamydia trachomatis

Answer

Neisseria gonorrhea

Answer

Haemophilus ducreyi

Question 4

What is the recommended treatment for penicillin-resistant gonorrhea?

Accepted Answer

Ceftriaxone

Answer

Ciprofloxacin

Answer

Streptomycin

Answer

Erythromycin

Question 5

Schirmer test is done for?

Accepted Answer

Facial nerve

Answer

Oculomotor nerve

Answer

Optic nerve

Answer

All

Question 6

A young man presents with asymptomatic macules and erythematous painless lesions over the glans with generalized lymphadenopathy. What is the treatment of choice in this condition?

Accepted Answer

Benzathine penicillin

Answer

Ceftriaxone

Answer

Acyclovir

Answer

Fluconazole

Question 7

Which of the following features is NOT associated with Chancroid?

Accepted Answer

Painless lymphadenopathy

Answer

Painful ulcer

Answer

School of fish appearance on staining

Answer

Azithromycin is useful in treatment

Question 8

What is the most common cause of nongonococcal urethritis?

Accepted Answer

Chlamydia

Answer

Mycoplasma

Answer

Trichomonas

Answer

Gram negative rod

Question 9

Which of the following infections is not sexually transmitted?

Accepted Answer

Bacterial vaginosis

Answer

Lymphogranuloma venereum

Answer

Genital herpes

Answer

Syphilis

Question 10

Tertiary syphilis most frequently involves which of the following structures?

Accepted Answer

Central nervous system (CNS)

Answer

Liver

Answer

Testes

Answer

Aorta

Venerology — MCQs

Venerology — MCQs

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