Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 121: A 30-year-old man had sexual exposure to a commercial sex worker and develops a painless indurated ulcer on the glans after 3 weeks. What is the diagnosis?

A. Syphilis (Correct Answer)
B. Chancroid
C. Herpes Simplex Virus (HSV)
D. Traumatic

Explanation: The clinical presentation of a **painless, indurated ulcer** following an incubation period of approximately 3 weeks (range 9–90 days) is the classic hallmark of **Primary Syphilis**, caused by *Treponema pallidum*. The lesion, known as a **Chancre**, typically presents as a solitary, clean-based ulcer with "cartilage-like" induration and is often accompanied by painless, non-suppurative regional lymphadenopathy. **Why other options are incorrect:** * **Chancroid (Haemophilus ducreyi):** Presents as a **painful**, soft ulcer with a ragged, undermined edge and a necrotic base. It is often associated with painful, suppurative inguinal lymphadenitis (buboes). * **Herpes Simplex Virus (HSV):** Typically presents as multiple, small, **painful vesicles** that rupture to form shallow, non-indurated erosions [1]. It has a much shorter incubation period (2–7 days) [1]. * **Traumatic Ulcer:** These occur immediately after the injury, lack induration, and usually have a history of clear mechanical or chemical trauma. **High-Yield Clinical Pearls for NEET-PG:** * **Incubation Period:** Syphilis (3 weeks) vs. Chancroid (3–7 days) vs. HSV (2–7 days). * **Diagnosis:** The gold standard for primary syphilis is **Dark Ground Microscopy (DGM)** to visualize spirochetes. Serological tests (VDRL/RPR) may be negative in the first 1–2 weeks of the chancre [1]. * **Treatment:** The drug of choice for primary syphilis is **Benzathine Penicillin G** (2.4 million units IM, single dose). * **Key Distinction:** Remember the mnemonic: **"Syphilis is Silently (Painless) Hard (Indurated), Chancroid is a Soft (Non-indurated) Sore (Painful)."**

Question 122: Which of the following conditions is typically associated with cancerous involvement?

A. Chancre
B. Mucous patch
C. Syphilitic glossitis (Correct Answer)
D. Gumma

Explanation: **Explanation:** The correct answer is **Syphilitic glossitis**. This condition, specifically **chronic superficial glossitis** (also known as "leukoplakia of the tongue"), occurs during the tertiary stage of syphilis. It is considered a **premalignant condition**. Chronic inflammation and endarteritis lead to atrophy of the lingual papillae and the development of white patches (leukoplakia), which carry a significant risk of transforming into **Squamous Cell Carcinoma (SCC)** of the tongue. **Analysis of Incorrect Options:** * **Chancre (Option A):** This is the hallmark of **Primary Syphilis**. It is a painless, indurated ulcer that heals spontaneously without scarring. It is an infectious lesion, not a premalignant one. * **Mucous Patch (Option B):** Seen in **Secondary Syphilis**, these are highly infectious, shallow, greyish-white ulcers on the oral mucosa. They resolve with treatment and do not lead to malignancy. * **Gumma (Option C):** A characteristic of **Tertiary Syphilis**, a gumma is a localized area of granulomatous inflammation and coagulative necrosis. While destructive to local tissues (like the hard palate), it is not typically associated with cancerous transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Syphilis and Cancer:** Among all syphilitic lesions, chronic interstitial glossitis is the only one with a strong association with oral malignancy. * **The "Great Imitator":** Syphilis is caused by *Treponema pallidum*. * **Tertiary Syphilis Triad:** Gummas, Cardiovascular syphilis (Aortitis), and Neurosyphilis (Tabes dorsalis). * **Hutchinson’s Triad (Congenital Syphilis):** Interstitial keratitis, sensorineural hearing loss, and Hutchinson’s teeth (notched incisors).

Question 123: A false positive Fluorescent Treponemal Antibody Absorption (FTA-ABS) test is seen in which of the following conditions?

A. Human Immunodeficiency Virus (HIV) infection
B. Lyme disease (Correct Answer)
C. Infectious mononucleosis
D. Systemic Lupus Erythematosus (SLE)

Explanation: The **FTA-ABS (Fluorescent Treponemal Antibody Absorption)** test is a treponemal-specific test used to confirm syphilis. It detects antibodies against *Treponema pallidum*. However, false positives occur due to **cross-reactivity** with other spirochetes. **Why Lyme Disease is correct:** Lyme disease is caused by ***Borrelia burgdorferi***, which is a spirochete closely related to *Treponema pallidum*. Because they share similar surface antigens, antibodies produced against *Borrelia* can cross-react with the antigens used in the FTA-ABS test, leading to a false-positive result. **Analysis of Incorrect Options:** * **Systemic Lupus Erythematosus (SLE):** SLE is a classic cause of false positives in **non-treponemal tests** (VDRL/RPR) due to the presence of anti-cardiolipin antibodies [1]. It typically does *not* cause a false positive in specific treponemal tests like FTA-ABS. * **Infectious Mononucleosis & HIV:** These viral infections are well-known causes of biological false positives (BFP) in **VDRL/RPR** tests [1] (due to transient tissue damage and lipid release), but they rarely affect the specificity of the FTA-ABS. **High-Yield Clinical Pearls for NEET-PG:** * **VDRL False Positives (Mnemonic: PAREVE):** **P**regnancy, **A**cute infection (Malaria, Mono), **R**heumatoid Arthritis, **E**nteric fever, **V**iral (HIV, Hepatitis), **E**rythematosus (SLE). * **FTA-ABS False Positives:** Primarily seen in other spirochetal infections (Lyme disease, Yaws, Pinta, Bejel) and occasionally in Lepromatous Leprosy. * **Sequence of Testing:** Screening is done with VDRL/RPR (high sensitivity); confirmation is done with FTA-ABS or TPHA (high specificity). * **Persistence:** Unlike VDRL, which becomes negative after treatment, the FTA-ABS remains positive for life ("Treponemal memory").

Question 124: What is the drug of choice and its dosage for primary syphilis?

A. Amoxicillin 500 mg for 5 days
B. Benzathine penicillin 2.4 million units deep IM (Correct Answer)
C. Erythromycin 2 gm daily for 2 weeks
D. Doxycycline 100 mg daily for 2 weeks

Explanation: The causative agent of syphilis, *Treponema pallidum*, is highly sensitive to Penicillin. **Benzathine Penicillin G (2.4 million units IM in a single dose)** is the drug of choice for primary, secondary, and early latent syphilis (<1 year duration). **Why it is the correct choice:** *Treponema pallidum* has a slow replication cycle (30–33 hours). Benzathine penicillin is a long-acting repository formulation that maintains treponemicidal serum levels for 2–3 weeks following a single injection, ensuring the organism is killed during its division phase. It must be given **deep intramuscularly** (usually in the gluteal muscle) to ensure proper absorption. **Analysis of Incorrect Options:** * **Option A (Amoxicillin):** While penicillins are effective, oral amoxicillin is not the standard of care due to poor compliance and lack of sustained blood levels compared to the repository IM form. * **Option C (Erythromycin):** It is less effective than penicillin and does not reliably cross the placental barrier, making it unsuitable for preventing congenital syphilis. It is no longer a preferred alternative. * **Option D (Doxycycline):** Doxycycline (100 mg BID for 14 days) is the **second-line** treatment for patients with a penicillin allergy. However, it is not the "drug of choice" and requires a twice-daily regimen, unlike the single-dose penicillin. **High-Yield Clinical Pearls for NEET-PG:** 1. **Jarisch-Herxheimer Reaction:** An acute febrile reaction occurring within 24 hours of starting treatment (most common in secondary syphilis). It is managed with antipyretics, not by stopping the antibiotic. [1] 2. **Late Latent/Tertiary Syphilis:** Requires 2.4 million units IM **weekly for 3 weeks** (total 7.2 million units). 3. **Neurosyphilis:** Treated with **Aqueous Crystalline Penicillin G** (18–24 million units IV daily) for 10–14 days. 4. **Pregnancy:** Penicillin is the *only* recommended treatment. If the mother is allergic, she must undergo **penicillin desensitization**.

Question 125: Which of the following conditions is not caused by Chlamydia trachomatis?

A. Cervicitis
B. Urethritis
C. Vulvitis (Correct Answer)
D. Epididymitis

Explanation: The correct answer is **Vulvitis**. *Chlamydia trachomatis* (Serotypes D-K) is an obligate intracellular bacterium that specifically targets **columnar or transitional epithelium**. The vulva is covered by **stratified squamous epithelium**, which is resistant to chlamydial infection. Therefore, *C. trachomatis* does not cause primary vulvitis. **Analysis of Options:** * **Cervicitis (Option A):** Chlamydia is the most common cause of bacterial cervicitis. It infects the columnar epithelium of the endocervix, often presenting with mucopurulent discharge and friability. * **Urethritis (Option B):** It is the leading cause of Non-Gonococcal Urethritis (NGU) in men [1]. It infects the transitional epithelium of the urethra. * **Epididymitis (Option D):** In men under 35 years of age, *C. trachomatis* is the most common cause of acute epididymitis via ascending infection from the urethra [1]. **Clinical Pearls for NEET-PG:** 1. **Tissue Tropism:** Remember that Chlamydia "hates" squamous cells but "loves" columnar cells. This explains why it causes cervicitis (endocervix) but not vaginitis or vulvitis (squamous). 2. **Serotypes:** * **A, B, Ba, C:** Trachoma (leading cause of preventable blindness). * **D-K:** Genital infections (Urethritis, PID, Neonatal conjunctivitis/pneumonia). * **L1, L2, L3:** Lymphogranuloma Venereum (LGV) characterized by the "Groove sign." 3. **Treatment:** The drug of choice is **Doxycycline** (100 mg BID for 7 days). Azithromycin (1g stat) is an alternative, especially in pregnancy. 4. **Co-infection:** Always screen for *Neisseria gonorrhoeae* when Chlamydia is suspected [1].

Question 126: A woman approaches a physician for contraceptive advice. On examination, there were two symmetrical ulcers on the vulva, which were well-defined with a firm base. Which of the following is the most likely cause?

A. Chancre (Correct Answer)
B. Herpes
C. Syphilis
D. Malignancy

Explanation: The clinical presentation of **symmetrical, well-defined ulcers with a firm base** on the vulva is a classic description of **Kissing Chancres**, which are the hallmark of **Primary Syphilis**. **1. Why "Chancre" is the correct answer:** A chancre is the primary lesion of syphilis, caused by *Treponema pallidum*. It is characteristically a single, painless, indurated (firm) ulcer with a clean base and well-defined margins [1]. In women, when these ulcers occur on opposing surfaces of the labia, they can develop as "kissing ulcers" due to autoinoculation, resulting in the symmetrical presentation described. **2. Why other options are incorrect:** * **Herpes (HSV-2):** Typically presents as multiple, shallow, extremely painful vesicles or erosions on an erythematous base [1]. They are not indurated (firm) and are rarely perfectly symmetrical "kissing" ulcers. * **Syphilis:** While a chancre is a manifestation of syphilis, in medical entrance exams, if both the clinical sign (Chancre) and the disease (Syphilis) are listed, the specific lesion name is often the preferred answer for "the most likely cause" of the physical finding. However, "Chancre" specifically describes the *ulcer* mentioned in the stem. * **Malignancy:** Vulvar squamous cell carcinoma usually presents as a chronic, irregular, fungating mass or a non-healing ulcer in older women, often associated with pruritus, rather than acute symmetrical ulcers. **Clinical Pearls for NEET-PG:** * **Hard Chancre (Syphilis):** Painless, indurated, clean base, heals spontaneously in 3–6 weeks. * **Soft Chancre (Chancroid/H. ducreyi):** Painful, non-indurated, ragged edges, necrotic/purulent base. * **Investigation of Choice:** Dark-ground microscopy (DGM) is the gold standard for primary syphilis; VDRL/RPR may be negative in the early stages. * **Treatment:** Injection Benzathine Penicillin G (2.4 million units IM) is the drug of choice.

Question 127: What is the drug of choice for the treatment of gonorrhoea in a pregnant patient who is allergic to beta-lactam antibiotics?

A. Piperacillin
B. Ceftriaxone
C. Spectinomycin (Correct Answer)
D. Ciprofloxacin

Explanation: **Explanation:** The management of Gonorrhoea in pregnancy requires drugs that are both effective against *Neisseria gonorrhoeae* and safe for the fetus (Category B). **1. Why Spectinomycin is correct:** While the standard first-line treatment for uncomplicated gonorrhoea is a single dose of Ceftriaxone (a beta-lactam), it is contraindicated in patients with documented **beta-lactam allergies**. In such scenarios, especially during **pregnancy**, **Spectinomycin (2g IM single dose)** is the drug of choice. It is an aminocyclitol antibiotic that inhibits protein synthesis. It is highly effective against *N. gonorrhoeae* and is considered safe for use in all trimesters of pregnancy. **2. Why other options are incorrect:** * **Piperacillin:** This is a penicillin derivative (beta-lactam) [1]. It would trigger an allergic reaction in this patient and is not the standard treatment for gonorrhoea. * **Ceftriaxone:** Although it is the overall drug of choice for gonorrhoea, it is a third-generation cephalosporin. Due to the risk of cross-reactivity in patients with beta-lactam/penicillin allergies, it is avoided here [1]. * **Ciprofloxacin:** Fluoroquinolones are generally avoided in pregnancy due to potential risks to fetal cartilage development. Furthermore, there is widespread global resistance of *N. gonorrhoeae* to ciprofloxacin. **Clinical Pearls for NEET-PG:** * **Dual Therapy:** Always remember to treat for co-existing **Chlamydia** infection (usually with Azithromycin) unless ruled out. * **Spectinomycin Limitation:** It is ineffective against pharyngeal gonorrhoea; it is primarily used for urogenital and anorectal infections. * **Alternative:** If Spectinomycin is unavailable, a high dose of **Azithromycin (2g orally)** can be used, though it is associated with significant GI distress.

Question 128: Which is the most frequent cause of recurrent genital ulceration in a sexually active male?

A. Syphilis
B. Chancroid
C. Aphthous ulcer
D. Herpes genitalis (Correct Answer)

Explanation: **Explanation:** The correct answer is **Herpes genitalis (Option D)**. **Why Herpes genitalis is correct:** Genital Herpes, caused primarily by **Herpes Simplex Virus type 2 (HSV-2)** and occasionally HSV-1, is the most common cause of genital ulcers worldwide [1]. The hallmark of HSV infection is its ability to establish **latency** in the dorsal root ganglia [2]. Periodic reactivation of the virus leads to **recurrent** outbreaks of painful, grouped vesicles on an erythematous base that progress to shallow ulcers [1]. While the primary episode is usually severe, subsequent recurrences are common, making it the leading cause of recurrent genital ulceration [1], [2]. **Why other options are incorrect:** * **Syphilis (Option A):** Caused by *Treponema pallidum*, the primary chancre is typically a **painless**, solitary, indurated ulcer. While a patient can be reinfected, it does not characteristically "recur" from a latent state in the same way HSV does. * **Chancroid (Option B):** Caused by *Haemophilus ducreyi*, it presents as **painful**, soft ulcers with ragged edges and associated painful inguinal lymphadenopathy (buboes). It is an acute bacterial infection and does not cause chronic recurrence. * **Aphthous ulcers (Option C):** While these can be recurrent (e.g., in Behçet’s disease), they are less common in the genital region compared to the oral mucosa and are far less frequent than HSV in sexually active populations. **NEET-PG High-Yield Pearls:** * **Tzanck Smear:** Look for **multinucleated giant cells** and Cowdry type A inclusion bodies (diagnostic for HSV). * **Gold Standard Diagnosis:** PCR is the most sensitive test for HSV [1]. * **Painful vs. Painless:** Remember, **H**erpes and **H**erpes and **H**aemophilus (*Chancroid*) are **H**urtful (painful), while Syphilis and LGV are typically painless. * **Behçet’s Disease:** Consider this if the question mentions the triad of recurrent oral ulcers, genital ulcers, and uveitis.

Question 129: A patient presents with features of ataxia and a history of a painless penile ulcer approximately 3 years ago, followed by a maculopapular rash. He is currently on treatment. Which is the MOST sensitive test to monitor his response to treatment?

A. VDRL (Veneral Disease Research Laboratory)
B. RPR
C. TPI
D. CSF pleocytosis (Correct Answer)

Explanation: ### Explanation The patient’s clinical history (painless penile ulcer followed by a rash) indicates a progression from primary to secondary syphilis [1]. The current presentation of **ataxia** suggests **Neurosyphilis** (specifically Tabes Dorsalis). **Why CSF Pleocytosis is the Correct Answer:** In neurosyphilis, monitoring treatment success relies on objective markers of inflammation. **CSF pleocytosis (elevated WBC count)** is the **most sensitive indicator** of active CNS infection and the first parameter to normalize following effective therapy. A decreasing white cell count in the CSF confirms a positive response to treatment. If the cell count does not decrease after 6 months or is not normal by 2 years, re-treatment is indicated. **Analysis of Incorrect Options:** * **VDRL/RPR (Options A & B):** These are non-treponemal tests used for screening and monitoring systemic (non-CNS) syphilis [2]. While CSF-VDRL is highly specific for diagnosing neurosyphilis, it is less sensitive than pleocytosis for monitoring the *immediate* response to treatment, as titers may decline slowly. * **TPI (Option C):** The Treponema Pallidum Immobilization (TPI) test is a specific treponemal test. Treponemal tests (like TPI, FTA-ABS, and TPHA) usually remain positive for life ("immunological memory") and are therefore **useless** for monitoring treatment response or detecting reinfection. **NEET-PG High-Yield Pearls:** * **Diagnosis of Neurosyphilis:** CSF-VDRL is the "Gold Standard" for diagnosis due to its high specificity, but it lacks sensitivity. * **Order of Normalization:** Following successful treatment of neurosyphilis, CSF pleocytosis resolves first, followed by CSF protein levels, and finally CSF-VDRL titers. * **Drug of Choice:** Aqueous Crystalline Penicillin G (18–24 million units per day) for 10–14 days is the treatment of choice for neurosyphilis.

Question 130: Which of the following conditions does NOT typically present with a bleeding penile ulcer?

A. Syphilis (Correct Answer)
B. Lymphogranuloma venereum (LGV)
C. Chancroid
D. Granuloma inguinale

Explanation: ### Explanation The key to distinguishing genital ulcers in NEET-PG lies in their clinical morphology, specifically the presence of pain, induration, and vascularity. [1] **1. Why Syphilis is the Correct Answer:** Primary syphilis presents as a **Chancre**, which is classically described as a **painless, clean-based, and indurated** ulcer. The hallmark of a syphilitic ulcer is its lack of vascularity and friability; it does not bleed on touch. The induration (firmness) is due to an intense perivascular infiltrate, which actually restricts bleeding. [1] **2. Analysis of Incorrect Options:** * **Chancroid (*Haemophilus ducreyi*):** These are "soft chancres" that are **painful, purulent, and highly friable**. They bleed easily upon manipulation or contact. * **Granuloma Inguinale (Donovanosis):** Characterized by "beefy red," exuberant granulation tissue. These ulcers are **highly vascular** and bleed readily on touch (pseudobuboes are also common). * **Lymphogranuloma Venereum (LGV):** While the primary lesion is often transient and may go unnoticed, it can present as a shallow ulcer. However, in the context of differential diagnosis for "bleeding ulcers," Syphilis remains the most distinct "non-bleeder" due to its clean, non-friable base. **3. Clinical Pearls for NEET-PG:** * **Painful Ulcers:** Chancroid and Herpes (Mnemonic: **"H"** for **H**urt – **H**erpes and **H**aemophilus). [1] * **Painless Ulcers:** Syphilis, LGV, and Granuloma Inguinale. * **Donovan Bodies:** Safety-pin appearance on Giemsa stain (pathognomonic for Granuloma Inguinale). * **School of Fish Appearance:** Characteristic arrangement of *H. ducreyi* on Gram stain. * **Groove Sign:** Seen in LGV due to the inguinal ligament compressing enlarged lymph nodes.

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Syphilis

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Gonorrhea

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Chlamydial Infections

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Chancroid and Other Genital Ulcers

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Genital Herpes

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Human Papillomavirus Infections

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HIV and STIs

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Pelvic Inflammatory Disease

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STI Screening and Prevention

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Partner Notification and Treatment

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Sexually Transmitted Enteric Infections

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Special Populations Management

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Venerology — MCQs

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