Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 131: A 43-year-old businessman presents with a purulent penile discharge, reporting unprotected sexual contact one week prior. Gram stain of the discharge does not show any organisms. What is the most likely cause of the discharge?

A. Bowen disease
B. Chlamydia trachomatis (Correct Answer)
C. Herpes simplex virus
D. Treponema pallidum

Explanation: **Explanation:** The clinical presentation of purulent penile discharge following unprotected sexual contact is characteristic of **Urethritis**. Urethritis is broadly classified into Gonococcal Urethritis (GU) and Non-Gonococcal Urethritis (NGU) [1]. **Why Chlamydia trachomatis is correct:** * **Gram Stain Findings:** The most crucial clue in this question is that the Gram stain shows **no organisms**. *Neisseria gonorrhoeae* (the cause of GU) would appear as Gram-negative intracellular diplococci. * **Aetiology of NGU:** *Chlamydia trachomatis* (serotypes D-K) is the most common cause of Non-Gonococcal Urethritis [1]. Because Chlamydia is an obligate intracellular bacterium, it does not visualize on a standard Gram stain, leading to the "sterile" appearance of the discharge under a microscope despite the presence of pus cells (neutrophils). * **Incubation Period:** The one-week timeframe fits the typical 7–14 day incubation period for Chlamydia (longer than the 2–5 days typical for Gonorrhea) [1]. **Why other options are incorrect:** * **Bowen disease:** This is a form of intraepidermal squamous cell carcinoma (carcinoma in situ) presenting as a persistent red, scaly plaque, not an acute purulent discharge [2]. * **Herpes simplex virus (HSV):** Typically presents with painful, grouped vesicles on an erythematous base that progress to shallow ulcers [2]. While it can cause dysuria, it does not cause purulent discharge. * **Treponema pallidum:** The causative agent of Syphilis, which typically presents as a painless, indurated ulcer (chancre). It is a spirochete and does not cause urethral discharge. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the investigation of choice for *C. trachomatis*. * **Treatment:** The current CDC recommendation for NGU/Chlamydia is **Doxycycline** (100 mg BID for 7 days). Azithromycin (1g single dose) is an alternative. * **Co-infection:** Always treat for both Gonorrhea and Chlamydia if the diagnosis is uncertain, as co-infection is highly prevalent.

Question 132: A patient presents with a painless penile ulcer of 2 weeks duration. A VDRL test is reactive at a dilution of 1:4. The patient also reports a recent diagnosis of hepatitis A. Which one of the following actions would be most appropriate?

A. Order a confirmatory test such as FTA-ABS test (Correct Answer)
B. Order a rapid plasma reagin (RPR) test
C. Perform a spinal tap to rule out neurosyphilis
D. Repeat the VDRL test

Explanation: ### Explanation The patient presents with a painless penile ulcer (chancre) and a reactive VDRL, which is highly suggestive of **Primary Syphilis**. However, the VDRL (Venereal Disease Research Laboratory) is a **non-treponemal test** that detects non-specific antibodies (reagin) against cardiolipin-cholesterol-lecithin antigen. **1. Why Option A is Correct:** Non-treponemal tests (VDRL, RPR) are prone to **Biological False Positives (BFP)** [1]. A BFP is defined as a reactive non-treponemal test with a negative treponemal test. Common causes of BFP include acute infections (like **Hepatitis A**, malaria, or infectious mononucleosis) and chronic conditions (SLE, leprosy, or pregnancy) [1]. Since this patient has a concurrent Hepatitis A infection and a low VDRL titer (1:4), it is mandatory to confirm the diagnosis with a **specific treponemal test** such as **FTA-ABS** (Fluorescent Treponemal Antibody Absorption) or TPHA [1]. **2. Why Other Options are Incorrect:** * **Option B:** RPR is another non-treponemal test. If VDRL is a false positive due to Hepatitis A, the RPR is also likely to be falsely reactive [1]. * **Option C:** A spinal tap is indicated for suspected Neurosyphilis (tertiary stage or neurological symptoms). It is not indicated for a primary painless ulcer. * **Option D:** Repeating the same non-specific test does not resolve the diagnostic dilemma of a potential biological false positive [1]. ### Clinical Pearls for NEET-PG * **Screening vs. Confirmatory:** Use non-treponemal tests (VDRL/RPR) for screening and monitoring treatment response (titers fall after therapy). Use treponemal tests (FTA-ABS/TPHA) for confirmation; these usually remain positive for life [1]. * **BFP Titers:** Biological false positives usually present with low titers (typically <1:8). * **Prozone Phenomenon:** A false-negative VDRL due to very high antibody titers (seen in secondary syphilis); requires serum dilution for detection [1]. * **Drug of Choice:** Parenteral **Benzathine Penicillin G** remains the gold standard for treating primary syphilis.

Question 133: Which of the following drugs are included in the 'Green STD kit'?

A. Azithromycin, Cefixime
B. Secnidazole, Fluconazole (Correct Answer)
C. Acyclovir
D. Azithromycin, Doxycycline

Explanation: In India, the National AIDS Control Organization (NACO) has standardized the management of Sexually Transmitted Infections (STIs) through color-coded kits for syndromic management [1]. This approach ensures immediate treatment based on clinical presentation without waiting for laboratory confirmation. ### **Explanation of the Correct Answer** **Option B (Secnidazole, Fluconazole)** is the correct answer because the **Green Kit** is designated for the treatment of **Vaginal Discharge** [1]. * **Fluconazole (150 mg, 1 tablet):** Targets *Candida albicans* (Candidiasis) [1]. * **Secnidazole (2 g, 1 tablet):** Targets *Trichomonas vaginalis* and anaerobic bacteria causing Bacterial Vaginosis. ### **Analysis of Incorrect Options** * **Option A (Azithromycin, Cefixime):** These are components of the **Grey Kit**, used for Urethral Discharge (Gonorrhea and Chlamydia) and Cervicovaginal Discharge. * **Option C (Acyclovir):** This is the **Red Kit**, used for Genital Herpes (Herpetic ulcers) [1]. * **Option D (Azithromycin, Doxycycline):** This combination is not a standard standalone kit. However, Azithromycin is part of the Grey/White kits, and Doxycycline is part of the White/Blue kits. ### **High-Yield Clinical Pearls for NEET-PG** To excel in Venerology questions, memorize the NACO Color Coding: | Kit Color | Indication | Drugs Included | | :--- | :--- | :--- | | **Grey** | Urethral/Cervical Discharge | Azithromycin (1g) + Cefixime (400mg) | | **Green** | Vaginal Discharge | **Fluconazole (150mg) + Secnidazole (2g)** | | **White** | Genital Ulcer (Non-herpetic) | Benzathine Penicillin (2.4 MU) + Azithromycin (1g) | | **Blue** | Genital Ulcer (Penicillin allergic) | Azithromycin (1g) + Doxycycline (100mg BID x 15 days) | | **Red** | Genital Ulcer (Herpetic) | Acyclovir (400mg TID x 7 days) | | **Yellow** | Lower Abdominal Pain (PID) | Ceftriaxone (IM) + Doxycycline + Metronidazole | | **Black** | Inguinal Bubo | Azithromycin (1g) + Doxycycline (100mg BID x 21 days) | **Key Fact:** The Green kit is unique because it consists of a single-day, single-dose oral regimen, improving patient compliance.

Question 134: An adult male presented 4 weeks after intercourse with fever, a rubbery ulcer, and inguinal lymphadenopathy. What is the causative organism?

A. Lymphogranuloma venereum (LGV) (Correct Answer)
B. Syphilis
C. Chancroid
D. Human Immunodeficiency Virus (HIV)

Explanation: ### Explanation The clinical presentation of a **rubbery ulcer** (primary lesion) followed by **inguinal lymphadenopathy** and systemic symptoms like **fever** approximately 3–6 weeks after exposure is characteristic of **Lymphogranuloma venereum (LGV)** [1]. **1. Why LGV is the Correct Answer:** LGV is caused by **Chlamydia trachomatis (serotypes L1, L2, L3)**. It progresses through three stages [1]: * **Primary stage:** A small, painless, often transient "rubbery" papule or ulcer at the site of inoculation. * **Secondary stage (Inguinal syndrome):** Occurs 2–6 weeks later, characterized by painful, firm inguinal lymphadenopathy (buboes) [1]. The "Groove sign" (enlargement of nodes above and below the inguinal ligament) is a classic pathognomonic finding. * **Systemic symptoms:** Fever, chills, and malaise are common during the lymphatic spread [1]. **2. Why the Other Options are Incorrect:** * **Syphilis (*Treponema pallidum*):** Presents with a **painless, indurated (hard)** chancre. While it causes regional lymphadenopathy, the nodes are typically non-tender and rubbery, and the primary ulcer usually heals before systemic symptoms (Secondary Syphilis) appear weeks later. * **Chancroid (*Haemophilus ducreyi*):** Presents with a **painful, soft, ragged ulcer** (non-rubbery) and painful, suppurative inguinal lymphadenopathy [1]. The incubation period is very short (3–7 days). * **HIV:** While acute retroviral syndrome causes fever and lymphadenopathy, it does not typically present with a localized genital ulcer as the primary manifestation. **3. NEET-PG Clinical Pearls:** * **Drug of Choice for LGV:** Doxycycline (100 mg BID for 21 days). * **Groove Sign:** Produced by the inguinal ligament dividing the matted superficial and deep inguinal nodes. * **Esthiomene:** A late-stage complication of LGV involving chronic lymphatic obstruction leading to elephantiasis of the external genitalia.

Question 135: Regarding syphilis, all of the following statements are true, except?

A. VDRL titre decreases or becomes absent after treatment (Correct Answer)
B. VDRL becomes positive 10-14 days after infection
C. The earliest serological test to become positive in untreated primary syphilis is TPHA
D. Yaws and Pinta cannot be differentiated from syphilis serologically

Explanation: ### Explanation **Correct Answer: A. VDRL titre decreases or becomes absent after treatment** *Note: In the context of this question, Option A is the "False" statement because it is generally considered a **true** clinical fact, but the question asks for the "Except" (the false statement). However, based on standard NEET-PG patterns, Option C is actually the most factually incorrect statement.* **1. Why Option C is the False Statement (The "Except"):** The earliest serological tests to become positive in syphilis are **FTA-ABS (Fluorescent Treponemal Antibody Absorption)** or **EIA/CLIA**, not TPHA [1]. FTA-ABS typically becomes positive within 3 weeks of infection (during the primary chancre stage), whereas TPHA (Treponema Pallidum Hemagglutination Assay) takes longer to turn positive and is often negative in early primary syphilis. **2. Analysis of Other Options:** * **Option A (True):** VDRL is a non-specific (reaginic) test used to monitor treatment response. A four-fold drop in titre (e.g., 1:32 to 1:8) indicates successful therapy. In many patients, it eventually becomes non-reactive (seroconversion). * **Option B (True):** VDRL usually becomes positive 1–2 weeks after the appearance of the primary chancre (approx. 4–6 weeks after initial infection) [1]. * **Option D (True):** Non-venereal treponematoses like Yaws (*T. pallidum pertenue*) and Pinta (*T. carateum*) are morphologically and serologically indistinguishable from Syphilis. Diagnosis relies on clinical presentation and geography. **Clinical Pearls for NEET-PG:** * **Screening Test:** VDRL / RPR (Non-specific, sensitive, used for monitoring) [1]. * **Specific/Confirmatory Test:** FTA-ABS, TPHA, TP-PA (Specific, remain positive for life). * **Prozone Phenomenon:** False negative VDRL due to very high antibody titres (seen in Secondary Syphilis); requires serum dilution [1]. * **Biological False Positive (BFP):** Seen in SLE, Leprosy, Malaria, and Pregnancy [1]. * **Jarisch-Herxheimer Reaction:** Acute febrile reaction following penicillin treatment due to release of endotoxins from dying spirochetes.

Question 136: What is the incubation period of syphilis?

A. 10-14 days
B. 30-60 days
C. 9-90 days (Correct Answer)
D. 3-6 months

Explanation: **Explanation:** Syphilis is a chronic systemic infection caused by the spirochete *Treponema pallidum*. The correct incubation period is **9 to 90 days**, with an average of **3 weeks (21 days)**. This period represents the time from initial inoculation through micro-abrasions in the skin or mucous membranes to the appearance of the primary chancre. * **Why Option C is correct:** The wide range (9–90 days) reflects the variability in host immune response and the size of the initial inoculum. After the spirochetes enter the body, they replicate locally and disseminate systemically via lymphatics and the bloodstream even before the primary lesion appears. * **Why Options A, B, and D are incorrect:** * **10-14 days:** This is too narrow and represents the incubation period for other STIs like Chancroid (usually 3–7 days) or Lymphogranuloma Venereum (3–30 days). * **30-60 days:** While this falls within the range, it misses the common earlier presentations. * **3-6 months:** This is significantly longer than the typical incubation for primary syphilis; however, secondary syphilis usually develops 2–8 weeks after the appearance of the chancre. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Syphilis:** Characterized by a **painless, indurated ulcer (Hard Chancre)** with painless regional lymphadenopathy. * **Diagnosis:** The investigation of choice for a primary chancre is **Dark Ground Microscopy (DGM)**, as serological tests (VDRL/RPR) may still be negative in the first 1–2 weeks of the lesion. * **Treatment:** The drug of choice for primary, secondary, and early latent syphilis is a single dose of **Benzathine Penicillin G (2.4 million units IM)**. * **Jarisch-Herxheimer Reaction:** An acute febrile reaction occurring within 24 hours of starting treatment, caused by the release of endotoxins from dying spirochetes.

Question 137: What is true about chancroid?

A. Incubation period is 3 to 10 weeks.
B. Characterised typically by prodromal symptoms and systemic reaction.
C. Painful ulcer with irregular erythematous non-indurated margins. (Correct Answer)
D. Ulcer base is hard and indurated.

Explanation: **Chancroid** is a sexually transmitted infection caused by the Gram-negative coccobacillus ***Haemophilus ducreyi*** [1]. It is a classic cause of painful genital ulcer disease [1]. ### **Explanation of Options** * **Correct Answer (C):** Chancroid is characterized by the **"Four P’s"**: **P**ainful, **P**urulent, **P**olymicrobial (historically thought), and **P**unced-out appearance. The ulcers are typically soft (non-indurated) with ragged, undermined, and erythematous margins [1]. The lack of induration is a key clinical differentiator from syphilis. * **Option A:** The incubation period of Chancroid is short, typically **3 to 7 days** [1]. An incubation period of 3 to 10 weeks is more characteristic of Lymphogranuloma Venereum (LGV) or Syphilis. * **Option B:** Chancroid is a localized infection. Prodromal symptoms and systemic reactions (fever, malaise) are characteristic of **Primary Herpes Simplex Virus (HSV)** infection, not chancroid. * **Option D:** A hard, indurated base is the hallmark of a **Chancre (Primary Syphilis)**. In contrast, Chancroid is often referred to as a "Soft Chancre" because the base is friable and non-indurated [1]. ### **High-Yield Clinical Pearls for NEET-PG** * **School of Fish Appearance:** On Gram stain, *H. ducreyi* shows a characteristic "railroad track" or "school of fish" pattern. * **Bubo Formation:** About 50% of patients develop painful, inflammatory inguinal lymphadenopathy (buboes), which are typically **unilateral** and may suppurate (rupture) [1]. * **Treatment:** The CDC recommends a single dose of **Azithromycin (1g orally)** or Ceftriaxone (250mg IM). * **Differential Diagnosis:** Always rule out Syphilis and HSV. Remember: **Syphilis is Painless; Chancroid is Painful.**

Question 138: What is the most common cause of genital herpes?

A. Herpes Simplex Virus type 1 (HSV-1)
B. Herpes Simplex Virus type 2 (HSV-2) (Correct Answer)
C. Varicella-Zoster Virus (HSV-3)
D. Epstein-Barr Virus (HSV-4)

Explanation: **Explanation:** Genital herpes is a chronic, lifelong viral infection primarily caused by the **Herpes Simplex Virus type 2 (HSV-2)**. While both HSV-1 and HSV-2 can cause genital lesions, HSV-2 remains the most common cause globally and is almost exclusively transmitted through sexual contact [1]. It typically presents with painful, grouped vesicular eruptions on an erythematous base, which later progress to shallow ulcers [2]. **Analysis of Options:** * **HSV-2 (Option B):** Historically and statistically, the majority of recurrent genital herpes cases are caused by HSV-2 [1]. It has a higher rate of viral shedding and a significantly higher frequency of symptomatic recurrences compared to HSV-1 in the genital tract. * **HSV-1 (Option A):** Traditionally associated with orofacial lesions ("cold sores"), HSV-1 is increasingly causing primary genital herpes in developed nations due to changes in sexual practices (oral-genital contact). However, it is still second to HSV-2 as the overall cause [1]. * **Varicella-Zoster Virus (Option C):** This virus causes Chickenpox (primary infection) and Herpes Zoster/Shingles (reactivation). It typically follows a dermatomal distribution and is not a cause of genital herpes. * **Epstein-Barr Virus (Option D):** EBV is the causative agent of Infectious Mononucleosis and certain malignancies (e.g., Burkitt lymphoma). It does not cause genital ulcerative disease. **NEET-PG High-Yield Pearls:** * **Diagnosis:** The gold standard is **Viral Culture** or **PCR** (PCR is more sensitive) [2]. * **Cytology:** **Tzanck Smear** shows characteristic **multinucleated giant cells** with Cowdry Type A inclusion bodies. * **Treatment:** Oral **Acyclovir**, Valacyclovir, or Famciclovir. Note that these drugs do not cure the latent infection in the sacral ganglia. * **Neonatal Herpes:** Most commonly occurs during delivery through an infected birth canal; HSV-2 carries a higher risk of transmission than HSV-1.

Question 139: Non-gonococcal urethritis is caused by which of the following?

A. Chlamydia (Correct Answer)
B. Lymphogranuloma venereum (LGV)
C. Syphilis
D. Gardnella vaginalis

Explanation: **Explanation:** **Non-gonococcal urethritis (NGU)** refers to an inflammation of the urethra not caused by *Neisseria gonorrhoeae* [1]. It is the most common sexually transmitted syndrome in men. 1. **Why Chlamydia is Correct:** * ***Chlamydia trachomatis* (Serotypes D-K)** is the most common cause of NGU worldwide, accounting for approximately 30–50% of cases [1]. It is an obligate intracellular bacterium. Patients typically present with a mucoid or clear urethral discharge and dysuria, often with a longer incubation period (7–14 days) compared to gonorrhea [1]. 2. **Why the Other Options are Incorrect:** * **Lymphogranuloma venereum (LGV):** Caused by *C. trachomatis* serotypes **L1, L2, and L3**. While it is a chlamydial infection, it primarily presents with painless genital ulcers followed by painful inguinal lymphadenopathy (buboes) rather than simple urethritis. * **Syphilis:** Caused by *Treponema pallidum*. Its primary manifestation is a **painless chancre** (hard sore). It does not typically cause urethral discharge or urethritis. * **Gardnerella vaginalis:** This is the primary organism associated with **Bacterial Vaginosis (BV)** in women. While it can be found in the male urethra, it is rarely a primary cause of symptomatic urethritis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of NGU:** *Chlamydia trachomatis* [1]. * **Second most common cause:** *Mycoplasma genitalium* (often associated with persistent or recurrent NGU) [1]. * **Diagnosis:** Presence of >2 WBCs per oil immersion field on a Gram stain of urethral discharge (and absence of Gram-negative intracellular diplococci). * **Treatment:** The current CDC recommendation for NGU is **Doxycycline** (100 mg BID for 7 days). Azithromycin is now considered a second-line option due to increasing resistance in *M. genitalium* [1]. * **Co-infection:** Always treat for both Gonorrhea and Chlamydia if the diagnosis is uncertain, as they frequently co-exist.

Question 140: A patient presents with mental confusion, visual and auditory hallucinations, perceived changes of body shape, swelling of the tongue, and a fear of impending death after being treated for primary chancre of syphilis with an intramuscular injection. What is the likely diagnosis?

A. Jarisch-Herxheimer Reaction
B. Hoigne Syndrome (Correct Answer)
C. Undiagnosed Psychosis
D. Schizophrenia

Explanation: ### Explanation The patient is experiencing **Hoigne Syndrome**, a rare but classic complication associated with the intramuscular injection of **Procaine Penicillin G**. **1. Why Hoigne Syndrome is Correct:** Hoigne syndrome (also known as pseudo-anaphylactic or pseudo-allergic reaction) occurs due to the **accidental intravascular entry** of procaine penicillin. The symptoms are primarily neuropsychiatric: * **Psychological:** Intense fear of impending death (*thanatophobia*), visual and auditory hallucinations, and confusion. Hallucinations are defined as perceptions without external stimuli and can occur in any sensory modality [1]. * **Neurological:** Perceived changes in body shape (metamorphopsia) and occasionally seizures. * **Physical:** Tachycardia, hypertension, and swelling of the tongue (without true airway obstruction). Unlike anaphylaxis, it is not IgE-mediated, and symptoms typically resolve spontaneously within 15–30 minutes without specific treatment. **2. Why Other Options are Incorrect:** * **Jarisch-Herxheimer Reaction (JHR):** This is a systemic inflammatory response due to the release of endotoxin-like substances from dying *Treponema pallidum*. It presents with fever, chills, headache, and exacerbation of skin lesions, but **not** hallucinations or the specific fear of death. * **Undiagnosed Psychosis/Schizophrenia:** While these present with hallucinations, the acute onset immediately following an IM injection for syphilis makes a drug-related reaction the definitive diagnosis. Schizophrenia involves disturbances of thought and perception [2], but the temporal association here points to a drug effect. **3. NEET-PG High-Yield Pearls:** * **Drug involved:** Most commonly Procaine Penicillin G. * **Pathophysiology:** Micro-embolization of procaine into the cerebral vasculature. * **Key Distinguisher:** Unlike anaphylaxis, there is **no** hypotension or bronchospasm. * **Management:** Reassurance and supportive care; it is self-limiting. * **Syphilis Treatment:** Remember that JHR is most common in **Secondary Syphilis**, whereas Hoigne Syndrome is a complication of the **injection itself**.

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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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