Venerology Practice Questions

Q: Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:

Gonorrhoea. **Gonorrhoea** - **Fitz-Hugh-Curtis syndrome** is a complication of **pelvic inflammatory disease (PID)**, which is predominantly caused by sexually transmitted infections like *Neisseria gonorrhoeae* and *Chlamydia trachomatis*. - Perihepatitis, or inflammation of the liver capsule, occurs when bacteria from the pelvic infection spread to the liver surface. *Syphilis* - **Syphilis** primarily presents with chancres, rashes, and neurological or cardiovascular complications in later stages. - It does not typically cause **perihepatitis** as a direct complication of the infection itself. *Tuberculosis* - **Tuberculosis** is caused by *Mycobacterium tuberculosis* and usually affects the lungs, but can spread to other organs. - While it can cause peritonitis, it is not associated with **perihepatitis** in the context of **Fitz-Hugh-Curtis syndrome**. *Moniliasis* - **Moniliasis** (candidiasis) is a fungal infection caused by *Candida* species. - It is commonly associated with vaginal yeast infections or thrush but does not cause **Fitz-Hugh-Curtis syndrome** or perihepatitis.

Q: A 32-year-old woman presents with recurrent genital ulcers. She was previously diagnosed with genital herpes based on clinical appearance, but current PCR testing for HSV is negative. She also reports occasional painful mouth sores. Serological tests for syphilis are negative. What is the most likely diagnosis?

Behçet's syndrome. Behçet's syndrome - Recurrent genital ulcers that are often painful and heal with scarring, in the absence of HSV or other STIs, are characteristic of Behçet's syndrome. - While other systemic symptoms such as oral ulcers, uveitis, and skin lesions (e.g., erythema nodosum) are common, the diagnosis can be made based on recurrent genital ulcers and the exclusion of other causes. Fixed drug eruption - A fixed drug eruption typically produces a solitary or a few localized skin or mucosal lesions que recur at the same site, usually within hours of drug re-exposure. - While it can cause genital ulcers, it's less likely to present with recurrent ulcers without a clear history of drug exposure or at multiple sites. Crohn's disease - Genital ulcers can occur in Crohn's disease, often as a manifestation of perianal disease or metastatic Crohn's, but they are typically associated with prominent gastrointestinal symptoms (e.g., chronic diarrhea, abdominal pain, weight loss). - The absence of other symptoms makes Crohn's disease less likely in this isolated presentation. Aphthous ulcers - Aphthous ulcers primarily affect the oral mucosa and are not typically found on the genitals [1]. - While Behçet's syndrome does include recurrent oral aphthous ulcers in its diagnostic criteria, genital aphthous ulcers as a solitary finding are not common without other associated symptoms or conditions [1].

Q: A 30-year-old woman is diagnosed with gonorrhea and reports a penicillin allergy (rash). Which alternative treatment regimen is most appropriate?

Spectinomycin 2g IM single dose. ***Spectinomycin 2g IM single dose*** - **Spectinomycin** is a safe and effective alternative for treating uncomplicated gonorrhea in patients with a history of severe penicillin or cephalosporin allergy. - It provides bactericidal activity against *Neisseria gonorrhoeae* and is administered as a **single intramuscular injection**. *Azithromycin 2g orally single dose* - While azithromycin is part of the dual therapy for gonorrhea (with ceftriaxone), using it as a **monotherapy** is not recommended due to increasing rates of resistance. - The CDC no longer recommends 2g azithromycin monotherapy for gonorrhea due to concerns about **macrolide resistance**. *Cefixime 400mg orally single dose* - **Cefixime** is a third-generation cephalosporin, and a penicillin allergy (especially a rash) may indicate a risk of **cross-reactivity** with cephalosporins. - While it's an alternative, it's generally avoided in significant penicillin allergy due to the potential for hypersensitivity reactions [1] and may have **lower efficacy** than ceftriaxone [2]. *Ciprofloxacin 500mg orally single dose* - **Ciprofloxacin** is a fluoroquinolone, and its use for gonorrhea is no longer recommended due to widespread and increasing **quinolone resistance** of *Neisseria gonorrhoeae* [2]. - Treatment with ciprofloxacin is associated with unacceptably high rates of **treatment failure** in many regions.

Q: A 19-year-old woman presents with painful genital ulcers and vesicles for 4 days, accompanied by fever, malaise, and tender inguinal lymphadenopathy. What is the most appropriate initial management?

Acyclovir 400mg orally TID for 7-10 days. Acyclovir 400mg orally TID for 7-10 days - The patient's presentation with painful genital ulcers and vesicles, fever, malaise, and tender inguinal lymphadenopathy is highly suggestive of primary herpes simplex virus (HSV) infection [1]. - Acyclovir is an antiviral medication that effectively reduces the duration and severity of symptoms in primary HSV outbreaks [1]. Azithromycin 1g orally as single dose - Azithromycin is primarily used to treat bacterial infections, particularly chlamydia and gonorrhea, which typically present with urethritis or cervicitis, not painful vesicles. - It is ineffective against viral infections such as HSV. Benzathine penicillin G 2.4 million units IM - Benzathine penicillin G is the treatment of choice for syphilis, which causes a painless chancre in its primary stage, not painful vesicles. - This antibiotic has no efficacy against HSV. Doxycycline 100mg orally BID for 14 days - Doxycycline is an antibiotic used for various bacterial infections, including chlamydia, lymphogranuloma venereum, and granuloma inguinale [1]. - These conditions typically present with different clinical features (e.g., painless ulcers, buboes) and not the vesicular rash seen in HSV.

Q: Which of the following is NOT characteristic of lymphogranuloma venereum proctitis?

Absence of inguinal lymphadenopathy. Absence of inguinal lymphadenopathy - **Lymphogranuloma venereum (LGV)** characteristically causes **inguinal lymphadenopathy** (buboes) due to its systemic nature and potential concurrent genital involvement, even in cases of isolated rectal infection [1]. - While the rectum drains primarily to **internal iliac and sacral lymph nodes**, LGV's systemic spread and inflammatory response typically result in inguinal lymph node involvement, making its absence atypical [1]. *Painful defecation* - **LGV proctitis** commonly causes **painful defecation** and **tenesmus** due to severe inflammation and ulceration of the rectal mucosa [1]. - The inflammatory process affects **nerve endings** in the rectal wall, leading to significant discomfort during bowel movements [1]. *Constipation alternating with diarrhea* - **Rectal inflammation** from LGV disrupts normal bowel function, causing **altered bowel habits** including constipation alternating with diarrhea. - **Rectal strictures** may develop in chronic cases, further contributing to irregular bowel patterns and incomplete evacuation. *Rectal discharge and bleeding* - **LGV proctitis** typically presents with **mucopurulent rectal discharge** due to extensive mucosal inflammation and secondary bacterial infection [1]. - **Rectal bleeding** occurs from **mucosal ulceration** and increased vascular fragility caused by the inflammatory process.

Q: Which of the following clinical manifestations is LEAST likely in secondary syphilis?

Chancre. ***Chancre*** - A **chancre** is the characteristic lesion of **primary syphilis**, appearing at the site of inoculation [1]. - By the time **secondary syphilis** develops (typically weeks to months later), the chancre of primary syphilis has usually healed spontaneously [1]. *Condylomata lata* - **Condylomata lata** are highly infectious, moist, wart-like lesions that occur in intertriginous areas and mucous membranes during **secondary syphilis** [1]. - They are a common manifestation due to the widespread dissemination of **Treponema pallidum** [1]. *Mucous patches* - **Mucous patches** are painless, white to gray lesions found on mucous membranes (e.g., mouth, pharynx, vagina, anus) during **secondary syphilis**. - These are highly infectious and result from the systemic spread of the spirochete. *Palmar and plantar rash* - A diffuse, non-pruritic, maculopapular rash, often involving the **palms and soles**, is a classic and highly characteristic sign of **secondary syphilis** [1]. - This rash indicates the systemic nature of the infection and can vary widely in appearance [1].

Q: A 32-year-old HIV-positive man (CD4 count 320/μL) presents with painless perianal ulcer for 3 weeks. Dark field microscopy shows spirochetes. What is the appropriate treatment?

Benzathine penicillin G 2.4 million units IM single dose. ***Benzathine penicillin G 2.4 million units IM single dose*** - The presence of a painless perianal ulcer and **spirochetes on dark field microscopy** is highly suggestive of **primary syphilis**. - For primary syphilis, the recommended treatment is a **single intramuscular dose of benzathine penicillin G 2.4 million units**, regardless of HIV status unless there's evidence of neurosyphilis. *Benzathine penicillin G 2.4 million units IM weekly for 3 weeks* - This regimen is typically reserved for **late latent syphilis** or syphilis of unknown duration. - It is not indicated for primary syphilis, which can be cured with a single dose. *Azithromycin 2g orally single dose* - **Azithromycin** is a potential alternative for syphilis in some cases, particularly for penicillin-allergic patients, but it is not the first-line treatment due to increasing rates of macrolide resistance. - The recommended dosage for early syphilis (including primary) is typically **2g orally as a single dose**, but penicillin remains superior. *Doxycycline 100mg orally twice daily for 14 days* - **Doxycycline** is an alternative treatment for early syphilis (primary, secondary, or early latent) in **penicillin-allergic patients**. - The standard duration for early syphilis is **14 days**, but it is not the preferred treatment for patients without penicillin allergy.

Q: Which screening test has the highest sensitivity for detecting early primary syphilis?

TPHA. ***TPHA*** - This **treponemal-specific test** (Treponema pallidum hemagglutination assay) becomes positive early in the infection and remains positive for life, making it highly sensitive for detecting antibodies specific to *Treponema pallidum* in primary syphilis [1]. - While other treponemal tests like FTA-ABS are also highly sensitive, TPHA is a commonly available and reliable option for early detection [1]. *Dark field microscopy* - This method directly visualizes the **spirochetes** from a chancre lesion. Although highly specific, its sensitivity is limited by the need for an active lesion and experienced personnel. - It may be negative if the lesion was treated with topical agents or if the number of spirochetes is low. *VDRL* - The **Venereal Disease Research Laboratory (VDRL)** test is a non-treponemal test that detects antibodies to cardiolipin. It becomes reactive 4-6 weeks after infection [1]. - Its sensitivity is lower than treponemal tests in early primary syphilis, as antibodies may not have developed yet or may be present at very low levels [1]. *PCR* - **Polymerase Chain Reaction (PCR)** can detect *Treponema pallidum* DNA directly from lesions or bodily fluids. While highly specific, its sensitivity for routine screening of early primary syphilis is not superior to treponemal antibody tests due to issues with specimen collection and varying bacterial loads. - PCR is more often used for atypical presentations or for clarifying indeterminate serological results.

Question 1

Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:

Accepted Answer

Gonorrhoea

Answer

Syphilis

Answer

Tuberculosis

Answer

Moniliasis

Question 2

A 32-year-old woman presents with recurrent genital ulcers. She was previously diagnosed with genital herpes based on clinical appearance, but current PCR testing for HSV is negative. She also reports occasional painful mouth sores. Serological tests for syphilis are negative. What is the most likely diagnosis?

Accepted Answer

Behçet's syndrome

Answer

Fixed drug eruption

Answer

Crohn's disease

Answer

Aphthous ulcers

Question 3

A 30-year-old woman is diagnosed with gonorrhea and reports a penicillin allergy (rash). Which alternative treatment regimen is most appropriate?

Accepted Answer

Spectinomycin 2g IM single dose

Answer

Azithromycin 2g orally single dose

Answer

Cefixime 400mg orally single dose

Answer

Ciprofloxacin 500mg orally single dose

Question 4

A 25-year-old man presents with penile ulcers for 10 days. Initial VDRL and dark field microscopy are negative. Two weeks later, repeat VDRL is 1:32. What is the most appropriate interpretation?

Accepted Answer

The initial presentation was in early primary syphilis before seroconversion

Answer

The second test is a false positive due to cross-reactivity

Answer

The first test was a false negative due to lab error

Answer

The patient acquired syphilis between the two tests

Question 5

A 19-year-old woman presents with painful genital ulcers and vesicles for 4 days, accompanied by fever, malaise, and tender inguinal lymphadenopathy. What is the most appropriate initial management?

Accepted Answer

Acyclovir 400mg orally TID for 7-10 days

Answer

Azithromycin 1g orally as single dose

Answer

Benzathine penicillin G 2.4 million units IM

Answer

Doxycycline 100mg orally BID for 14 days

Question 6

Which of the following is NOT characteristic of lymphogranuloma venereum proctitis?

Accepted Answer

Absence of inguinal lymphadenopathy

Answer

Painful defecation

Answer

Constipation alternating with diarrhea

Answer

Rectal discharge and bleeding

Question 7

Which of the following clinical manifestations is LEAST likely in secondary syphilis?

Accepted Answer

Chancre

Answer

Condylomata lata

Answer

Mucous patches

Answer

Palmar and plantar rash

Question 8

A 32-year-old HIV-positive man (CD4 count 320/μL) presents with painless perianal ulcer for 3 weeks. Dark field microscopy shows spirochetes. What is the appropriate treatment?

Accepted Answer

Benzathine penicillin G 2.4 million units IM single dose

Answer

Benzathine penicillin G 2.4 million units IM weekly for 3 weeks

Answer

Azithromycin 2g orally single dose

Answer

Doxycycline 100mg orally twice daily for 14 days

Question 9

What is the underlying pathophysiology of post-gonococcal urethritis?

Accepted Answer

Concurrent chlamydial infection unaffected by gonococcal treatment

Answer

Development of antibiotic resistance

Answer

Immunological reaction to gonococcal antigens

Answer

Incomplete treatment of gonorrhea

Question 10

Which screening test has the highest sensitivity for detecting early primary syphilis?

Accepted Answer

TPHA

Answer

Dark field microscopy

Answer

VDRL

Answer

PCR

Venerology — MCQs

Venerology — MCQs

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