Venerology Practice Questions

Q: A 30-year-old woman presents with dysuria, urinary frequency, and lower abdominal pain for 3 days. She has a new sexual partner. On examination, she has suprapubic tenderness but no cervical motion tenderness or vaginal discharge. Urine dipstick shows positive leukocyte esterase but negative nitrites. Microscopy reveals numerous WBCs but no bacteria. What is the most likely diagnosis and appropriate management?

Acute urethral syndrome due to C. trachomatis - Doxycycline. ### Acute urethral syndrome due to C. trachomatis - Doxycycline - The presence of **dysuria**, **frequency**, **pyuria** (leukocyte esterase, WBCs) without **bacteriuria** or positive nitrites, especially in a sexually active young woman with a new partner, is highly suggestive of **acute urethral syndrome** often caused by *Chlamydia trachomatis* [1]. - **Doxycycline** is the recommended first-line treatment for *Chlamydia trachomatis* infections [3]. *Gonorrheal urethritis - Ceftriaxone* - While *Neisseria gonorrhoeae* can cause **urethritis**, it typically presents with purulent urethral discharge, which is absent here [2]. - While Ceftriaxone is appropriate for gonorrhea, the clinical picture and lab findings (no bacteria, high WBCs) are more consistent with chlamydia [3]. *Interstitial cystitis - Pain management and urinary analgesics* - **Interstitial cystitis** typically presents with chronic (more than 6 weeks) pelvic pain, urinary urgency, and frequency, often without evidence of infection or a clear trigger like a new sexual partner. - The acute onset and clear inflammatory markers (pyuria) make this diagnosis less likely. *Acute bacterial cystitis - Empiric antibiotic therapy* - Although there is **dysuria** and **frequency**, the **absence of nitrites** and **bacteria** on microscopy and dipstick makes bacterial cystitis less likely. - The presence of pyuria without bacteriuria in this context points to urethritis, likely non-gonococcal [1].

Q: A 40-year-old man with a history of untreated syphilis presents with ataxia, diminished deep tendon reflexes, and impaired vibratory and position sense. He was recently diagnosed with HIV (CD4 count 450/μL). VDRL is 1:8, and TPHA is positive. CSF shows pleocytosis, elevated protein, and positive VDRL. Which form of neurosyphilis is most likely?

Tabes dorsalis. ***Tabes dorsalis*** - This condition is characterized by **demyelination of the dorsal columns** and dorsal roots, leading to **ataxia**, **diminished deep tendon reflexes**, and impairment of **vibratory and position sense.** - These symptoms are classic for tabes dorsalis and are consistent with long-term, untreated syphilis. *Syphilitic meningitis* - This form typically presents with **meningeal signs** like headache, neck stiffness, and cranial neuropathies, which are not the primary symptoms described. - While present, the CSF findings are more broadly indicative of neurosyphilis rather than specifically localizing to meningitis as the dominant clinical picture. *General paresis* - This condition primarily affects the **cerebral cortex** and presents with symptoms of dementia, personality changes, and psychiatric disturbances. - The patient's symptoms are more focused on sensory and motor deficits rather than cognitive decline. *Meningovascular syphilis* - This involves inflammation of blood vessels in the brain or spinal cord, leading to **strokes** or transient ischemic attacks. - While a possibility with neurosyphilis, the patient's presentation of ataxia and sensory deficits [1] is less typical of a vascular event.

Q: Which statement about the CDC recommendation for gonorrhea treatment is MOST accurate?

Monotherapy with high-dose ceftriaxone is now preferred. ***Monotherapy with high-dose ceftriaxone is now preferred*** - The CDC recently updated its recommendations, endorsing **monotherapy with a single, higher dose of ceftriaxone (500 mg IM)** for uncomplicated gonococcal infections in adults [1]. - This change reflects concerns about rising **antimicrobial resistance** and simplifies treatment strategies [1]. *Spectinomycin is the recommended alternative for cephalosporin allergy* - While spectinomycin *was* an alternative in some regions, it is **not available in the United States**, rendering it impractical for current CDC recommendations. - For patients with **cephalosporin allergy**, alternative regimens such as gentamicin plus azithromycin or azithromycin monotherapy (if susceptibility can be confirmed) are considered. *Fluoroquinolones remain first-line for uncomplicated infection* - **Fluoroquinolones are no longer recommended** for gonorrhea treatment due to widespread resistance; this recommendation was withdrawn in 2007. - The CDC specifically advises against the use of **ciprofloxacin, ofloxacin, or levofloxacin** for gonorrhea [1]. *Dual therapy with ceftriaxone plus azithromycin is recommended* - **Dual therapy with ceftriaxone and azithromycin** was recommended in the past to prevent the development of resistance. - However, due to concerns about **azithromycin resistance** and data showing the efficacy of higher-dose ceftriaxone monotherapy, the CDC has revised its guidelines [1].

Q: A 26-year-old man presents with painful inguinal lymphadenopathy for 2 weeks. On examination, there is unilateral inguinal lymphadenopathy with fluctuance and overlying erythema. No genital lesions are visible. What is the most appropriate diagnostic test?

Nucleic acid amplification test for C. trachomatis. Painful, unilateral inguinal lymphadenopathy with fluctuance and erythema, especially in the absence of genital lesions, is highly suggestive of lymphogranuloma venereum (LGV), caused by specific serovars of C. trachomatis. A nucleic acid amplification test (NAAT), particularly from a lymph node aspirate or swab of the bubo, is the most sensitive and specific diagnostic method for detecting C. trachomatis LGV biovars [1]. Blood cultures are generally used for systemic infections causing sepsis or widespread bacteremia, not typically for localized inguinal lymphadenopathy as seen here. While LGV is a bacterial infection, it rarely leads to bacteremia warranting a blood culture. Dark field microscopy is the gold standard for diagnosing primary syphilis by visualizing Treponema pallidum from a chancre. The patient's presentation of painful, fluctuant inguinal lymphadenopathy without a primary genital ulcer is not consistent with primary syphilis. While lymph node aspiration might be performed for symptomatic relief or diagnosis, a standard Gram stain and routine bacterial culture would likely be negative or non-specific for LGV, as C. trachomatis is an intracellular bacterium and does not readily grow on conventional media or stain well with Gram stain. This method would be more appropriate for typical bacterial adenitis, not LGV.

Q: A 25-year-old woman is diagnosed with first-episode genital herpes. Which clinical feature best predicts the likelihood of frequent recurrences?

HSV-2 versus HSV-1 etiology. ***HSV-2 versus HSV-1 etiology*** - **HSV-2 infections** are associated with significantly **higher recurrence rates** (typically 4-5 recurrences per year) compared to genital HSV-1 infections (approximately one recurrence every two years) [1]. - The **anatomical site** (genital vs. oral) and the **viral serotype** are key determinants of recurrence frequency [1]. *Severe primary episode* - While a severe primary episode may indicate a higher viral load or a less robust immune response, it does **not reliably predict the frequency of future recurrences**. - Its severity is more indicative of the **initial symptomatic presentation** rather than the long-term recurrence pattern [1]. *Presence of prodromal symptoms* - **Prodromal symptoms** (e.g., tingling, itching) precede a recurrence but **do not predict the likelihood or frequency** of subsequent recurrences. - They are an important patient cue for an impending outbreak, but not a prognostic factor for recurrence rate. *Duration of lesions >10 days* - The **duration of primary lesions** is characteristic of the initial infection's severity and the time taken for healing, but it does **not predict the frequency of future recurrences**. - Longer lesion duration may reflect a more widespread or intense initial viral shedding, rather than persistent viral activity over time.

Q: A 40-year-old man presents with a 2-week history of a non-tender penile ulcer. Dark field microscopy is negative, and initial VDRL is non-reactive. What is the most appropriate next step?

Repeat VDRL in 1-2 weeks. ***Repeat VDRL in 1-2 weeks*** - This is the most appropriate next step because **serologic tests for syphilis** (like VDRL) can be negative early in the disease course, especially within the first few weeks of chancre appearance, known as the **"window period."** - Repeating the VDRL allows time for **antibodies to develop** and become detectable, confirming or ruling out primary syphilis. *Perform biopsy of the lesion* - A biopsy might be considered if the diagnosis remains uncertain after further serological testing or if there are atypical features, but it's not the **initial test** of choice given the typical presentation of a syphilitic chancre. - Doing a biopsy prematurely can delay definitive diagnosis and treatment if the ulcer is indeed a syphilitic chancre. *Treat empirically with benzathine penicillin* - While penicillin is the treatment for syphilis, **empirical treatment** without a confirmed diagnosis is generally discouraged to prevent unnecessary antibiotic use and potential delayed diagnosis of other conditions. - A definitive diagnosis is crucial, especially in cases where the initial tests were negative. *Test for herpes simplex virus* - HSV causes **tender, painful, vesicular lesions** that often recur, which is inconsistent with the description of a non-tender penile ulcer. - While HSV testing can be done, it's less likely given the **non-tender nature** of the lesion, and syphilis remains a primary concern that needs to be definitively ruled out first.

Q: Which of the following is a defining characteristic of Lymphogranuloma venereum (LGV)?

Pronounced lymphadenopathy often with suppuration. Pronounced lymphadenopathy often with suppuration - **Lymphogranuloma venereum** (LGV) is characterized by a transient, often unnoticed, primary lesion followed by significant **regional lymphadenopathy** [1]. - The swollen lymph nodes (buboes) can become **fluctuant** and **suppurate**, forming draining fistulas [1]. *Painful genital ulcers with undermined edges* - This description is more characteristic of **chancroid**, caused by *Haemophilus ducreyi* [1]. - LGV's initial lesions are typically **painless vesicles** or small ulcers that heal quickly and are often missed. *Painless, clean-based ulcers with induration* - This accurately describes the **chancre** of **primary syphilis**, caused by *Treponema pallidum*. - Unlike syphilis, LGV's primary lesion is generally not indurated and is less distinct. *Beefy red granulation tissue in the genital area* - This presentation is typical of **donovanosis** (granuloma inguinale), caused by *Klebsiella granulomatis* [1]. - Donovanosis is characterized by **progressive, destructive lesions** with extensive granulation tissue, which differs from LGV's lymphatic involvement.

Q: A 23-year-old woman presents with recurrent genital herpes despite continuous suppressive therapy with valacyclovir 1g daily for 6 months. She reports adherence to medication. HIV test is negative. What is the most appropriate next step in management?

Perform viral culture with acyclovir sensitivity testing. ***Perform viral culture with acyclovir sensitivity testing*** - **Recurrent genial herpes** despite **continuous suppressive therapy** with 1g daily valacyclovir is suggestive of possible **antiviral resistance**. - A **viral culture with sensitivity testing** is crucial to confirm resistance and guide appropriate treatment [1]. *Increase valacyclovir to 1g twice daily* - While increasing the dose might be considered in some cases of treatment failure, it is not the most appropriate first step here given the **recurrent infections** despite an already high dose and excellent adherence. - Doing so without first checking for **resistance** might delay appropriate management. *Add topical foscarnet to current regimen* - Topical foscarnet is generally reserved for **acyclovir-resistant herpes simplex virus (HSV)** infections, especially in immunocompromised patients, and is typically used as monotherapy or an alternative systemic treatment. - It would be premature to add an alternative agent without confirming **resistance** and the HSV strain. *Switch to famciclovir suppressive therapy* - Famciclovir and valacyclovir have similar mechanisms of action and **cross-resistance** is common, particularly if the resistance is due to a **thymidine kinase (TK) mutation**. - Switching medications without determining the cause of **treatment failure** is unlikely to be effective [1].

Q: Which of the following genital ulcer diseases is LEAST likely to cause inguinal lymphadenopathy?

Granuloma inguinale. ***Granuloma inguinale*** - While ulcers are present, **granuloma inguinale** typically causes a **painless, progressive ulcerative lesion** and is notable for a lack of significant **lymphadenopathy** [1]. - Systemic manifestations are rare, and regional lymph node involvement, if present, is usually due to **secondary bacterial infection**. *Lymphogranuloma venereum* - Characterized by **painful inguinal lymphadenopathy** (buboes) developing weeks after a transient, often unnoticed, primary ulcer [1]. - The **buboes** can become fluctuant, rupture, and drain, a hallmark feature of the disease. *Chancroid* - Causes **painful genital ulcers** and frequently leads to **tender, unilateral inguinal lymphadenopathy** [1]. - The affected lymph nodes (buboes) can also become suppurative and may rupture. *Genital herpes* - Often presents with painful vesicular lesions that progress to ulcers, accompanied by **tender bilateral inguinal lymphadenopathy** [1], [2]. - The lymphadenopathy is typically more generalized and less likely to suppurate compared to chancroid or LGV.

Q: A 35-year-old HIV-positive woman (CD4 count 320/μL) presents with extensive genital warts not responding to conventional treatments. Which of the following is the most appropriate management?

Intralesional interferon. **Intralesional interferon** - In **immunocompromised** patients, such as those with HIV, **genital warts** can be extensive and resistant to conventional therapies. **Intralesional interferon** can enhance the local immune response against the **human papillomavirus (HPV)**. - It is particularly useful for **recalcitrant** or large warts that have not responded to topical or destructive methods, by directly addressing the viral replication and host immunity at the site. *Surgical excision* - While surgical excision can remove large or bothersome warts, it carries a higher risk of **recurrence** and **scarring**, especially with extensive lesions in an immunocompromised patient. - It provides immediate removal but does not prevent the growth of new lesions from existing **subclinical HPV infection**, which is common in HIV-positive individuals. *Podophyllin resin application* - **Podophyllin resin** is a **cytotoxic agent** that inhibits cell mitosis and is commonly used for genital warts in immunocompetent individuals. - However, it can be quite **toxic** and irritating, and its efficacy is often diminished in immunocompromised patients, leading to poor response or severe side effects without clearing the extensive lesions. *Oral isotretinoin* - **Oral isotretinoin** is primarily used for severe **acne** and certain other dermatological conditions, but it is **not a standard treatment** for genital warts. - While it has some immune-modulating effects, its role in treating **HPV-induced warts** is not well-established, and it has potential for significant adverse effects, making it an inappropriate first-line choice for this condition.

Question 1

A 30-year-old woman presents with dysuria, urinary frequency, and lower abdominal pain for 3 days. She has a new sexual partner. On examination, she has suprapubic tenderness but no cervical motion tenderness or vaginal discharge. Urine dipstick shows positive leukocyte esterase but negative nitrites. Microscopy reveals numerous WBCs but no bacteria. What is the most likely diagnosis and appropriate management?

Accepted Answer

Acute urethral syndrome due to C. trachomatis - Doxycycline

Answer

Gonorrheal urethritis - Ceftriaxone

Answer

Interstitial cystitis - Pain management and urinary analgesics

Answer

Acute bacterial cystitis - Empiric antibiotic therapy

Question 2

A 40-year-old man with a history of untreated syphilis presents with ataxia, diminished deep tendon reflexes, and impaired vibratory and position sense. He was recently diagnosed with HIV (CD4 count 450/μL). VDRL is 1:8, and TPHA is positive. CSF shows pleocytosis, elevated protein, and positive VDRL. Which form of neurosyphilis is most likely?

Accepted Answer

Tabes dorsalis

Answer

Syphilitic meningitis

Answer

General paresis

Answer

Meningovascular syphilis

Question 3

Which statement about the CDC recommendation for gonorrhea treatment is MOST accurate?

Accepted Answer

Monotherapy with high-dose ceftriaxone is now preferred

Answer

Spectinomycin is the recommended alternative for cephalosporin allergy

Answer

Fluoroquinolones remain first-line for uncomplicated infection

Answer

Dual therapy with ceftriaxone plus azithromycin is recommended

Question 4

A 26-year-old man presents with painful inguinal lymphadenopathy for 2 weeks. On examination, there is unilateral inguinal lymphadenopathy with fluctuance and overlying erythema. No genital lesions are visible. What is the most appropriate diagnostic test?

Accepted Answer

Nucleic acid amplification test for C. trachomatis

Answer

Blood culture

Answer

Dark field microscopy

Answer

Lymph node aspiration with Gram stain and culture

Question 5

A 25-year-old woman is diagnosed with first-episode genital herpes. Which clinical feature best predicts the likelihood of frequent recurrences?

Accepted Answer

HSV-2 versus HSV-1 etiology

Answer

Severe primary episode

Answer

Presence of prodromal symptoms

Answer

Duration of lesions >10 days

Question 6

A 40-year-old man presents with a 2-week history of a non-tender penile ulcer. Dark field microscopy is negative, and initial VDRL is non-reactive. What is the most appropriate next step?

Accepted Answer

Repeat VDRL in 1-2 weeks

Answer

Perform biopsy of the lesion

Answer

Treat empirically with benzathine penicillin

Answer

Test for herpes simplex virus

Question 7

Which of the following is a defining characteristic of Lymphogranuloma venereum (LGV)?

Accepted Answer

Pronounced lymphadenopathy often with suppuration

Answer

Painful genital ulcers with undermined edges

Answer

Painless, clean-based ulcers with induration

Answer

Beefy red granulation tissue in the genital area

Question 8

A 23-year-old woman presents with recurrent genital herpes despite continuous suppressive therapy with valacyclovir 1g daily for 6 months. She reports adherence to medication. HIV test is negative. What is the most appropriate next step in management?

Accepted Answer

Perform viral culture with acyclovir sensitivity testing

Answer

Increase valacyclovir to 1g twice daily

Answer

Add topical foscarnet to current regimen

Answer

Switch to famciclovir suppressive therapy

Question 9

Which of the following genital ulcer diseases is LEAST likely to cause inguinal lymphadenopathy?

Accepted Answer

Granuloma inguinale

Answer

Lymphogranuloma venereum

Answer

Chancroid

Answer

Genital herpes

Question 10

A 35-year-old HIV-positive woman (CD4 count 320/μL) presents with extensive genital warts not responding to conventional treatments. Which of the following is the most appropriate management?

Accepted Answer

Intralesional interferon

Answer

Surgical excision

Answer

Podophyllin resin application

Answer

Oral isotretinoin

Venerology — MCQs

Venerology — MCQs

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