Venerology Practice Questions

Q: A 45-year-old man presents with a long history of ulcers on the bottom of his feet. He recalls having a similar looking ulcer on the side of his penis when he was 19 years old for which he never sought treatment. The patient denies any fever, chills, or constitutional symptoms. He reports multiple sexual partners and a very promiscuous sexual history. He has also traveled extensively as a writer since he was 19. The patient is afebrile, and his vital signs are within normal limits. A rapid plasma reagin (RPR) test is positive, and the result of a Treponema pallidum particle agglutination (TP-PA) is pending. Which of the following findings would most likely be present in this patient?

Positive Romberg's sign. ***Positive Romberg's sign*** - The patient's history of untreated penile ulcers at age 19, extensive sexual history, and positive RPR strongly suggest **late-stage syphilis** [3]. - A positive Romberg's sign indicates **sensory ataxia**, which is a classic finding in **tabes dorsalis**, a manifestation of neurosyphilis involving degeneration of the dorsal columns and dorsal roots of the spinal cord [1]. *Hyperreflexia* - **Hyperreflexia** is typically seen in **upper motor neuron lesions**, while tabes dorsalis primarily affects the **sensory pathways** (dorsal columns), leading to sensory deficits rather than motor spasticity. - In some neurosyphilis cases, **hyporeflexia or areflexia** may be observed due to damage to the dorsal roots. *Memory loss* - **Memory loss** can occur in neurosyphilis, particularly in conditions like **general paresis**, which is a form of neurosyphilis affecting the cerebral cortex [3]. - However, the symptom of **foot ulcers** points more directly to sensory neuropathy, making **ataxia** (and thus Romberg's sign) a more likely direct neurological finding. *Wide-based gait with a low step* - A **wide-based gait with a high stepping (steppage) gait** is characteristic of **foot drop** or **motor neuropathy**, which is less typical for tabes dorsalis. - A **wide-based gait** can occur in tabes dorsalis due to **sensory ataxia** [2], but the "low step" component is less specific compared to the clear indication of sensory loss by Romberg's sign. *Agraphesthesia* - **Agraphesthesia** (inability to recognize writing on the skin) is a sign of **parietal lobe dysfunction** or severe sensory pathway damage. - While neurosyphilis can affect various parts of the CNS, **tabes dorsalis** primarily causes problems with proprioception and vibratory sense, leading to ataxia and a positive Romberg's sign.

Q: All of the following are manifestations of congenital syphilis except:-

Gumma. ***Gumma*** - **Gumma** is a manifestation of **tertiary syphilis** in adults, typically appearing years after the initial infection [1]. - While syphilis can be transmitted congenitally, **gummatous lesions** are not a characteristic finding in congenital syphilis [1]. *Olympian brow* - **Olympian brow** (also known as frontal bossing) is a feature of **congenital syphilis**, characterized by prominent frontal bones [2]. - It results from **periostitis** and abnormal bone development due to chronic infection in utero. *Interstitial keratitis* - **Interstitial keratitis** is a classic manifestation of **late congenital syphilis**, affecting the cornea [2]. - It presents as **bilateral corneal inflammation** leading to vision impairment, often appearing in childhood or adolescence. *Hutchinson's teeth* - **Hutchinson's teeth** are a pathognomonic sign of **congenital syphilis**, characterized by notched, peg-shaped, and widely spaced incisors. - This dental abnormality results from the treponemal infection disrupting the **enamel formation** during tooth development.

Q: Groove sign:

LGV. ***LGV*** - The **groove sign** is a characteristic clinical finding in **lymphogranuloma venereum (LGV)**, specifically in the inguinal syndrome stage [1]. - It refers to the presence of enlarged, tender **inguinal lymph nodes** separated by the inguinal ligament, creating a "groove" appearance [1]. *Chancroid* - Chancroid typically presents with **painful, ragged-edged ulcers** on the genitalia, often with associated **inguinal lymphadenopathy** (buboes) [1]. - It does not characteristically display the specific **groove sign** seen in LGV. *Genital herpes* - Genital herpes is characterized by **clusters of painful vesicles** that rupture to form shallow ulcers, which then crust over. - While it can cause **inguinal lymphadenopathy**, it does not present with the distinct **groove sign**. *Donovaniasis* - Donovaniasis, or **granuloma inguinale**, is characterized by **painless, progressive ulcerative lesions** that are highly vascular and bleed easily [1]. - It primarily involves subcutaneous tissue and can cause **pseudobuboes** but does not feature the characteristic **groove sign** [1].

Q: A 30-year-old male, Kallu, with a history of sexual exposure presents with a painless indurated ulcer over the penis with everted margins. The diagnosis is:

Syphilis. ***Syphilis*** - The description of a **painless, indurated ulcer with everted margins** (a **chancre**) is the classic presentation of **primary syphilis** [1]. - **Sexual exposure** is the primary mode of transmission for *Treponema pallidum*, the causative agent. *Granuloma inguinale* - Characterized by **painless, progressive ulcerative lesions** without regional lymphadenopathy, often described as "beefy red." - The lesions caused by *Klebsiella granulomatis* are typically **friable** and do not present with the distinct induration and everted margins of a syphilitic chancre. *Chancroid* - Presents with **tender, painful genital ulcers** with irregular, undermined borders and often associated with **tender inguinal lymphadenopathy** [1]. - This contrasts sharply with the **painless** and **indurated** nature of the ulcer described in the patient. *Lymphogranuloma venereum* - Begins with a transient, **small, painless papule or ulcer** at the site of inoculation, which often goes unnoticed leading to delayed diagnosis. - The prominent feature is later development of **unilateral, painful inguinal lymphadenitis** (buboes) and associated systemic symptoms, which are not mentioned in this presentation.

Q: A patient has asymptomatic painless burrowing ulcer in the palate. He might be suffering from

Syphilis. ***Syphilis*** - A **painless burrowing ulcer** in the palate, particularly a **gumma**, is characteristic of tertiary syphilis. - While primary syphilis causes a chancre (also painless), the burrowing nature suggests a more advanced stage of the disease. *Actinomycosis* - Often presents as a **chronic, indurated, suppurative lesion** with draining sinuses, sometimes referred to as "lumpy jaw." - It’s typically associated with **yellow sulfur granules** and is usually painful or causes discomfort. *Tuberculosis* - Oral manifestations of tuberculosis are commonly seen as **painful, irregular ulcers** on the tongue or buccal mucosa. - Palatal lesions are less common and tend to be painful, unlike the case described. *Histoplasmosis* - Systemic histoplasmosis can manifest as **painful oral ulcers** or granulomatous lesions, often presenting with symptoms like fever, weight loss, and hepatosplenomegaly. - The ulcers are usually not described as "burrowing" and are typically painful.

Q: Painful matted suppurative lymphadenitis after healing of genital lesion is seen in:

LGV. **LGV** - **Lymphogranuloma venereum (LGV)** is caused by specific serovars of *Chlamydia trachomatis* and is characterized by a transient, painless genital ulcer followed by **painful, matted suppurative lymphadenopathy** in the inguinal region, often forming **buboes** and **fistulas** [1]. - The healing of the initial genital lesion before the onset of prominent lymphadenitis is a classic presentation of LGV [1]. *Syphilis* - While syphilis can cause **painless lymphadenopathy** (buboes), it is typically non-suppurative and does not result in the matted, suppurative nodes or fistula formation seen in LGV [2]. - The initial lesion, a **chancre**, is usually painless and firm [2]. *Donovanosis* - Donovanosis, caused by *Klebsiella granulomatis*, presents with **progressive, ulcerative lesions** that are highly vascular and bleed easily, not discrete genital lesions followed by prominent lymphadenitis [1]. - **Lymphadenitis** is rare; however, subcutaneous granulomas in the inguinal region (pseudobuboes) can occur, but these are not suppurative lymph nodes [1]. *Chancroid* - Chancroid, caused by *Haemophilus ducreyi*, characteristically causes **painful genital ulcers** and **painful, suppurative inguinal lymphadenitis** (buboes) [1]. - However, the lymphadenopathy usually appears concurrently with or shortly after the ulcer, and the ulcers are typically persistent and painful, unlike the transient, often unnoticed lesion of LGV [1].

Q: Incubation period of LGV:

1 month. ***1 month*** - The incubation period for the primary lesion (a small, painless papule or vesicle) in **lymphogranuloma venereum (LGV)** is typically **1-4 weeks**, with 1 month being a common estimate [1]. - This primary lesion often goes unnoticed as it heals rapidly, usually within a few days [1]. *15-45 days* - While technically encompassing the range, **15-45 days** might be seen as slightly broad or less precise than the more common "1 month" estimate for the primary lesion. - The more prominent secondary stage with lymphadenopathy typically develops a few weeks after the primary lesion [1]. *6 months* - An incubation period of **6 months** is far too long for LGV. The disease characteristics usually manifest within weeks. - Such a long incubation period would suggest a different type of infection or a very delayed presentation, which is not characteristic of typical LGV. *3-12 days* - An incubation period of **3-12 days** is too short for LGV. This timeframe is more typical for diseases like **genital herpes** or **chancroid** [1]. - LGV caused by *Chlamydia trachomatis* serovars L1, L2, or L3, generally has a longer incubation before the primary lesion appears.

Q: Secondary syphilis is characterised by all except (choose the MOST appropriate answer)

Gummatous ulcers. ***Gummatous ulcers*** - **Gummas** are characteristic lesions of **tertiary syphilis**, not secondary syphilis. - They are granulomatous lesions that can affect various organs, including skin, bone, and internal organs. *Cutaneous coppery rashes* - **Coppery (or ham-colored)** macular or papular rashes are a hallmark of **secondary syphilis**, commonly appearing on the trunk, palms, and soles [1]. - These rashes are typically non-itchy and can resolve spontaneously without treatment [1]. *Moth - eaten alopecia* - **Patchy, non-scarring alopecia**, often described as "moth-eaten," is a common manifestation of **secondary syphilis** [2]. - It results from diffuse hair loss due to inflammatory infiltrates around hair follicles. *Ivory sequestrum* - **Skeletal gummas** in **tertiary syphilis** can result in bone necrosis, leading to the formation of an **ivory sequestrum**, which is a dead piece of bone. - This is a feature of **tertiary syphilis** and not seen in the secondary stage.

Q: A 40-year-old female with multiple sexual partners presented with fever, rash, and articular symptoms. Migratory arthritis and tenosynovitis of knees, hands, wrists, feet, and ankles were noticed during clinical examination. Synovial fluid leukocyte count was 12,000/ml and culture was sterile. The patient has been successfully treated with injection ceftriaxone 1 g Q24 hours for 7 days. What was the diagnosis in this setting?

Disseminated gonococcal infection. ***Disseminated gonococcal infection*** - The classic triad of **fever**, **rash**, and **articular symptoms (migratory polyarthralgia or tenosynovitis)** in a sexually active individual strongly suggests disseminated gonococcal infection (**DGI**). - The positive response to **ceftriaxone**, an antibiotic effective against *Neisseria gonorrhoeae*, further supports this diagnosis. *Gonococcal septic arthritis* - While *N. gonorrhoeae* can cause septic arthritis, it typically presents as a **monoarticular** joint infection with severe pain and swelling, not **migratory polyarthritis** and tenosynovitis. - The synovial fluid in septic arthritis would show a significantly **higher leukocyte count** (often >50,000 cells/mm³) and frequently a positive culture if bacteria are adequately cultured. *Syphilitic arthritis* - Syphilitic arthritis is uncommon and often presents in **secondary or tertiary syphilis**, characterized by chronic inflammation and unique bone lesions, not acute migratory polyarthritis or tenosynovitis. - The rash of secondary syphilis is typically **macropapular and non-pruritic**, often involving the palms and soles, which differs from the rash seen in DGI. *Arthritis due to Pseudomonas aeruginosa* - *Pseudomonas aeruginosa* arthritis is rare and typically occurs in individuals with **immunocompromise**, **intravenous drug use**, or following **puncture wounds**, none of which are mentioned here. - The clinical picture of **migratory polyarthralgia and tenosynovitis** is not characteristic of *Pseudomonas* arthritis, which is usually purulent and monoarticular.

Q: False about syphilis is :

Syphilitic ulcers(Chancre) are extremely painful. ***Syphilitic ulcers (Chancre) are extremely painful*** - **Syphilitic chancres** are typically **painless** ulcers, which is a key diagnostic feature differentiating them from other genital ulcers [1]. - The absence of pain often leads individuals to delay seeking medical attention, contributing to disease progression. *Secondary syphilis is due to hematological dissemination* - **Secondary syphilis** arises from the **hematogenous (bloodstream) and lymphatic dissemination** of Treponema pallidum throughout the body [1]. - This widespread dissemination accounts for the **systemic symptoms** and mucocutaneous lesions observed in secondary syphilis [1]. *"General paresis of Insane" is due to CNS involvement in tertiary syphilis.* - **General paresis of the insane** (or **paretic neurosyphilis**) is a manifestation of **tertiary neurosyphilis**, resulting from chronic inflammation and atrophy of the brain parenchyma. - It leads to progressive **cognitive decline, personality changes, and neurological deficits** due to central nervous system (CNS) damage by the spirochete. *Incubation period is 9-90 days* - The **incubation period** for syphilis, from exposure to the appearance of a **chancre**, typically ranges from **9 to 90 days**, with an average of about 21 days. - This variability depends on factors such as the inoculum size and the individual's immune response.

Question 1

A 45-year-old man presents with a long history of ulcers on the bottom of his feet. He recalls having a similar looking ulcer on the side of his penis when he was 19 years old for which he never sought treatment. The patient denies any fever, chills, or constitutional symptoms. He reports multiple sexual partners and a very promiscuous sexual history. He has also traveled extensively as a writer since he was 19. The patient is afebrile, and his vital signs are within normal limits. A rapid plasma reagin (RPR) test is positive, and the result of a Treponema pallidum particle agglutination (TP-PA) is pending. Which of the following findings would most likely be present in this patient?

Accepted Answer

Positive Romberg's sign

Answer

Hyperreflexia

Answer

Memory loss

Answer

Wide-based gait with a low step

Answer

Agraphesthesia

Question 2

All of the following are manifestations of congenital syphilis except:-

Accepted Answer

Gumma

Answer

Olympian brow

Answer

Interstitial keratitis

Answer

Hutchinson's teeth

Question 3

Groove sign:

Accepted Answer

LGV

Answer

Chancroid

Answer

Genital herpes

Answer

Donovaniasis

Question 4

A 30-year-old male, Kallu, with a history of sexual exposure presents with a painless indurated ulcer over the penis with everted margins. The diagnosis is:

Accepted Answer

Syphilis

Answer

Granuloma inguinale

Answer

Chancroid

Answer

Lymphogranuloma venereum

Question 5

A patient has asymptomatic painless burrowing ulcer in the palate. He might be suffering from

Accepted Answer

Syphilis

Answer

Actinomycosis

Answer

Tuberculosis

Answer

Histoplasmosis

Question 6

Painful matted suppurative lymphadenitis after healing of genital lesion is seen in:

Accepted Answer

LGV

Answer

Syphilis

Answer

Donovanosis

Answer

Chancroid

Question 7

Incubation period of LGV:

Accepted Answer

1 month

Answer

15-45 days

Answer

6 months

Answer

3-12 days

Question 8

Secondary syphilis is characterised by all except (choose the MOST appropriate answer)

Accepted Answer

Gummatous ulcers

Answer

Cutaneous coppery rashes

Answer

Moth - eaten alopecia

Answer

Ivory sequestrum

Question 9

A 40-year-old female with multiple sexual partners presented with fever, rash, and articular symptoms. Migratory arthritis and tenosynovitis of knees, hands, wrists, feet, and ankles were noticed during clinical examination. Synovial fluid leukocyte count was 12,000/ml and culture was sterile. The patient has been successfully treated with injection ceftriaxone 1 g Q24 hours for 7 days. What was the diagnosis in this setting?

Accepted Answer

Disseminated gonococcal infection

Answer

Gonococcal septic arthritis

Answer

Syphilitic arthritis

Answer

Arthritis due to Pseudomonas aeruginosa

Question 10

False about syphilis is :

Accepted Answer

Syphilitic ulcers(Chancre) are extremely painful

Answer

Secondary syphilis is due to hematological dissemination

Answer

"General paresis of Insane" is due to CNS involvement in tertiary syphilis.

Answer

Incubation period is 9-90 days

Venerology — MCQs

Venerology — MCQs

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