Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 11: Painful ulcers over the genitalia are caused by which of the following conditions?

A. Primary syphilis
B. Granuloma inguinale
C. Chancroid (Correct Answer)
D. Lymphogranuloma venereum

Explanation: **Explanation:** The clinical differentiation of genital ulcers is a high-yield topic for NEET-PG. The primary distinction lies in whether the ulcer is **painful** or **painless**. [1] **Why Chancroid is Correct:** Chancroid, caused by *Haemophilus ducreyi*, is characterized by the "Painful Triad": **Painful** ulcer, **soft** consistency (Soft Chancre), and **painful** inguinal lymphadenopathy (buboes). [2] The ulcers are often multiple, have ragged/undermined edges, and a necrotic base. **Analysis of Incorrect Options:** * **Primary Syphilis (Option A):** Caused by *Treponema pallidum*. It presents as a **painless**, indurated (hard) ulcer known as a **Hard Chancre**. [1] Lymphadenopathy is also typically painless and non-suppurative. * **Granuloma Inguinale (Option B):** Also known as Donovanosis (caused by *Klebsiella granulomatis*). It presents as **painless**, beefy-red, velvety ulcers that bleed on touch. [2] There is no true lymphadenopathy; instead, "pseudo-buboes" occur. * **Lymphogranuloma Venereum (Option C):** Caused by *Chlamydia trachomatis* (L1-L3). The initial genital ulcer is small, transient, and **painless**, often disappearing before the patient seeks help. [2] The hallmark is painful, suppurative inguinal lymphadenopathy (Groove sign). **NEET-PG High-Yield Pearls:** 1. **Painful Ulcers:** Chancroid and Genital Herpes (Herpes is usually multiple, vesicular, and recurrent). [1] 2. **Painless Ulcers:** Syphilis, Granuloma Inguinale, and LGV. [2] 3. **School of Fish Appearance:** Characteristic Gram stain finding for *H. ducreyi*. 4. **Donovan Bodies:** Safety-pin appearance in crushed tissue smears for Granuloma Inguinale. 5. **Groove Sign:** Seen in LGV when the inguinal ligament divides the matted lymph nodes.

Question 12: Multiple necrotic ulcers in the prepuce of the penis with tender, suppurative inguinal nodes are caused by which organism?

A. Chlamydia
B. Haemophilus ducreyi (Correct Answer)
C. Herpes simplex
D. Syphilis

Explanation: The clinical presentation described—**multiple necrotic ulcers** associated with **tender, suppurative inguinal lymphadenopathy**—is the classic hallmark of **Chancroid**, caused by the gram-negative coccobacillus ***Haemophilus ducreyi***. [1] ### Why Haemophilus ducreyi is correct: * **The Ulcer:** Unlike syphilis, the ulcers in chancroid are **painful**, deep, and have ragged, undermined edges with a necrotic/purulent base. They are often multiple due to autoinoculation. * **The Bubo:** The inguinal lymphadenopathy (bubo) is typically **unilateral, extremely tender, and prone to suppuration** (fluctuant), often leading to spontaneous rupture if not aspirated. [1] ### Why the other options are incorrect: * **Chlamydia (LGV):** Caused by *C. trachomatis* (L1-L3). While it causes painful buboes (the "Groove sign"), the initial primary lesion is a small, **painless**, and transient papule/ulcer that usually heals before the nodes enlarge. [1] * **Herpes simplex (HSV-2):** Presents as multiple, superficial, **vesicular** lesions on an erythematous base. While painful, they are not typically deep necrotic ulcers, and lymphadenopathy is usually bilateral and non-suppurative. * **Syphilis (*Treponema pallidum*):** Characterized by a **painless**, single, indurated ulcer (Hard Chancre) with **painless**, rubbery, non-suppurative regional lymphadenopathy. ### NEET-PG High-Yield Pearls: * **Mnemonic:** "Ducreyi makes you **cry**" (because it is painful), whereas Syphilis is "Sssh-philis" (silent/painless). * **School of Fish Appearance:** On Gram stain (uncommonly done), *H. ducreyi* shows a characteristic "railroad track" or "school of fish" arrangement. * **Treatment of Choice:** A single dose of **Azithromycin (1g orally)** or Ceftriaxone (250mg IM). * **Differential Diagnosis:** Always rule out a "mixed infection" (Chancroid + Syphilis) if the clinical picture is overlapping.

Question 13: What is the most appropriate diagnostic test for asymptomatic neurosyphilis?

A. VDRL (Venereal Disease Research Laboratory) (Correct Answer)
B. TPHA (Treponema Pallidum Hemagglutination Assay)
C. FTA-Abs (Fluorescent Treponemal Antibody Absorption Test)
D. TPI (Treponema Pallidum Immobilization Test)

Explanation: ### Explanation The diagnosis of neurosyphilis, especially in asymptomatic cases, relies on the examination of Cerebrospinal Fluid (CSF). **Why VDRL is the Correct Answer:** The **CSF-VDRL** is considered the gold standard for the diagnosis of neurosyphilis. While it has low sensitivity (it can be negative in 30-70% of confirmed cases), it is **highly specific**. A reactive CSF-VDRL in the absence of gross blood contamination is considered diagnostic of neurosyphilis [1]. In asymptomatic neurosyphilis, where clinical signs are absent, a positive CSF-VDRL is the most definitive laboratory evidence required to initiate treatment. **Analysis of Incorrect Options:** * **TPHA & FTA-Abs (Options B & C):** These are treponemal tests. While they are highly sensitive in the CSF, they are **not specific**. Treponemal antibodies can cross the blood-brain barrier from the serum even in the absence of active neurosyphilis [1]. Therefore, a positive result does not confirm active CNS infection, though a negative result can help rule it out. * **TPI (Option D):** The Treponema Pallidum Immobilization test was once the "gold standard" for syphilis but is now obsolete. It is technically difficult, expensive, and no longer used in routine clinical practice or NEET-PG diagnostic algorithms. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** Serum RPR/VDRL is used for screening; however, for **neurosyphilis**, CSF-VDRL is the specific test of choice. * **Sensitivity vs. Specificity:** CSF-FTA-Abs is the most *sensitive* (useful for ruling out), while CSF-VDRL is the most *specific* (useful for ruling in). * **CSF Findings:** In addition to VDRL, look for pleocytosis (>5 WBCs/mm³) and elevated protein (>45 mg/dL) as supportive evidence of neurosyphilis. * **Treatment:** The drug of choice for neurosyphilis is **Aqueous Crystalline Penicillin G** (18–24 million units per day) for 10–14 days.

Question 14: Typical lesion in hard chancre is:

A. Painless and indurated (Correct Answer)
B. Painful and indurated
C. Painless and non-indurated
D. Painful and non-indurated

Explanation: **Explanation:** The **Hard Chancre** is the hallmark clinical lesion of **Primary Syphilis**, caused by the spirochete *Treponema pallidum* [2]. 1. **Why Option A is Correct:** The term "Hard" in hard chancre refers specifically to **induration** (firmness upon palpation), which occurs due to intense perivascular infiltration of plasma cells and lymphocytes. Characteristically, these lesions are **painless** because the infection does not typically trigger an acute inflammatory response that involves sensory nerve endings [2]. On examination, it appears as a solitary, clean-based ulcer with button-like hardness. 2. **Why Other Options are Incorrect:** * **Options B & D (Painful):** Painful ulcers are characteristic of **Chancroid** (caused by *Haemophilus ducreyi*), which is often referred to as a "Soft Chancre." Herpes Simplex Virus (HSV) also presents with painful vesicles/ulcers [1]. * **Options C & D (Non-indurated):** A lack of induration is typical of Chancroid or early herpetic lesions. The presence of induration is the primary clinical feature that differentiates Syphilis from other causes of genital ulcer disease (GUD). **NEET-PG High-Yield Pearls:** * **Incubation Period:** Usually 3 weeks (range 9–90 days). * **Lymphadenopathy:** Primary syphilis is associated with **painless, non-suppurative, "rubbery" bilateral inguinal lymphadenopathy** [2]. * **Diagnosis:** The gold standard for early primary syphilis (before antibodies develop) is **Dark-field Microscopy**, which shows corkscrew-shaped motility. * **Treatment:** The drug of choice is **Benzathine Penicillin G** (2.4 million units IM, single dose). * **Rule of Thumb:** "Syphilis is Painless (Hard Chancre), Chancroid is Painful (Soft Chancre)."

Question 15: The primary lesion of syphilis, the Hunterian chancre, is characterized by which of the following features, EXCEPT?

A. Painless
B. Indurated
C. Bleeding (Correct Answer)
D. Shallow ulcer

Explanation: The primary lesion of syphilis, the **Hunterian chancre**, is the hallmark of primary syphilis, appearing approximately 3 weeks after inoculation with *Treponema pallidum*. [1] ### **Why "Bleeding" is the Correct Answer** A classic syphilitic chancre is characterized by its **clean base**. Unlike many other genital ulcers, it does **not bleed easily** on manipulation. If the surface is scraped, it typically exudes a clear, serous fluid rich in treponemes (visible on dark-field microscopy) rather than blood. ### **Explanation of Other Options** * **Painless (Option A):** This is a defining feature. The chancre is characteristically non-tender unless secondary bacterial infection occurs. [1] * **Indurated (Option B):** The term "Hunterian" refers to the button-like, firm, or cartilaginous consistency (induration) of the ulcer's base and margins. * **Shallow Ulcer (Option C):** The lesion typically begins as a papule that erodes into a shallow, well-demarcated ulcer with a "punched-out" appearance. ### **High-Yield Clinical Pearls for NEET-PG** * **Lymphadenopathy:** Primary syphilis is associated with **painless, non-suppurative, rubbery** regional lymphadenopathy (usually bilateral inguinal). [1] * **Diagnosis:** The gold standard for primary syphilis is **Dark-field microscopy**. Serological tests (VDRL/RPR) may be negative in the first 1–2 weeks of the chancre's appearance. * **Differential Diagnosis:** * **Chancroid (Haemophilus ducreyi):** Painful, soft, and **bleeds easily** (the opposite of syphilis). * **Herpes Simplex:** Multiple, painful, superficial vesicles/ulcers. * **Treatment:** The drug of choice is **Benzathine Penicillin G** (2.4 million units IM, single dose).

Question 16: The groove sign is characteristically seen in which of the following conditions?

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

Explanation: The **Groove Sign (Greenblatt’s Sign)** is a pathognomonic clinical finding in **Lymphogranuloma venereum (LGV)**, caused by *Chlamydia trachomatis* (serotypes L1, L2, and L3) [1]. **Why LGV is correct:** In the secondary stage of LGV, patients develop painful inguinal lymphadenopathy (buboes). The "Groove Sign" occurs when the **inguinal ligament** divides the enlarged superficial inguinal and femoral lymph nodes [1]. This creates a linear depression or "groove" between the two groups of inflamed nodes, visible through the skin. **Analysis of Incorrect Options:** * **Chancroid:** Caused by *Haemophilus ducreyi*, it presents with painful, soft ulcers and painful inguinal buboes [1]. However, these buboes are typically unilocular and do not form a groove sign. * **Syphilis:** Primary syphilis presents with a **painless** chancre, and secondary syphilis involves generalized lymphadenopathy. The nodes are usually firm, discrete, and non-suppurative, unlike the matted nodes in LGV. * **Psoriasis:** This is a non-venereal, autoimmune inflammatory skin condition characterized by silvery scales on erythematous plaques. It does not involve inguinal lymphadenopathy or the groove sign. **High-Yield Clinical Pearls for NEET-PG:** * **Causative Agent:** *Chlamydia trachomatis* L1–L3 (Obligate intracellular bacterium). * **Stages:** Primary (painless papule/ulcer), Secondary (Inguinal syndrome with Groove sign), Tertiary (Genito-anorectal syndrome/Elephantiasis) [1]. * **Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the gold standard. * **Treatment:** **Doxycycline** 100 mg BID for 21 days (Drug of Choice). Erythromycin is an alternative for pregnant patients.

Question 17: Roth's spots are seen in which of the following conditions?

A. Diabetic retinopathy
B. CMV retinitis
C. Infective endocarditis (Correct Answer)
D. HIV retinopathy

Explanation: ### Explanation **Correct Answer: C. Infective Endocarditis** **Medical Concept:** Roth’s spots are retinal hemorrhages characterized by a **pale/white center** composed of coagulated fibrin. Historically, they were thought to be pathognomonic for Subacute Bacterial Endocarditis (SBE) due to septic emboli. However, the modern understanding is that they represent a non-specific **immune-complex mediated vasculitis** (Type III Hypersensitivity). The white center is not always pus or bacteria; it is typically a fibrin-platelet plug at the site of vessel rupture [1]. **Analysis of Incorrect Options:** * **A. Diabetic Retinopathy:** Characterized by microaneurysms, hard exudates, and "dot-and-blot" hemorrhages, but lacks the specific white-centered spots seen in Roth’s spots. * **B. CMV Retinitis:** Typically presents with a "pizza-pie" or "cottage cheese and ketchup" appearance (perivascular exudates and hemorrhages). It is the most common opportunistic ocular infection in AIDS patients. * **D. HIV Retinopathy:** Presents with **Cotton Wool Spots** (micro-infarcts of the nerve fiber layer) without the hemorrhagic component seen in Roth’s spots. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis for Roth’s Spots:** While classic for Infective Endocarditis, they are also seen in **Leukemia** (most common non-IE cause), Severe Anemia, Diabetes Mellitus, and Carbon Monoxide poisoning. * **Other Peripheral Stigmata of IE:** * **Janeway Lesions:** Painless, erythematous macules on palms/soles (Embolic) [1]. * **Osler Nodes:** Painful, pea-sized nodules on finger/toe pads (Immune-mediated) [1]. * **Splinter Hemorrhages:** Linear subungual streaks [1]. * **Mnemonic:** "Roth's spots are **R**ound spots in the **R**etina."

Question 18: All are cardiovascular manifestations of late syphilis, EXCEPT?

A. Uncomplicated aoitis
B. Saccular aneurysm (usually of the ascending aorta)
C. Coronary ostial stenosis
D. Pulmonary stenosis (Correct Answer)

Explanation: **Explanation:** Cardiovascular syphilis is a manifestation of **Tertiary (Late) Syphilis**, typically occurring 10–30 years after the primary infection [1]. The underlying pathology is **obliterative endarteritis of the vasa vasorum**, which leads to ischemia and destruction of the elastic tissue in the tunica media (mesoaortitis). **Why Pulmonary Stenosis is the correct answer:** Syphilis primarily affects the **aorta** due to its rich supply of vasa vasorum. It does not involve the pulmonary valves or the pulmonary artery. Pulmonary stenosis is typically a congenital heart defect or a result of rheumatic heart disease, not a sequela of *Treponema pallidum* infection. **Analysis of Incorrect Options:** * **Uncomplicated Aortitis:** This is the most common manifestation. It involves asymptomatic dilation of the ascending aorta, often identified only by linear calcification on a chest X-ray. * **Saccular Aneurysm:** Weakening of the aortic media leads to aneurysm formation [2]. These are typically **saccular** (rather than fusiform) and most commonly involve the **ascending aorta**, followed by the aortic arch. * **Coronary Ostial Stenosis:** The inflammatory process and scarring at the root of the aorta can narrow the openings (ostia) of the coronary arteries, leading to angina or myocardial infarction. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ascending aorta (unlike atherosclerotic aneurysms, which favor the abdominal aorta). * **Aortic Regurgitation:** Syphilitic aortitis causes dilation of the aortic ring, leading to valvular insufficiency. * **Tree-barking appearance:** Gross pathological finding of the aortic intima due to patchy subintimal scarring. * **Diagnosis:** Screening with VDRL/RPR; confirmation with FTA-ABS or TPPA. * **Treatment:** Penicillin G is the drug of choice, though it cannot reverse existing structural damage.

Question 19: Painful lymphadenopathy is seen in which of the following conditions?

A. Donovanosis
B. Syphilis
C. Chancroid (Correct Answer)
D. All of the above

Explanation: **Explanation:** In the context of Sexually Transmitted Infections (STIs), the presence or absence of pain in both the primary lesion and the associated lymphadenopathy is a critical diagnostic differentiator. **1. Why Chancroid is correct:** Chancroid, caused by *Haemophilus ducreyi*, is characterized by the "Double Pain" rule: **Painful ulcer** and **Painful lymphadenopathy**. The lymphadenopathy (buboes) in Chancroid is typically unilateral, inflammatory, and prone to suppuration and spontaneous rupture. [1] **2. Why the other options are incorrect:** * **Syphilis (Option B):** Caused by *Treponema pallidum*, primary syphilis presents with a **painless** ulcer (chancre) and **painless**, firm, non-suppurative regional lymphadenopathy. * **Donovanosis (Option A):** Also known as Granuloma Inguinale (caused by *Klebsiella granulomatis*), it presents with painless, beefy-red ulcers. A key diagnostic feature is **Pseudobuboes**—these are not true lymph node involvements but rather subcutaneous granulation tissue that mimics lymphadenopathy. [1] * **Lymphogranuloma Venereum (LGV):** (Not an option, but relevant) While LGV features painful lymphadenopathy (the "Groove Sign"), the primary lesion is usually a transient, painless papule. **Clinical Pearls for NEET-PG:** * **Painful Ulcers:** Chancroid, Herpes Simplex (HSV). * **Painless Ulcers:** Syphilis, Donovanosis, LGV. * **School of Fish Appearance:** Classic histopathology for *H. ducreyi* (Chancroid). * **Donovan Bodies:** Safety-pin appearance in crushed tissue smears (Donovanosis). * **Treatment of choice for Chancroid:** Azithromycin (1g oral single dose) or Ceftriaxone.

Question 20: In which stage of syphilis does seropositivity typically become evident?

A. Chancre (primary syphilis)
B. Muco patches (secondary syphilis) (Correct Answer)
C. Gum ma (tertiary syphilis)
D. Congenital syphilis

Explanation: ### Explanation **Correct Answer: B. Muco patches (secondary syphilis)** **Medical Concept:** Seropositivity in syphilis refers to the detection of antibodies via non-treponemal (VDRL, RPR) or treponemal (FTA-ABS, TPHA) tests. In **Primary Syphilis**, the immune system has just been exposed to *Treponema pallidum*; therefore, tests are often negative during the first 1–3 weeks of the chancre's appearance (the "seronegative primary" phase) [1]. By the time the disease progresses to **Secondary Syphilis** (characterized by mucous patches, condyloma lata, and maculopapular rashes), the bacterial load is at its peak and the antibody response is fully developed [1]. Consequently, **seropositivity is 100%** in the secondary stage. **Analysis of Incorrect Options:** * **A. Chancre (Primary Syphilis):** Only about 30–50% of patients are seropositive when the chancre first appears. Diagnosis at this stage relies primarily on **Dark Ground Microscopy (DGM)** to visualize spirochetes. * **C. Gumma (Tertiary Syphilis):** While patients are seropositive here, this is a late manifestation occurring years after infection. The question asks when it *typically becomes evident*, which occurs much earlier in the secondary stage. * **D. Congenital Syphilis:** This is a mode of transmission (vertical) rather than a chronological stage of the primary infection sequence in an adult. **NEET-PG High-Yield Pearls:** * **Gold Standard for Primary Syphilis:** Dark Ground Microscopy (DGM). * **Secondary Syphilis:** Known as the "Great Imitator" and represents the most infectious stage [1]. * **Prozone Phenomenon:** Can cause a false-negative VDRL in secondary syphilis due to excessively high antibody titers; requires serum dilution for diagnosis [1]. * **Specific Test of Choice:** FTA-ABS is usually the first serological test to become positive (earlier than VDRL).

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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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