Venerology Practice Questions

Q: A patient with anogenital warts has not responded to conventional therapy after 3 months. Next best step is:

HIV testing. ### HIV testing - **Persistent, recalcitrant anogenital warts** that do not respond to conventional therapy after 3 months are a strong indicator of **immunocompromise** [1]. - **HIV infection** is a common cause of immunosuppression that can lead to treatment failure for anogenital warts [1]. *Switch to imiquimod* - While **imiquimod** is a topical treatment for anogenital warts, switching therapies without investigating the cause of treatment failure is not the initial best step. - The lack of response suggests an underlying issue rather than simply a need for a different treatment type. *Continue same treatment longer* - Continuing the same treatment when there has been **no response after 3 months** is unlikely to be effective and delays appropriate management. - This approach does not address the underlying reason for treatment failure. *Biopsy lesion* - While a **biopsy** can be important to confirm the diagnosis or rule out malignancy, it is typically considered after addressing potential underlying causes for treatment resistance, such as **immunocompromise**. - In this scenario, the primary concern is the lack of response to therapy, which points towards an immune system issue.

Q: A sex worker presents with purulent urethral discharge and gram-negative diplococci in culture. What is the most likely diagnosis?

Neisseria gonorrhoeae. ***Neisseria gonorrhoeae*** - **Purulent urethral discharge** and identification of **Gram-negative diplococci** on microscopy are classic diagnostic features of gonococcal urethritis [1]. - This sexually transmitted infection is common among sexually active individuals, including **sex workers** [1]. *Treponema pallidum* - This bacterium causes **syphilis**, which is characterized by **chancres** in the primary stage, and widespread rashes or lesions in later stages [2]. - It would not typically present with Gram-negative diplococci or purulent urethral discharge [2]. *Haemophilus ducreyi* - This organism is responsible for **chancroid**, a sexually transmitted infection that causes painful **genital ulcers** with ragged borders and often associated with lymphadenopathy [3]. - It would not lead to purulent urethral discharge, and while Gram-negative, it is typically seen as pleomorphic rods in chains. *Chlamydia trachomatis* - **Chlamydia** infection often presents with mucopurulent urethral discharge, but it is typically less purulent than gonorrhea and may be **asymptomatic** [1]. - **Chlamydia** is an **obligate intracellular bacterium** and would not be visualized as Gram-negative diplococci on a Gram stain [1].

Q: What is the most commonly preferred first-line treatment for external genital warts caused by HPV?

Cryotherapy. **Cryotherapy** - **Cryotherapy** is a commonly preferred first-line treatment for external genital warts due to its effectiveness and good cosmetic outcomes [2], [3]. - It involves freezing the warts with **liquid nitrogen**, leading to their destruction [2], [3]. *5-FU* - **5-fluorouracil (5-FU)** cream is an antimetabolite that inhibits cell proliferation but is generally not a first-line treatment for external genital warts. - It can cause significant **local skin irritation, erosion, and pain**, making it less favorable for widespread use in this area. *Imiquimod* - **Imiquimod** is an immune response modifier that stimulates the production of cytokines but it's not considered as the first-line treatment [1]. - It requires multiple applications over several weeks and can cause **local inflammatory reactions** like erythema, itching, and burning [1]. *Podophyllin* - **Podophyllin** resin is an antimitotic agent but its use is limited due to potential systemic toxicity and local side effects like skin irritation [1]. - It is applied topically but must be washed off after a few hours to prevent severe reactions, and it is **contraindicated in pregnancy** [1].

Q: Which STI has the highest rates of antibiotic resistance?

Gonorrhea. ***Gonorrhea*** - **Neisseria gonorrhoeae** has developed resistance to multiple classes of antibiotics, including **penicillins**, **tetracyclines**, **fluoroquinolones**, and increasingly to **cephalosporins**, making treatment challenging [1]. - This high rate of antibiotic resistance is a major public health concern, leading to treatment failures and the need for **dual therapy** with azithromycin and ceftriaxone to improve cure rates and slow resistance development [1]. *Chancroid* - Caused by **Haemophilus ducreyi**, which is generally susceptible to macrolides (e.g., azithromycin) and cephalosporins (e.g., ceftriaxone). - While resistance can occur, it is significantly **less prevalent** and widespread compared to gonorrhea. *Donovanosis* - Caused by **Klebsiella granulomatis**, which typically responds well to antibiotics like azithromycin, doxycycline, or trimethoprim-sulfamethoxazole. - Resistance is **rarely reported** and does not pose a major clinical challenge. *Syphilis* - Caused by **Treponema pallidum**, which remains highly susceptible to **penicillin G**, the drug of choice for all stages of syphilis [2]. - Although isolated cases of macrolide resistance have been noted, penicillin resistance is **extremely rare** and has not significantly impacted treatment recommendations [2].

Q: A 25-year-old woman presents with painful genital ulcers and tender inguinal lymphadenopathy. PCR confirms an HSV-2 infection. What is the treatment of choice?

Acyclovir. ***Acyclovir*** - **Acyclovir** is an **antiviral medication** that effectively inhibits the replication of HSV-2 by interfering with viral DNA synthesis, reducing the severity and duration of outbreaks. - It is the **treatment of choice** for genital **herpes simplex virus (HSV) infections**, helping to manage painful ulcers and prevent recurrences [1]. *Azithromycin* - **Azithromycin** is a **macrolide antibiotic** primarily used to treat bacterial infections, such as those caused by *Chlamydia trachomatis* [1] or respiratory pathogens. - It has **no antiviral activity** against HSV-2 and would therefore be ineffective for this infection. *Metronidazole* - **Metronidazole** is an **antibiotic and antiprotozoal medication** used for anaerobic bacterial infections and parasitic infections, such as trichomoniasis or bacterial vaginosis. - It possesses **no antiviral properties** against HSV-2 and is not indicated for the treatment of herpes. *Ciprofloxacin* - **Ciprofloxacin** is a **fluoroquinolone antibiotic** used to treat a wide range of bacterial infections, including urinary tract infections and certain sexually transmitted infections like chancroid. - It is **ineffective against viral infections** such as HSV-2, and its use in this context would be inappropriate.

Q: A 25-year-old male presents with multiple painful genital ulcers and tender inguinal lymphadenopathy. The likely diagnosis is:

Chancroid. **Chancroid** - **Chancroid** presents with **multiple, painful, ragged genital ulcers** with a grayish base and associated **tender inguinal lymphadenopathy** (buboes) [1]. - It is caused by the bacterium *Haemophilus ducreyi*. *Primary syphilis* - Primary syphilis typically presents as a **single, painless chancre** with a firm, indurated base and usually non-tender, rubbery regional lymphadenopathy. - The ulcers described are multiple and painful, which is inconsistent with a syphilic chancre. *Genital herpes* - Genital herpes causes **multiple, painful vesicles** that progress to shallow ulcers, often preceded by a prodrome of tingling or burning [2]. - While painful, herpes lesions are typically vesicular initially and do not commonly present with the deep, ragged ulcers and classic tender buboes seen in chancroid [1]. *Lymphogranuloma venereum* - LGV typically starts as a **small, painless papule or ulcer** that often goes unnoticed, followed by the development of **large, often suppurative, unilateral inguinal lymphadenopathy** (buboes) in later stages [1]. - The initial lesion in LGV is often transient and painless, unlike the prominent, painful ulcers described here.

Q: The groove sign is most commonly associated with which condition?

Lymphogranuloma venereum (LGV). ***Lymphogranuloma venereum (LGV)*** - The **groove sign** is a classic clinical finding in LGV, particularly in the inguinal region, characterized by a visible and palpable furrow separating swollen lymph nodes above and below the inguinal ligament. - This sign is due to the involvement of both superficial and deep inguinal lymphatics, leading to marked **lymphadenopathy** that is compartmentalized by the inguinal ligament. *Syphilis* - Syphilis is typically associated with a **chancre** (painless ulcer) in primary syphilis, and a widespread rash in secondary syphilis, but not the groove sign. - Lymphadenopathy in syphilis is usually generalized and less prominent or compartmentalized compared to LGV. *Dermatomyositis* - Dermatomyositis is an **inflammatory myopathy** characterized by muscle weakness and distinctive skin rashes, such as Gottron's papules and a heliotrope rash. - It does not involve significant lymphadenopathy or the specific anatomical signs like the groove sign. *Systemic lupus erythematosus* - Systemic lupus erythematosus is a **chronic autoimmune connective tissue disease** with diverse manifestations affecting multiple organ systems. - While it can cause lymphadenopathy, it does not produce the characteristic compartmentalized swelling known as the groove sign.

Q: A 45-year-old female with a history of genital herpes presents with painful vesicular lesions on her vulva, fever, and malaise. She has experienced multiple recurrences despite suppressive therapy. What is the most appropriate change in her treatment regimen?

Increase dose of valacyclovir for suppressive therapy. **Increase dose of valacyclovir for suppressive therapy** - For patients with **frequent recurrent genital herpes** despite suppressive therapy, increasing the dose of daily oral antiviral medication is often recommended to achieve better control. - In this case, **valacyclovir** is a prodrug of acyclovir, offering improved bioavailability and simplified dosing which is effective for both episodic treatment and suppression [1]. *Discontinue antiviral therapy and manage symptoms* - Discontinuing antiviral therapy would likely lead to **more frequent and severe recurrences**, as she is already experiencing multiple recurrences on suppressive therapy. - Management of symptoms alone would not address the underlying **viral replication** or prevent future outbreaks. *Use topical acyclovir as needed* - **Topical acyclovir** is generally less effective than oral antiviral therapy for managing genital herpes outbreaks and is not recommended for recurrent episodes, especially when systemic symptoms like fever and malaise are present [1]. - It does not prevent recurrences and its efficacy for acute treatment of established lesions is limited. *Switch to famciclovir for suppressive therapy to improve control of recurrences.* - While **famciclovir** is an alternative antiviral agent for herpes suppression, there is no strong evidence to suggest it would be significantly more effective than a higher dose of valacyclovir in a patient already failing standard suppressive therapy [1]. - The most straightforward and often effective approach is to first try **optimizing the current effective therapy** (valacyclovir) by increasing its dosage.

Q: Which sexually transmitted infection is associated with the formation of condylomata lata?

Secondary syphilis. ***Secondary syphilis*** - **Condylomata lata** are highly infectious, flat-topped, moist, fleshy papules that are characteristic lesions of **secondary syphilis**, often found in warm, moist areas like the anogenital region [1]. - They represent a mucocutaneous manifestation of widespread **spirochete dissemination** during the secondary stage [1]. *Genital herpes* - Genital herpes is characterized by painful **vesicles** and **ulcers**, not flat, warty lesions like condylomata lata [1]. - It is caused by the **herpes simplex virus (HSV)**, predominantly HSV-2. *Lymphogranuloma venereum* - This infection presents with a transient, often unnoticed, primary lesion followed by **inguinal lymphadenopathy** (buboes) and associated systemic symptoms. - It is caused by specific serovars of **_Chlamydia trachomatis_** and does not typically involve condylomata lata. *Primary syphilis* - Primary syphilis is characterized by a single, painless lesion called a **chancre** at the site of inoculation [1]. - This stage precedes the disseminated manifestations, including condylomata lata, seen in secondary syphilis [1].

Q: A 40-year-old male presents with multiple vesicles on his penis that later ulcerate. Which test is most likely to confirm the diagnosis?

PCR for HSV. PCR for HSV - PCR (Polymerase Chain Reaction) for herpes simplex virus (HSV) is the most sensitive and specific test for confirming an active HSV infection, especially in the presence of vesicular or ulcerative lesions [1]. - It detects the viral DNA directly from the lesion fluid, providing a definitive diagnosis of genital herpes [2]. Tzanck smear - A Tzanck smear can reveal multinucleated giant cells and acantholytic cells, which are characteristic of herpes simplex virus (HSV) or varicella-zoster virus (VZV) infections. - However, it has lower sensitivity and specificity compared to PCR, as it does not distinguish between HSV and VZV and can produce false negatives. Viral culture - Viral culture was historically the gold standard for HSV diagnosis and can confirm the presence of live virus [1]. - However, it has lower sensitivity than PCR, especially in later stages of lesion evolution or with crusted lesions, and can take longer to yield results [2]. Serology for HSV antibodies - Serology for HSV antibodies detects the presence of IgG or IgM antibodies to HSV, indicating past exposure or primary infection [3]. - While useful for diagnosing recurrent or past infections and differentiating between HSV-1 and HSV-2, it does not confirm an acute, active infection causing current lesions, as antibodies may take weeks to appear after initial infection [2].

Question 1

A patient with anogenital warts has not responded to conventional therapy after 3 months. Next best step is:

Accepted Answer

HIV testing

Answer

Switch to imiquimod

Answer

Continue same treatment longer

Answer

Biopsy lesion

Question 2

A sex worker presents with purulent urethral discharge and gram-negative diplococci in culture. What is the most likely diagnosis?

Accepted Answer

Neisseria gonorrhoeae

Answer

Treponema pallidum

Answer

Haemophilus ducreyi

Answer

Chlamydia trachomatis

Question 3

What is the most commonly preferred first-line treatment for external genital warts caused by HPV?

Accepted Answer

Cryotherapy

Answer

5-FU

Answer

Imiquimod

Answer

Podophyllin

Question 4

Which STI has the highest rates of antibiotic resistance?

Accepted Answer

Gonorrhea

Answer

Chancroid

Answer

Donovanosis

Answer

Syphilis

Question 5

A 25-year-old woman presents with painful genital ulcers and tender inguinal lymphadenopathy. PCR confirms an HSV-2 infection. What is the treatment of choice?

Accepted Answer

Acyclovir

Answer

Azithromycin

Answer

Metronidazole

Answer

Ciprofloxacin

Question 6

A 25-year-old male presents with multiple painful genital ulcers and tender inguinal lymphadenopathy. The likely diagnosis is:

Accepted Answer

Chancroid

Answer

Primary syphilis

Answer

Genital herpes

Answer

Lymphogranuloma venereum

Question 7

The groove sign is most commonly associated with which condition?

Accepted Answer

Lymphogranuloma venereum (LGV)

Answer

Syphilis

Answer

Dermatomyositis

Answer

Systemic lupus erythematosus

Question 8

A 45-year-old female with a history of genital herpes presents with painful vesicular lesions on her vulva, fever, and malaise. She has experienced multiple recurrences despite suppressive therapy. What is the most appropriate change in her treatment regimen?

Accepted Answer

Increase dose of valacyclovir for suppressive therapy

Answer

Discontinue antiviral therapy and manage symptoms

Answer

Use topical acyclovir as needed

Answer

Switch to famciclovir for suppressive therapy to improve control of recurrences.

Question 9

Which sexually transmitted infection is associated with the formation of condylomata lata?

Accepted Answer

Secondary syphilis

Answer

Genital herpes

Answer

Lymphogranuloma venereum

Answer

Primary syphilis

Question 10

A 40-year-old male presents with multiple vesicles on his penis that later ulcerate. Which test is most likely to confirm the diagnosis?

Accepted Answer

PCR for HSV

Answer

Tzanck smear

Answer

Viral culture

Answer

Serology for HSV antibodies

Venerology — MCQs

Venerology — MCQs

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