Venerology Practice Questions

Q: A 31-year-old male presents with dysuria and urethral discharge. NAAT confirms gonorrhea. Which additional infection should be treated empirically?

Chlamydia trachomatis. ***Chlamydia trachomatis*** - Due to the high rate of **coinfection** with *Neisseria gonorrhoeae*, empirical treatment for *Chlamydia trachomatis* is recommended when gonorrhea is diagnosed. - This approach ensures comprehensive treatment for common sexually transmitted infections, even if NAAT results for Chlamydia are pending. *Treponema pallidum* - This bacterium causes **syphilis**, which typically presents with a **chancre** in its primary stage or a rash in its secondary stage. - While syphilis is also an STI, its presentation is distinct from the patient's symptoms of dysuria and urethral discharge, and routine empirical treatment alongside gonorrhea is not standard unless there's clinical suspicion. *Herpes simplex virus* - This virus causes **genital herpes**, characterized by **painful genital ulcers or vesicles**. - The patient's symptoms of dysuria and urethral discharge are not typical for a primary HSV infection, and empirical treatment is not indicated in this scenario. *Trichomonas vaginalis* - This protozoan causes **trichomoniasis**, which can present with dysuria and discharge, often described as frothy and odorous. - While it causes similar symptoms, it is less frequently co-infected with gonorrhea compared to Chlamydia, and current guidelines prioritize empirical treatment for Chlamydia.

Q: Which test is the best to monitor the response to treatment in a patient with neurosyphilis?

RPR. RPR - The **Rapid Plasma Reagin (RPR)** test is a non-treponemal test used to monitor treatment response due to its quantitative nature, with **titers decreasing (fourfold or more)** after successful treatment [1]. - While typically done on serum, a **cerebrospinal fluid (CSF) RPR** is the most specific non-treponemal test for neurosyphilis treatment monitoring. *VDRL* - The **Venereal Disease Research Laboratory (VDRL)** test is also a non-treponemal test, but it is less sensitive than RPR in serum, especially in later stages of syphilis [1]. - Although **CSF VDRL** is highly specific for neurosyphilis diagnosis, RPR titers are generally preferred for monitoring treatment response due to their ease of quantification and reproducibility. *TPI* - The **Treponema pallidum immobilization (TPI)** test is a highly specific treponemal test used for confirming syphilis diagnosis, particularly in cases with ambiguous reactive non-treponemal tests. - However, treponemal tests like TPI usually remain **reactive for life** even after successful treatment and are therefore not suitable for monitoring treatment response. *FTA-ABS* - The **Fluorescent Treponemal Antibody Absorption (FTA-ABS)** test is another treponemal test, used for diagnostic confirmation because of its high sensitivity and specificity. - Similar to other treponemal tests, FTA-ABS **titers do not decrease significantly** after successful treatment and thus cannot be used to monitor the effectiveness of therapy.

Q: Which of the following conditions can present as a painless genital ulcer?

Primary syphilis. ***Primary syphilis*** - A **chancre**, the hallmark lesion of primary syphilis, is typically a **painless, indurated ulcer** with a clean base. - This characteristic makes it a common cause of painless genital ulcers. *Genital herpes* - Genital herpes typically presents with **multiple, painful vesicular lesions** [1] that can rupture and form shallow ulcers. - Pain is a distinguishing feature, making it less likely to be a painless ulcer [1]. *Chancroid* - Chancroid is caused by *Haemophilus ducreyi* and produces **painful, ragged-edged ulcers** with a grayish base [2]. - The ulcers are usually accompanied by **tender, suppurative lymphadenopathy** [2]. *Lymphogranuloma venereum* - The primary lesion of LGV can be a **small, painless vesicle or ulcer**, but it is often fleeting and unnoticed [2]. - The more prominent and characteristic presentation involves **painful, often suppurative inguinal lymphadenopathy** (buboes) [2].

Q: A patient presents with flu-like symptoms and a maculopapular rash on the palms and soles. What is the most likely diagnosis?

Secondary syphilis. ### Secondary syphilis - **Maculopapular rash on the palms and soles** is a classic and highly characteristic feature of secondary syphilis [1]. - **Flu-like symptoms** (fever, malaise, headache) frequently precede or accompany the rash in secondary syphilis [1]. *Rocky Mountain spotted fever* - While it causes a **maculopapular rash**, it typically starts on the ankles and wrists and spreads centrally, not initially on the palms and soles. - The rash can become **petechial**, a feature not mentioned, and patients often have a history of **tick bite**. *Measles* - The characteristic rash of measles is **maculopapular** but typically starts on the **face** and behind the ears, spreading downwards, not on the palms and soles. - It's usually associated with **Koplik spots** (small white spots with red halos on the buccal mucosa) and **cough, coryza, and conjunctivitis**. *Hand, foot, and mouth disease* - Caused by **coxsackievirus**, it primarily affects young children and causes tender, papulovesicular lesions [2]. - The rash involves the **hands, feet, and oral cavity**, but is typically vesicular, not primarily maculopapular, and less commonly affects the palms and soles as a sole presentation without other characteristic findings [2].

Q: A 60-year-old male with a history of diabetes presents with painful urination and white patches on the glans penis. Which condition is most likely responsible?

Candidiasis. ***Candidiasis*** - **Painful urination** and **white patches on the glans penis** in a diabetic patient are classic symptoms of **candidal balanitis**. - Patients with **diabetes mellitus** are at higher risk for fungal infections due to immunocompromise and elevated glucose levels. *Herpes simplex virus* - Characterized by **painful vesicles** that rupture to form ulcers, not typically white patches [1]. - While it can cause painful urination due to urethritis, the appearance of the lesions is different [1]. *Human papillomavirus* - Causes **genital warts**, which are typically flesh-colored, cauliflower-like growths, not white patches or painful urination. - These warts are usually asymptomatic or cause mild itching. *Syphilis* - Presents initially as a **painless chancre** (a firm, round, solitary ulcer) at the site of infection [1]. - Later stages involve rash, fever, and other systemic symptoms, which do not match this presentation.

Q: Which sexually transmitted infection is associated with a painless, indurated ulcer?

Primary syphilis. Primary syphilis - **Primary syphilis** is classically characterized by a **chancre**, which is a **painless, indurated ulcer** that develops at the site of infection [1]. - The chancre typically appears 10 to 90 days after exposure and usually resolves spontaneously within 3 to 6 weeks, even without treatment. *Genital herpes* - Genital herpes typically presents with **painful, vesicular lesions** that often rupture to form shallow ulcers, which is distinct from a painless, indurated ulcer [1]. - The vesicles are usually preceded by itching or tingling and can recur. *Chancroid* - Chancroid is characterized by **painful, ragged-edged ulcers** with a gray or yellow exudate, often accompanied by tender inguinal lymphadenopathy. - Unlike syphilis, the ulcers of chancroid are noticeably painful and often **purulent**. *Lymphogranuloma venereum* - **Lymphogranuloma venereum (LGV)** often begins with a small, **painless ulcer or papule** that might go unnoticed, but its hallmark is severe, often unilateral, **inguinal lymphadenopathy** (buboes) that can rupture. - The initial lesion is typically transient and not the primary defining feature of the disease's progression.

Q: A 42-year-old female presents with a painless, indurated ulcer on her labia that has been present for 3 weeks. She has bilateral non-tender inguinal lymphadenopathy. Darkfield microscopy of the ulcer is positive for spirochetes. Analyze and determine the best treatment approach.

Single dose of intramuscular penicillin G. ***Single dose of intramuscular penicillin G*** - The clinical presentation of a **painless, indurated labial ulcer** (chancre) with **inguinal lymphadenopathy**, along with **positive darkfield microscopy for spirochetes**, is characteristic of **primary syphilis** [1]. - **Penicillin G benzathine** is the **first-line and most effective treatment** for all stages of syphilis, particularly effective as a single intramuscular dose for primary syphilis. *Oral doxycycline for 14 days* - **Doxycycline** is an alternative treatment for primary syphilis, especially in patients with a **penicillin allergy**. - However, it requires a **14-day course of oral therapy**, which may lead to compliance issues, making it less ideal than a single-dose injection if penicillin is tolerated. *Ceftriaxone 250mg IM once* - **Ceftriaxone** is typically used for the treatment of **gonorrhea** and is not considered a first-line agent for syphilis [2]. - While it has some efficacy against *Treponema pallidum*, **penicillin** remains the superior and recommended treatment. *Azithromycin 2g orally once* - **Azithromycin** is used to treat various bacterial infections, including **chlamydia** and some cases of **gonorrhea and chancroid**. - It is **not effective** against syphilis due to widespread resistance and is therefore not recommended for its treatment.

Q: A 29-year-old male presents with a painless ulcer on his genitalia and a maculopapular rash on his palms and soles. What is the causative organism?

Treponema pallidum. ***Treponema pallidum*** - The presentation of a **painless genital ulcer (chancre)** followed by a **maculopapular rash on the palms and soles** is highly characteristic of **secondary syphilis**, caused by *Treponema pallidum* [1]. - *Treponema pallidum* is a **spirochete** that causes syphilis, which progresses through distinct stages with varied clinical manifestations [1]. *Chlamydia trachomatis* - **Chlamydia trachomatis** is a common cause of **urethritis**, **cervicitis**, and **lymphogranuloma venereum**, but it does not typically cause a painless chancre followed by a widespread maculopapular rash on palms and soles. - Genital ulcers caused by *Chlamydia trachomatis* in **lymphogranuloma venereum** are usually transient and small, followed by significant **lymphadenopathy**. *Haemophilus ducreyi* - *Haemophilus ducreyi* causes **chancroid**, which is characterized by **painful genital ulcers** with irregular, undermined borders and frequently associated with **inguinal lymphadenopathy**. - The ulcers are typically **painful**, which contrasts with the patient's painless ulcer. *Herpes simplex virus* - **Herpes simplex virus (HSV)** causes **genital herpes**, which presents as painful, vesicular lesions that ulcerate, often accompanied by **flu-like symptoms** during the primary infection [2]. - The lesions are typically **painful vesicles** and ulcers, not a painless, indurated ulcer (chancre), and the maculopapular rash on palms and soles is not a typical manifestation of HSV infection [2].

Q: A patient presents with a painless ulcer and a positive RPR test. What is the most likely diagnosis?

Primary syphilis. **Primary syphilis** - The presence of a **painless ulcer**, known as a **chancre**, is the classic hallmark of primary syphilis [1]. - A **positive RPR test** (Rapid Plasma Reagin) indicates active syphilis infection [1]. *Chancroid* - Caused by **Haemophilus ducreyi**, chancroid typically presents with **multiple, painful, and tender ulcers**. - The RPR test would be **negative**, as it is not a test for chancroid. *Lymphogranuloma venereum* - Initial lesion is often a **transient, painless papule or vesicle** that may go unnoticed, followed by painful **inguinal lymphadenopathy (buboes)**. - While it can be associated with genital ulcers, they are usually not the primary diagnostic feature, and the RPR test would be negative. *Genital herpes* - Characterized by **multiple, painful vesicular or ulcerative lesions** on an erythematous base [1]. - The RPR test would be **negative** as it is a viral infection, not bacterial [1].

Q: A 58-year-old male presents with chronic genital ulceration, inguinal lymphadenopathy, and foul-smelling discharge. A biopsy shows granulomatous inflammation with Donovan bodies. Analyze and determine the most appropriate treatment.

Doxycycline 100mg orally BID for 21 days. ***Doxycycline 100mg orally BID for 21 days*** - This regimen is the **recommended treatment** for **donovanosis (granuloma inguinale)**, characterized by chronic genital ulcers and the presence of **Donovan bodies**. - **Doxycycline** targets the causative organism, *Klebsiella granulomatis*, effectively resolving the infection. *Azithromycin 1g orally once a week for 3 weeks* - While azithromycin is used for some sexually transmitted infections, the **weekly dosing** for donovanosis is typically **1g once weekly for at least 3 weeks**, but **doxycycline** is generally preferred for initial treatment. - This regimen is sometimes used as an alternative, but continuous daily dosing of **doxycycline** is often more effective in achieving sustained therapeutic levels. *Ceftriaxone 250mg IM once* - **Ceftriaxone** [1] is the standard treatment for **gonorrhea** and is often used in combination with azithromycin for suspected chlamydial coinfection. - It is **not effective** against *Klebsiella granulomatis* and therefore would not treat donovanosis. *Penicillin G 2.4 million units IM once* - This is the standard treatment for primary, secondary, and early latent **syphilis**. - **Penicillin G** does not have activity against *Klebsiella granulomatis* and would be ineffective for donovanosis.

Question 1

A 31-year-old male presents with dysuria and urethral discharge. NAAT confirms gonorrhea. Which additional infection should be treated empirically?

Accepted Answer

Chlamydia trachomatis

Answer

Treponema pallidum

Answer

Herpes simplex virus

Answer

Trichomonas vaginalis

Question 2

Which test is the best to monitor the response to treatment in a patient with neurosyphilis?

Accepted Answer

RPR

Answer

VDRL

Answer

TPI

Answer

FTA-ABS

Question 3

Which of the following conditions can present as a painless genital ulcer?

Accepted Answer

Primary syphilis

Answer

Genital herpes

Answer

Chancroid

Answer

Lymphogranuloma venereum

Question 4

A patient presents with flu-like symptoms and a maculopapular rash on the palms and soles. What is the most likely diagnosis?

Accepted Answer

Secondary syphilis

Answer

Rocky Mountain spotted fever

Answer

Measles

Answer

Hand, foot, and mouth disease

Question 5

A 60-year-old male with a history of diabetes presents with painful urination and white patches on the glans penis. Which condition is most likely responsible?

Accepted Answer

Candidiasis

Answer

Herpes simplex virus

Answer

Human papillomavirus

Answer

Syphilis

Question 6

Which sexually transmitted infection is associated with a painless, indurated ulcer?

Accepted Answer

Primary syphilis

Answer

Genital herpes

Answer

Chancroid

Answer

Lymphogranuloma venereum

Question 7

A 42-year-old female presents with a painless, indurated ulcer on her labia that has been present for 3 weeks. She has bilateral non-tender inguinal lymphadenopathy. Darkfield microscopy of the ulcer is positive for spirochetes. Analyze and determine the best treatment approach.

Accepted Answer

Single dose of intramuscular penicillin G

Answer

Oral doxycycline for 14 days

Answer

Ceftriaxone 250mg IM once

Answer

Azithromycin 2g orally once

Question 8

A 29-year-old male presents with a painless ulcer on his genitalia and a maculopapular rash on his palms and soles. What is the causative organism?

Accepted Answer

Treponema pallidum

Answer

Chlamydia trachomatis

Answer

Haemophilus ducreyi

Answer

Herpes simplex virus

Question 9

A patient presents with a painless ulcer and a positive RPR test. What is the most likely diagnosis?

Accepted Answer

Primary syphilis

Answer

Chancroid

Answer

Lymphogranuloma venereum

Answer

Genital herpes

Question 10

A 58-year-old male presents with chronic genital ulceration, inguinal lymphadenopathy, and foul-smelling discharge. A biopsy shows granulomatous inflammation with Donovan bodies. Analyze and determine the most appropriate treatment.

Accepted Answer

Doxycycline 100mg orally BID for 21 days

Answer

Azithromycin 1g orally once a week for 3 weeks

Answer

Ceftriaxone 250mg IM once

Answer

Penicillin G 2.4 million units IM once

Venerology — MCQs

Venerology — MCQs

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