Venerology Practice Questions

Q: A 50-year-old male presents with a painless genital ulcer and non-tender inguinal lymphadenopathy. The initial RPR is negative, but there is a high suspicion for syphilis. What is the next best diagnostic test?

FTA-ABS. ***FTA-ABS*** - **Fluorescent Treponemal Antibody Absorption (FTA-ABS)** is a **treponemal test** that remains positive for life and is useful in confirming syphilis in cases of high suspicion, especially when non-treponemal tests like RPR are negative (e.g., in early stages or due to the **prozone phenomenon**) [1]. - It directly detects antibodies specific to *Treponema pallidum* and is more sensitive than RPR in early syphilis [1]. *Dark field microscopy* - **Dark field microscopy** directly visualizes spirochetes from a chancre [1], but its utility is limited by the need for fresh samples and specialized equipment. - While it offers immediate diagnosis, a negative result does not rule out syphilis, especially if the lesion is healing or if antibiotics have been used. *PCR for T. pallidum* - **PCR for *T. pallidum*** is highly sensitive and specific but is not routinely available in all clinical settings, and its use is typically reserved for challenging cases or research. - While it can be useful in detecting DNA from the bacteria, it's not the initial confirmatory test of choice when a treponemal serum assay is widely available and appropriate. *HIV test* - An **HIV test** is crucial for patients with syphilis as coinfection is common, but it does not directly diagnose syphilis. - While important for comprehensive patient care, it does not address the immediate diagnostic question regarding syphilis itself.

Q: Which of the following is a common clinical manifestation of secondary syphilis?

Maculopapular rash. **Maculopapular rash** - The **maculopapular rash** of secondary syphilis is highly characteristic, often affecting the **palms and soles**, and can be widespread [1]. - This rash results from widespread dissemination of **Treponema pallidum** through the bloodstream [1]. *Chancre* - A **chancre** is a **painless ulcer** that is the hallmark lesion of **primary syphilis**, appearing at the site of infection [1]. - It typically heals spontaneously within 3-6 weeks, even without treatment, before secondary syphilis manifestations occur [1]. *Gummas* - **Gummas** are **granulomatous lesions** that are characteristic of **tertiary syphilis**, a late complication of untreated infection [1]. - They can affect various organs, including skin, bone, and internal organs, leading to significant tissue destruction. *Aortic aneurysm* - An **aortic aneurysm**, specifically **syphilitic aortitis**, is a serious manifestation of **tertiary syphilis**, often occurring decades after the initial infection [1]. - It results from chronic inflammation of the aortic wall, leading to weakening and dilation of the aorta.

Q: Which of the following conditions is not a typical feature of secondary syphilis?

Gummas. Self-Correction: Gummas are a characteristic feature of tertiary syphilis, not secondary syphilis, representing chronic granulomatous lesions. They can affect various organs, including skin, bones, and internal organs, appearing years after the initial infection. *Maculopapular rash* - A diffuse maculopapular rash, often involving the palms and soles, is a classic presentation of secondary syphilis [1]. - This rash is typically non-itchy and can vary in appearance, sometimes becoming papulosquamous [1]. *Condyloma lata* - Condyloma lata are moist, wart-like lesions that appear in intertriginous areas (e.g., genital, perianal) during secondary syphilis [1]. - These lesions are highly infectious and result from widespread spirochetemia. *Alopecia* - Patchy alopecia, often described as a "moth-eaten" appearance, can occur during secondary syphilis. - This type of hair loss is temporary and usually resolves with treatment.

Q: Which of the following is a hallmark of tertiary syphilis?

Aortic aneurysm. ***Aortic aneurysm*** – **Aortic aneurysm** (specifically **thoracic aortic aneurysm**) is a classic manifestation of tertiary syphilis, resulting from chronic inflammation of the vasa vasorum leading to weakening of the aortic wall. – It can also manifest as **neurosyphilis** (e.g., tabes dorsalis, general paresis) or **gummas** (granulomatous lesions) affecting various organs [1]. *Chancre* – A **chancre** is a **painless ulcerative lesion** that characterizes the **primary stage** of syphilis [1]. – It typically appears at the site of infection about 3 weeks after exposure and resolves spontaneously [1]. *Condylomata lata* – **Condylomata lata** are **wart-like lesions** that appear in the **secondary stage** of syphilis, often in moist areas like the anogenital region or skin folds [1]. – They are highly infectious and contain numerous spirochetes. *Maculopapular rash* – A **maculopapular rash** is a common and distinctive feature of **secondary syphilis**, often affecting the palms and soles [1]. – This rash is typically non-itchy and can appear a few weeks to months after the chancre has resolved [1].

Q: What is the most appropriate treatment for a patient diagnosed with lymphogranuloma venereum?

Doxycycline. ***Doxycycline*** - **Doxycycline** is the recommended first-line treatment for **lymphogranuloma venereum (LGV)** due to its effectiveness against *Chlamydia trachomatis* serovars L1, L2, and L3, which cause LGV. - Treatment typically involves a 21-day course to ensure complete eradication of the infection and resolution of symptoms like **lymphadenopathy** and **genital ulcers** [1]. *Penicillin* - **Penicillin** is primarily used to treat bacterial infections like **syphilis**, **streptococcal pharyngitis**, and certain **gonococcal infections**. - It is **ineffective** against *Chlamydia trachomatis*, the causative agent of LGV. *Ceftriaxone* - **Ceftriaxone** is a third-generation cephalosporin commonly used for treating **gonorrhea**, **meningitis**, and other severe bacterial infections [1]. - It has **poor activity** against *Chlamydia trachomatis* and is not an appropriate treatment for LGV. *Metronidazole* - **Metronidazole** is an antimicrobial highly effective against **anaerobic bacteria** and **protozoa**, commonly used for conditions like **trichomoniasis**, **bacterial vaginosis**, and **amebiasis**. - It has **no activity** against *Chlamydia trachomatis* and is therefore not used for LGV.

Q: A 40-year-old woman presents with a painless ulcer on her genitalia and reports a recent new sexual partner. What is the most likely diagnosis?

Syphilis. Syphilis - **Primary syphilis** is characterized by a **painless chancre** (ulcer) at the site of infection [1], which typically appears 10 to 90 days after exposure. - The history of a new sexual partner increases the likelihood of acquiring a sexually transmitted infection like syphilis [2]. *Gonorrhea* - Primarily causes **urethritis** in men and **cervicitis** in women, leading to symptoms like discharge and dysuria, not typically a painless ulcer. - While it can cause pharyngitis or proctitis, a painless genital ulcer is not its classic presentation. *Chlamydia* - Often causes **asymptomatic infections** or symptoms similar to gonorrhea, such as **cervicitis** or **urethritis**, with discharge and dysuria [2]. - It does not typically present with a **painless genital ulcer**. *Genital herpes* - Characterized by **painful vesicles** and **ulcers** [3], usually preceded by prodromal symptoms like tingling or burning. - The ulcers associated with herpes are typically *painful* [4], which contrasts with the symptom presented in the question.

Q: A 28-year-old male presents with dysuria and purulent urethral discharge. A Gram stain reveals gram-negative diplococci. What is the most likely diagnosis?

Gonorrhea. ***Gonorrhea*** - The presence of **dysuria**, **purulent urethral discharge**, and **gram-negative diplococci** on Gram stain is the classic presentation for *Neisseria gonorrhoeae* [1]. - *Neisseria gonorrhoeae* is a **Gram-negative diplococcus** and is readily identifiable microscopically from urethral exudates in males [1]. *Chlamydia trachomatis* - While *Chlamydia trachomatis* also causes urethritis with dysuria and discharge, the discharge is typically **less purulent** or **mucopurulent**, not frankly purulent as described [1]. - *Chlamydia trachomatis* is an **intracellular bacterium** and cannot be visualized as gram-negative diplococci on a Gram stain. *Trichomoniasis* - *Trichomoniasis* is caused by the parasite *Trichomonas vaginalis* and causes urethritis, but it would not appear as **gram-negative diplococci** on Gram stain [1]. - **Urethral discharge** due to *Trichomonas vaginalis* is often frothy and green-yellow, and microscopy reveals motile trichomonads, not bacteria. *Syphilis* - **Syphilis** is caused by the spirochete *Treponema pallidum* and typically presents with a **chancre** in the primary stage, followed by diffuse rash in the secondary stage [2]. - *Treponema pallidum* is a **spirochete** and cannot be seen on Gram stain; it requires darkfield microscopy for visualization.

Q: A neonate is diagnosed with congenital syphilis. Which serological test is the most specific for confirming the diagnosis in the mother?

TPHA. PH (Treponema Pallidum Hemagglutination Assay) - **TPHA** is a **treponemal-specific test** that directly detects antibodies against *Treponema pallidum*, making it highly reliable for confirming syphilis, particularly in cases of suspected congenital syphilis in the mother. - It remains positive even after treatment, indicating past or present infection, and provides a definitive confirmation absent in non-treponemal tests. *VDRL (Venereal Disease Research Laboratory)* - **VDRL** is a **non-treponemal test** that detects antibodies to cardiolipin, a lipid-like substance released from damaged host cells, and is primarily used for screening and monitoring treatment response. [1] - While useful for initial screening and assessing disease activity, it lacks the specificity for definitive confirmation since biological false positives can occur due to other conditions such as pregnancy. [1] *RPR (Rapid Plasma Reagin)* - **RPR** is also a **non-treponemal test** similar to VDRL, detecting antibodies to cardiolipin and is widely used for screening due to its ease of performance. [1] - Like VDRL, it is not specific enough for confirmation due to potential **false positives** and is mainly used for screening and monitoring treatment effectiveness. [1] *EIA (Enzyme Immunoassay)* - **EIA** can be used as either a **treponemal-specific** or **non-treponemal** test, depending on the antigens used in the assay. [1] - While some **EIAs** are highly sensitive and specific for detecting treponemal antibodies, the term "EIA" itself is too broad, and its specificity for confirmation depends entirely on the type of antigen used, requiring further clarification for definitive diagnosis over **TPHA**.

Q: Which of the following is the treatment of choice for chancroid?

Azithromycin. ***Azithromycin*** - **Azithromycin** 1 gram orally in a **single dose** is a highly effective and convenient treatment for chancroid caused by *Haemophilus ducreyi*. - Its long half-life allows for single-dose administration, which improves **patient adherence** and reduces the risk of further transmission. *Ceftriaxone* - **Ceftriaxone** is primarily used to treat **gonorrhea** [1] and is also effective against other bacterial infections. While it has some activity against *Haemophilus ducreyi*, **azithromycin** or **ciprofloxacin** are generally preferred for chancroid. *Penicillin* - **Penicillin** is the cornerstone of treatment for **syphilis**, caused by *Treponema pallidum*. - It is **not effective** against *Haemophilus ducreyi*, the causative agent of chancroid. *Doxycycline* - **Doxycycline** is a broad-spectrum antibiotic used to treat various infections, including **chlamydia** and **syphilis** (as an alternative to penicillin). - It is **not the preferred first-line treatment** for chancroid; single-dose azithromycin or ceftriaxone are generally more effective.

Question 1

A 50-year-old male presents with a painless genital ulcer and non-tender inguinal lymphadenopathy. The initial RPR is negative, but there is a high suspicion for syphilis. What is the next best diagnostic test?

Accepted Answer

FTA-ABS

Answer

Dark field microscopy

Answer

PCR for T. pallidum

Answer

HIV test

Question 2

A 25-year-old male with a history of unprotected sex presents with dysuria, urethral discharge, and conjunctivitis. Laboratory results show a negative gram stain, and NAAT is pending. What is the next best step in management?

Accepted Answer

Empiric treatment with ceftriaxone and azithromycin for suspected gonococcal and chlamydial infections

Answer

Delay treatment until NAAT results are available

Answer

Topical antibiotics for conjunctivitis only

Answer

Penicillin G intramuscularly for suspected gonorrhea

Question 3

Which of the following is a common clinical manifestation of secondary syphilis?

Accepted Answer

Maculopapular rash

Answer

Chancre

Answer

Gummas

Answer

Aortic aneurysm

Question 4

Which of the following conditions is not a typical feature of secondary syphilis?

Accepted Answer

Gummas

Answer

Condyloma lata

Answer

Alopecia

Answer

Maculopapular rash

Question 5

Which of the following is a hallmark of tertiary syphilis?

Accepted Answer

Aortic aneurysm

Answer

Chancre

Answer

Condylomata lata

Answer

Maculopapular rash

Question 6

What is the most appropriate treatment for a patient diagnosed with lymphogranuloma venereum?

Accepted Answer

Doxycycline

Answer

Penicillin

Answer

Ceftriaxone

Answer

Metronidazole

Question 7

A 40-year-old woman presents with a painless ulcer on her genitalia and reports a recent new sexual partner. What is the most likely diagnosis?

Accepted Answer

Syphilis

Answer

Gonorrhea

Answer

Chlamydia

Answer

Genital herpes

Question 8

A 28-year-old male presents with dysuria and purulent urethral discharge. A Gram stain reveals gram-negative diplococci. What is the most likely diagnosis?

Accepted Answer

Gonorrhea

Answer

Chlamydia trachomatis

Answer

Trichomoniasis

Answer

Syphilis

Question 9

A neonate is diagnosed with congenital syphilis. Which serological test is the most specific for confirming the diagnosis in the mother?

Accepted Answer

TPHA

Answer

VDRL

Answer

RPR

Answer

EIA

Question 10

Which of the following is the treatment of choice for chancroid?

Accepted Answer

Azithromycin

Answer

Ceftriaxone

Answer

Penicillin

Answer

Doxycycline

Venerology — MCQs

Venerology — MCQs

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