Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 21: What is the main clinical feature of gonorrhoea?

A. Purulent discharge from the urethra (Correct Answer)
B. Inguinal adenitis
C. Ulcer on the glans penis
D. Rashes

Explanation: **Explanation:** **Gonorrhea**, caused by the Gram-negative diplococcus *Neisseria gonorrhoeae*, primarily infects the columnar and cuboidal epithelium of the urogenital tract. 1. **Why Option A is correct:** The hallmark clinical feature of gonococcal urethritis in men is a **profuse, thick, creamy, purulent urethral discharge**, typically appearing after an incubation period of 2–5 days [1]. This is often accompanied by intense dysuria and meatal erythema. The purulence is due to the intense inflammatory response and recruitment of polymorphonuclear leukocytes (PMNs) to the site of infection. 2. **Why other options are incorrect:** * **Option B (Inguinal adenitis):** While mild lymphadenopathy can occur, it is the defining feature of **Lymphogranuloma Venereum (LGV)** or **Chancroid**, rather than gonorrhea [3]. * **Option C (Ulcer on the glans penis):** Ulcers are characteristic of **Syphilis** (painless chancre), **Chancroid** (painful soft chancre), or **Herpes Simplex** (vesicles/erosions). Gonorrhea is a mucosal infection and does not typically cause primary ulcers. * **Option D (Rashes):** Rashes are characteristic of **Secondary Syphilis** (palmoplantar maculopapular rash). In gonorrhea, skin lesions (pustules/hemorrhagic bullae) are only seen in **Disseminated Gonococcal Infection (DGI)**, which is a complication, not the main clinical feature. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Culture on **Thayer-Martin medium**. * **Point-of-Care:** Gram stain showing **Intracellular Gram-negative diplococci** (highly sensitive in males). * **Treatment:** Current CDC/NACO guidelines recommend **Ceftriaxone (IM)** [2]. Always co-treat for Chlamydia (using Azithromycin or Doxycycline) as co-infection is common. * **Complication:** In females, it is a leading cause of **Pelvic Inflammatory Disease (PID)** and subsequent infertility.

Question 22: A 35-year-old male presents with a painless indurated ulcer on the penis and enlarged, non-tender genital lymph nodes. What is the most likely diagnosis?

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

Explanation: **Explanation:** The clinical presentation of a **painless, indurated ulcer** (Hard Chancre) associated with **non-tender, rubbery lymphadenopathy** is the classic hallmark of **Primary Syphilis** [1], caused by *Treponema pallidum*. **1. Why Syphilis is correct:** The primary chancre typically appears 3 weeks after exposure. Its defining features are its lack of pain and "button-like" induration (firmness). The associated inguinal lymphadenopathy is characteristically bilateral, painless, and non-suppurative, which matches the patient's description perfectly [1]. **2. Why other options are incorrect:** * **Chancroid (*Haemophilus ducreyi*):** Presents as a **painful**, soft ulcer with a ragged edge. The associated lymphadenopathy (bubo) is very painful and often undergoes suppuration [2]. * **Herpes Genitalis (HSV-2):** Presents as multiple, small, **painful vesicles** on an erythematous base that rupture to form shallow ulcers [1]. It is not indurated. * **Lymphogranuloma Venereum (LGV):** The initial primary lesion is a transient, painless papule or ulcer that often heals unnoticed. The dominant clinical feature is painful, massive inguinal lymphadenopathy (the "Groove sign") [2]. **Clinical Pearls for NEET-PG:** * **Investigation of choice:** Dark-field microscopy (to see corkscrew motility) is used for early lesions; VDRL/RPR are used for screening (but may be negative in the first 1-2 weeks of the chancre). * **Treatment:** Benzathine Penicillin G (2.4 million units IM single dose) remains the gold standard. * **Induration:** If an ulcer is firm/hard, think Syphilis; if it is soft/friable, think Chancroid.

Question 23: Which of the following is the drug of choice for Non-Gonococcal Urethritis?

A. Ceftriaxone
B. Ciprofloxacin
C. Doxycycline (Correct Answer)
D. Minocycline

Explanation: **Explanation:** **Non-Gonococcal Urethritis (NGU)** refers to inflammation of the urethra not caused by *Neisseria gonorrhoeae*. The most common causative organism is ***Chlamydia trachomatis*** (30–50% of cases), followed by *Mycoplasma genitalium* and *Ureaplasma urealyticum* [1]. **1. Why Doxycycline is the Correct Answer:** According to the latest CDC and WHO guidelines, **Doxycycline (100 mg twice daily for 7 days)** is the first-line drug of choice for NGU. It has superior efficacy in eradicating *Chlamydia* and is more effective against *Mycoplasma genitalium* compared to single-dose regimens. While Azithromycin was previously a co-first-line option, rising resistance in *Mycoplasma* has made Doxycycline the preferred agent [2]. **2. Why Other Options are Incorrect:** * **Ceftriaxone:** This is a third-generation cephalosporin and the drug of choice for **Gonococcal Urethritis** (Gonorrhea), not NGU [1]. It has no activity against cell-wall-deficient organisms like *Chlamydia*. * **Ciprofloxacin:** Fluoroquinolones are generally not recommended for NGU due to high rates of resistance and poor efficacy against *Chlamydia* compared to tetracyclines [2]. * **Minocycline:** While it is a tetracycline effective against *Chlamydia*, it is not the standard first-line agent due to a higher side-effect profile (vestibular toxicity) compared to Doxycycline. **Clinical Pearls for NEET-PG:** * **Dual Therapy:** In clinical practice, patients with urethral discharge often receive "syndromic management" covering both Gonorrhea and NGU (e.g., Ceftriaxone + Doxycycline). * **Incubation Period:** NGU has a longer incubation period (7–14 days) compared to Gonorrhea (2–5 days) [1]. * **Discharge Characteristics:** NGU typically presents with mucoid/clear discharge, whereas Gonorrhea presents with profuse, thick, purulent discharge [1]. * **Gold Standard for Diagnosis:** Nucleic Acid Amplification Test (NAAT).

Question 24: Which of the following is NOT true regarding Jarisch-Herxheimer reaction?

A. It occurs in late syphilis.
B. It is an acute febrile reaction.
C. Ophthalmic involvement is typically worsened. (Correct Answer)
D. Prednisolone for 3 days is given in treatment.

Explanation: The **Jarisch-Herxheimer Reaction (JHR)** is a transient clinical phenomenon occurring shortly after the initiation of antibiotic therapy (usually Penicillin) for spirochetal infections, most notably syphilis. [2] ### **Explanation of the Correct Answer** **Option C is NOT true** because, while JHR causes systemic symptoms, it can occasionally cause the worsening of neurological (cerebral artery occlusion) or ophthalmic (uveitis, optic neuritis) disease, meaning it can indeed affect organ-specific involvement. [2] In fact, JHR is generally self-limiting and does not lead to permanent damage or exacerbation of local syphilitic lesions (unlike the "therapeutic paradox" seen in late syphilis). ### **Analysis of Other Options** * **Option A (Occurs in late syphilis):** This is **true**. While JHR is most common in primary (30-60%) and secondary syphilis (up to 90%), it can occur at any stage, including late/tertiary syphilis, although it is rarer in late stages. [2] * **Option B (Acute febrile reaction):** This is **true**. It is characterized by the sudden onset of fever, chills, headache, myalgia, and tachycardia, usually within 2–12 hours of the first dose of treatment. [2] * **Option D (Prednisolone for 3 days):** This is **true**. In cases where JHR might be dangerous (e.g., neurosyphilis or cardiovascular syphilis), corticosteroids like Prednisolone (10-20 mg three times daily for 3 days) are administered, starting before penicillin, to blunt the cytokine release. [2] ### **Pathophysiology & Clinical Pearls** * **Mechanism:** It is caused by the rapid release of **lipopolysaccharides and lipoproteins** from dying spirochetes, triggering a massive release of cytokines (TNF-α, IL-6, and IL-8). * **Management:** For most patients, treatment is **supportive** (antipyretics and fluids). Steroids are reserved for high-risk cases. [2] * **High-Yield Fact:** JHR is **not an allergic reaction** to penicillin; therefore, the treatment should not be discontinued. It is also commonly seen in **Lyme disease** [1] and **Relapsing fever**.

Question 25: What is the mean incubation period for a primary syphilitic chancre?

A. 1 week
B. 2 weeks
C. 3 weeks (Correct Answer)
D. 4 weeks

Explanation: The causative agent of Syphilis, *Treponema pallidum*, enters the body through minute abrasions in the skin or mucous membranes. The **incubation period** for the development of a primary chancre typically ranges from **10 to 90 days**, with a **mean (average) of 21 days (3 weeks)**. * **Why Option C is Correct:** In clinical practice and standard textbooks (like Harrison’s or Fitzpatrick), 3 weeks is the classic duration cited for the appearance of the primary lesion. After inoculation, the spirochetes multiply locally, leading to a painless, indurated ulcer (chancre) at the site of entry [1]. * **Why Options A, B, and D are Incorrect:** While 1, 2, or 4 weeks fall within the broad range of 10–90 days, they do not represent the statistical mean. 1 week is generally too short for the inflammatory response to manifest as a chancre, while 4 weeks is slightly beyond the average peak incidence. **High-Yield Clinical Pearls for NEET-PG:** 1. **The Chancre:** Characteristically painless, solitary, indurated (hard base), and associated with painless, non-suppurative regional lymphadenopathy [1]. 2. **Diagnosis:** Dark-ground microscopy (DGM) is the gold standard for primary syphilis as serological tests (VDRL/RPR) may be negative in the first 1–2 weeks of the chancre's appearance. 3. **Window Period:** It takes approximately 4–6 weeks after infection for non-specific serological tests to become positive. 4. **Treatment:** The drug of choice for primary syphilis is **Benzathine Penicillin G (2.4 million units IM)** in a single dose.

Question 26: Which of the following are non-venereal treponemas?

A. T. pertenue and T. carateum
B. T. pertenue and T. pallidum (Correct Answer)
C. T. pertenue and T. cuniculi
D. T. carateum and T. cuniculi

Explanation: The genus *Treponema* includes both venereal (sexually transmitted) and non-venereal (endemic) species. The non-venereal treponematoses are chronic bacterial infections caused by organisms morphologically and serologically identical to *T. pallidum* subsp. *pallidum* (Syphilis), but they are transmitted via direct skin-to-skin contact, usually in childhood [1]. **Explanation of the Correct Answer:** **Option B** is correct because it refers to the subspecies of *Treponema pallidum* and *Treponema pertenue*. Specifically: * ***T. pallidum* subsp. *pertenue***: Causes **Yaws**, the most common non-venereal treponematosis, characterized by skin, bone, and joint lesions [1]. * ***T. pallidum* subsp. *endemicum***: Causes **Bejel** (Endemic Syphilis) [1]. * ***T. carateum***: Causes **Pinta** [1]. Note: In many textbooks and exams, *T. pertenue* is used as shorthand for the subspecies that causes Yaws. **Analysis of Incorrect Options:** * **Option A & D:** While *T. carateum* is a non-venereal treponeme (Pinta), these options are less complete or include *T. cuniculi*. * **Option C:** *T. cuniculi* is the causative agent of rabbit syphilis. While it is a treponeme, it is not a human pathogen and therefore not the focus of clinical venereology. **High-Yield NEET-PG Pearls:** 1. **Transmission:** Non-venereal treponematoses are NOT sexually transmitted; they spread through direct contact or shared utensils in overcrowded/poor hygienic conditions [1]. 2. **Diagnosis:** They all produce positive results on **VDRL/RPR** and **FTA-ABS** tests, making them serologically indistinguishable from venereal syphilis [2]. 3. **Treatment:** A single intramuscular injection of **Benzathine Penicillin G** is the drug of choice for all endemic treponematoses. 4. **Pinta (*T. carateum*):** Unique because it involves **only the skin** (no bone or visceral involvement).

Question 27: Pseudo Bubo is seen in which of the following conditions?

A. Chancroid
B. Lymphogranuloma venereum (LGV)
C. Granuloma inguinale (Donovanosis) (Correct Answer)
D. Syphilis

Explanation: The correct answer is **Granuloma inguinale (Donovanosis)**. **1. Why Granuloma Inguinale is correct:** In Granuloma inguinale, caused by *Klebsiella granulomatis*, the infection typically presents as painless, beefy-red, highly vascular ulcers. Unlike other sexually transmitted infections, it does **not** involve true regional lymphadenopathy. Instead, it causes subcutaneous inflammatory nodules or granulation tissue in the inguinal region that mimic the appearance of an enlarged lymph node (bubo). Because this swelling is due to subcutaneous involvement rather than actual lymph node enlargement, it is termed a **"Pseudo Bubo."** [1] **2. Why other options are incorrect:** * **Chancroid:** Caused by *Haemophilus ducreyi*, it presents with painful ulcers and **true buboes** (suppurative lymphadenopathy) that are often unilateral and may rupture. [1] * **Lymphogranuloma venereum (LGV):** Caused by *Chlamydia trachomatis* (L1-L3), it is characterized by significant **true lymphadenopathy**. It often presents with the "Groove sign," where the inguinal ligament divides the matted lymph nodes. [1] * **Syphilis:** Primary syphilis presents with a painless chancre and firm, non-suppurative, painless **true regional lymphadenopathy**. **Clinical Pearls for NEET-PG:** * **Donovan Bodies:** Diagnosis of Granuloma inguinale is confirmed by seeing "safety-pin" shaped organisms within macrophages on a Giemsa or Wright stain. * **Beefy Red Ulcer:** A classic descriptor for Donovanosis; these ulcers bleed easily on touch. * **Treatment:** Azithromycin (1g weekly or 500mg daily) is the first-line treatment for Granuloma inguinale. * **Groove Sign:** Pathognomonic for LGV, not Pseudo Bubo.

Question 28: A 25-year-old laborer presented 3 years ago with an untreated penile ulcer. Later, he developed neurological symptoms for which he received treatment. What is the test used to monitor the response to treatment?

A. VDRL (Correct Answer)
B. FTA-ABS
C. TPI
D. RPR

Explanation: The clinical presentation describes a patient with **Neurosyphilis** (neurological symptoms following an untreated primary penile ulcer). In syphilis management, tests are categorized into **Treponemal** (specific) and **Non-treponemal** (non-specific) tests [1]. **1. Why VDRL is correct:** VDRL (Venereal Disease Research Laboratory) is a non-treponemal test that measures IgG and IgM antibodies against cardiolipin-lecithin-cholesterol antigen. These antibody titers correlate with disease activity. A successful response to treatment is indicated by a **four-fold decline in titers** (e.g., from 1:32 to 1:8). Furthermore, **CSF-VDRL** is the gold standard for diagnosing neurosyphilis and monitoring its resolution. **2. Why other options are incorrect:** * **FTA-ABS (Fluorescent Treponemal Antibody Absorption):** This is a treponemal test. These tests remain positive for life ("immunological memory") regardless of treatment; therefore, they cannot be used to monitor treatment response or distinguish between a new and old infection. * **TPI (Treponema Pallidum Immobilization):** This is a highly specific treponemal test but is technically difficult and rarely used today. Like FTA-ABS, it remains positive for life. * **RPR (Rapid Plasma Reagin):** While RPR is also a non-treponemal test used for monitoring systemic syphilis, **VDRL is the preferred test specifically for Neurosyphilis** (especially in CSF) due to its standardized performance in that medium [1]. **Clinical Pearls for NEET-PG:** * **Screening:** RPR/VDRL [1]. * **Confirmation:** FTA-ABS/TPHA. * **Monitoring/Prognosis:** VDRL titers. * **Prozone Phenomenon:** Can cause false negatives in secondary syphilis due to very high antibody titers [1]. * **Jarisch-Herxheimer Reaction:** An acute febrile reaction seen within 24 hours of starting Penicillin treatment for syphilis.

Question 29: Which of the following is NOT a primary site of acute gonococcal infection?

A. Urethra
B. Bartholin's gland
C. Skene's gland (paraurethral glands)
D. Ectocervix (Correct Answer)

Explanation: The primary sites of acute gonococcal infection are determined by the type of epithelium present. *Neisseria gonorrhoeae* has a strong predilection for **columnar and transitional epithelium**, while it is resistant to the stratified squamous epithelium found in the adult vagina and ectocervix. **Why Ectocervix is the Correct Answer:** In adult females, the **endocervix** (lined by columnar epithelium) is the most common primary site of infection. The **ectocervix**, however, is covered by **stratified squamous epithelium**, which is resistant to gonococcal invasion. Therefore, it is not a primary site of infection. **Analysis of Other Options:** * **Urethra (A):** Lined by transitional and columnar epithelium, it is the most common site of infection in men and a frequent site in women. * **Bartholin's Glands (B):** These are located in the posterior third of the labia majora. Their ducts are lined by columnar epithelium, making them a common site for acute gonococcal abscess formation. * **Skene's Glands (C):** Also known as paraurethral glands, these are lined by columnar epithelium and are frequently involved in female gonococcal infections. **Clinical Pearls for NEET-PG:** * **Primary Sites in Females:** Endocervix (most common), Urethra, Skene’s glands, and Bartholin’s glands. * **Vulvovaginitis:** While adults are resistant due to squamous epithelium, **pre-pubertal girls** can develop gonococcal vulvovaginitis because their vaginal mucosa is thin and has not yet undergone squamous cornification (due to low estrogen). * **Gold Standard Diagnosis:** Culture on **Thayer-Martin medium** (a selective Chocolate agar). * **Treatment:** Due to rising resistance, the current CDC/WHO recommendation is typically a single dose of **Ceftriaxone (IM)** [1]. Always screen for co-infection with *Chlamydia trachomatis*.

Question 30: What is the treatment of choice for late cardiovascular syphilis?

A. Benzathine penicillin 7.2 million units in three divided doses (Correct Answer)
B. Benzathine penicillin 2.4 million units single dose
C. Benzylpenicillin 12-24 million units for 21 days
D. Tetracycline 2g daily

Explanation: **Explanation:** The treatment of choice for **late cardiovascular syphilis** (as well as late latent syphilis and gummatous syphilis) is **Benzathine Penicillin G, 7.2 million units total**, administered as three weekly doses of 2.4 million units IM. **1. Why Option A is Correct:** Syphilis is caused by *Treponema pallidum*. In late stages, the organism divides very slowly. To ensure eradication, the serum concentration of penicillin must be maintained above the minimal inhibitory concentration (MIC) for an extended period. A single dose is insufficient; hence, three weekly doses are required to cover the slow replication cycle of the bacteria in tertiary stages. **2. Why Other Options are Incorrect:** * **Option B:** 2.4 million units as a single dose is the standard treatment for **Early Syphilis** (Primary, Secondary, or Early Latent <1 year) [1]. * **Option C:** High-dose IV Benzylpenicillin (18–24 million units daily) is the treatment of choice for **Neurosyphilis**. While cardiovascular syphilis patients should be screened for neurosyphilis, the standard cardiac regimen uses the IM Benzathine form. * **Option D:** Tetracyclines (or Doxycycline) are second-line alternatives for patients with penicillin allergies, but the dosage and duration listed are not the primary recommendation for late syphilis. **High-Yield Clinical Pearls for NEET-PG:** * **Jarisch-Herxheimer Reaction:** An acute febrile reaction occurring within 24 hours of starting treatment. It is most common in secondary syphilis. In cardiovascular syphilis, it can theoretically cause coronary ostial edema; some clinicians co-administer steroids. * **Late Syphilis Definition:** Syphilis of >2 years duration (WHO) or >1 year (CDC). * **Drug of Choice:** Penicillin remains the gold standard; *T. pallidum* has never developed resistance to it.

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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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Special Populations Management

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Venerology — MCQs

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