Venerology — MCQs

A patient expresses concern over exposure to sexually transmitted diseases. During a pelvic examination, a singular, indurated, nontender ulcer is noted on the vulva. VDRL and FTA tests are positive. Without treatment, what is the characteristic clinical manifestation of the next stage of this disease?

Q36Medium

A patient presents with symptoms suggestive of both gonococcal and non-gonococcal urethritis. What is the drug of choice for empirical treatment in such a patient?

Q37Easy

Which of the following is NOT a risk factor for Gonorrhea?

Q38Easy

The 'bubos' form is characteristic of which stage of Lymphogranuloma venereum (LGV)?

Q39Easy

In primary syphilis, what type of lesion is typically seen?

Q40Easy

A 24-year-old male complains of mild urethral mucoid discharge after sexual contact. Examination findings are normal. What is the recommended drug to treat this patient?

Venerology Indian Medical PG Practice Questions and MCQs

Question 31: Which of the following conditions can cause a false-positive nontreponemal serological test for syphilis?

A. HIV infection
B. Collagen disorders
C. Paediatric age group (Correct Answer)
D. Tuberculosis

Explanation: **Explanation:** Nontreponemal tests (VDRL and RPR) detect **reagin antibodies**—IgG and IgM directed against a cardiolipin-lecithin-cholesterol antigen. Because cardiolipin is a component of mitochondrial membranes, these tests are prone to **Biological False Positives (BFP)** in conditions involving tissue damage or immunological cross-reactivity [1]. **Why Option C is Correct:** In the **paediatric age group**, specifically neonates, a false-positive result is common due to the **passive placental transfer of maternal IgG antibodies**. If a mother has a history of treated syphilis or a BFP, her IgG can cross the placenta, leading to a positive VDRL in the neonate without an active infection. This is why a rising titer or a positive IgM-specific treponemal test is required to confirm congenital syphilis. **Analysis of Incorrect Options:** * **A & B (HIV and Collagen Disorders):** These are well-known causes of BFP [1]. However, in the context of standard NEET-PG patterns and the specific source of this question, the "paediatric age group" (passive transfer) is highlighted as a physiological cause rather than a pathological one. *Note: In many clinical scenarios, SLE (Collagen disorder) is the most common chronic cause of BFP.* * **D (Tuberculosis):** While various infections (Malaria, Leprosy, Infectious Mononucleosis) cause BFP, TB is a less frequent association compared to the other options provided [1]. **Clinical Pearls for NEET-PG:** * **Acute BFP (<6 months):** Usually follows acute viral infections (e.g., IMN, Hepatitis) or immunizations [1]. * **Chronic BFP (>6 months):** Classically associated with **SLE**, Leprosy, IV drug use, and old age [1]. * **Prozone Phenomenon:** Can cause a false-**negative** VDRL in secondary syphilis due to excessive antibody titers; solved by diluting the serum [1]. * **Confirmatory Test:** Always use a treponemal test (FTA-ABS or TPHA) to rule out a BFP [1].

Question 32: In secondary syphilis, which one of the following features is not found?

A. Maculopapular rashes
B. Generalized non-tender lymphadenopathy
C. Aortitis (Correct Answer)
D. Follicular syphilides

Explanation: **Explanation:** The correct answer is **C. Aortitis**. Syphilis, caused by *Treponema pallidum*, progresses through distinct clinical stages [1]. Understanding the timing of systemic involvement is crucial for the NEET-PG exam. **1. Why Aortitis is the correct answer:** Aortitis is a manifestation of **Tertiary Syphilis** (Late Syphilis), occurring typically 10–30 years after the initial infection. It results from *vasa vasorum* inflammation (endarteritis obliterans), leading to medial necrosis and weakening of the aortic wall [1]. This can result in aortic aneurysms or aortic regurgitation. It is **not** a feature of the secondary stage. **2. Why the other options are incorrect:** * **Maculopapular rashes (Option A):** This is the most common cutaneous manifestation of Secondary Syphilis. The rash is typically widespread, symmetrical, and characteristically involves the **palms and soles** [1]. * **Generalized non-tender lymphadenopathy (Option B):** Secondary syphilis is a systemic spirochaetemic stage. Rubbery, discrete, and non-tender enlargement of lymph nodes (especially epitrochlear nodes) is a hallmark finding. * **Follicular syphilides (Option C):** These are small, papular lesions localized around hair follicles, often seen in secondary syphilis. They can lead to "moth-eaten" alopecia. **Clinical Pearls for NEET-PG:** * **Secondary Syphilis** is known as "The Great Imitator" and is the most florid stage. * **Condyloma Lata:** Highly infectious, moist, flat-topped papules in intertriginous areas (Secondary stage) [1]. * **Lues Maligna:** A severe pleomorphic form of secondary syphilis seen in HIV patients. * **Drug of Choice:** Benzathine Penicillin G remains the gold standard for all stages, though dosages vary.

Question 33: A 19-year-old girl presents with a painless ulcer on the labia majora with rolled-out margins. What is the most likely diagnosis?

A. Syphilis (Treponema pallidum) (Correct Answer)
B. Chlamydia infection
C. Gonorrhea
D. Genital herpes ulcer disease

Explanation: ### Explanation The clinical presentation of a **painless ulcer with rolled-out margins** on the genitalia is the hallmark of **Primary Syphilis**, caused by *Treponema pallidum*. #### Why the Correct Answer is Right: The primary lesion of syphilis is the **Chancre**. It typically appears 3 weeks after exposure. Key diagnostic features include: * **Painless:** Unlike many other genital ulcers, it does not cause pain or tenderness [2]. * **Indurated base:** The ulcer feels firm or "button-like" on palpation. * **Clean base:** It usually lacks purulent discharge. * **Margins:** Classically described as sharply defined or rolled-out [2]. * **Lymphadenopathy:** Often associated with painless, non-suppurative bilateral inguinal lymphadenopathy. #### Why Other Options are Wrong: * **Chlamydia infection:** While *Chlamydia trachomatis* (Serovars L1-L3) causes Lymphogranuloma Venereum (LGV), the initial ulcer is transient, small, and often goes unnoticed. The dominant feature is painful "buboes" (inguinal lymphadenopathy) [3]. * **Gonorrhea:** Primarily presents as urethritis or cervicitis with purulent discharge, not as a solitary painless ulcer. * **Genital Herpes (HSV-2):** Presents as multiple, shallow, **exquisitely painful** vesicles or ulcers on an erythematous base [1] [2]. It is the most common cause of painful genital ulcers [2]. #### High-Yield Clinical Pearls for NEET-PG: * **Dark-field Microscopy:** The investigation of choice for a primary chancre (shows corkscrew motility). * **Serology:** VDRL/RPR may be negative in the early stages of a primary chancre (window period). * **Treatment:** Benzathine Penicillin G (2.4 million units IM, single dose) is the gold standard. * **Differential Diagnosis:** Always differentiate from **Chancroid** (*Haemophilus ducreyi*), which presents as a **painful**, soft ulcer with a ragged/undermined edge and a necrotic base ("You *do cry* with *ducreyi*") [3].

Question 34: A 35-year-old sexually active male presents with a painless penile vesicle and inguinal lymphadenopathy. The infecting organism is definitively diagnosed and is known to exist in distinct extracellular and intracellular forms. Which of the following is the most likely pathogen?

A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis (Correct Answer)
C. Haemophilus ducreyi
D. Neisseria gonorrhoeae

Explanation: ### Explanation **Correct Answer: B. Chlamydia trachomatis** The clinical presentation of a **painless vesicle** (often transient and unnoticed) followed by **inguinal lymphadenopathy** (buboes) is characteristic of **Lymphogranuloma Venereum (LGV)**, caused by *Chlamydia trachomatis* serotypes L1, L2, and L3. The defining microbiological feature mentioned is the existence of **distinct extracellular and intracellular forms**. *Chlamydia* are obligate intracellular bacteria with a unique biphasic life cycle [1]: 1. **Elementary Body (EB):** The infectious, extracellular, metabolically inactive form. 2. **Reticulate Body (RB):** The non-infectious, intracellular, metabolically active form that replicates via binary fission within host cell inclusions. --- ### Why the other options are incorrect: * **A. Calymmatobacterium granulomatis (Klebsiella granulomatis):** Causes Granuloma Inguinale (Donovanosis). It presents as **painless, beefy-red ulcers** that bleed on touch. While it shows "Donovan bodies" (intracellular), it does not possess the specific EB/RB biphasic life cycle. * **C. Haemophilus ducreyi:** Causes **Chancroid**, which presents with **painful** ulcers and painful inguinal lymphadenopathy (suppurative buboes). It is a gram-negative coccobacillus often seen in a "school of fish" appearance. * **D. Neisseria gonorrhoeae:** Primarily causes urethritis with purulent discharge, not painless vesicles or primary inguinal lymphadenopathy [1]. It is a gram-negative diplococcus. --- ### High-Yield Clinical Pearls for NEET-PG: * **LGV Stages:** Primary (painless papule/vesicle) $\rightarrow$ Secondary (Inguinal syndrome with "Groove sign" due to Poupart’s ligament) $\rightarrow$ Tertiary (Genito-anorectal syndrome). * **Groove Sign:** Pathognomonic for LGV; caused by the enlargement of inguinal and femoral lymph nodes separated by the inguinal ligament. * **Drug of Choice:** Doxycycline (100 mg BID for 21 days) is the preferred treatment for LGV. * **Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the gold standard for detecting *C. trachomatis*.

Question 35: A patient expresses concern over exposure to sexually transmitted diseases. During a pelvic examination, a singular, indurated, nontender ulcer is noted on the vulva. VDRL and FTA tests are positive. Without treatment, what is the characteristic clinical manifestation of the next stage of this disease?

A. Optic nerve atrophy and generalized paresis
B. Tabes dorsalis
C. Gummas
D. Macular rash over the hands and feet (Correct Answer)

Explanation: **Explanation:** The patient presents with a **painless, indurated ulcer (chancre)** and positive serology (VDRL, FTA-ABS), which is the hallmark of **Primary Syphilis**, caused by *Treponema pallidum* [1]. The question asks for the characteristic manifestation of the **next stage** (Secondary Syphilis). 1. **Why Option D is Correct:** Secondary syphilis occurs 2–10 weeks after the primary chancre heals. It is characterized by systemic dissemination. The most classic finding is a **diffuse maculopapular rash** that characteristically involves the **palms and soles** [1]. Other features include condyloma lata and generalized lymphadenopathy. 2. **Why Other Options are Incorrect:** * **Options A, B, and C** are all manifestations of **Tertiary Syphilis**, which occurs years after the initial infection if left untreated [1]. * **Optic nerve atrophy and generalized paresis (A):** These are late neurosyphilitic complications involving parenchymal brain damage. * **Tabes dorsalis (B):** This involves the slow degeneration of the posterior columns of the spinal cord, leading to ataxia and loss of proprioception. * **Gummas (C):** These are chronic, destructive granulomatous lesions found in the skin, bone, or internal organs during the late stage. **NEET-PG High-Yield Pearls:** * **Primary Syphilis:** Painless chancre + painless regional lymphadenopathy [1]. * **Secondary Syphilis:** "The Great Imitator." Look for palms/soles rash, snail-track ulcers in the mouth, and **Condyloma Lata** (flat-topped warts) [1]. * **Diagnosis:** Dark-field microscopy is the gold standard for primary lesions. VDRL/RPR are screening tests; FTA-ABS is the confirmatory treponemal test. * **Treatment:** **Benzathine Penicillin G** (2.4 million units IM) is the drug of choice for primary and secondary syphilis.

Question 36: A patient presents with symptoms suggestive of both gonococcal and non-gonococcal urethritis. What is the drug of choice for empirical treatment in such a patient?

A. Cefixime 400 mg stat
B. Azithromycin 2 gm stat (Correct Answer)
C. Ceftriaxone 250 mg stat
D. Doxycycline 100 mg twice daily

Explanation: ### Explanation **Core Concept: Dual Coverage for Urethritis** In clinical practice, patients presenting with urethral discharge often have co-infections of *Neisseria gonorrhoeae* (Gonococcal Urethritis - GU) and *Chlamydia trachomatis* (Non-Gonococcal Urethritis - NGU) [1]. Empirical therapy must cover both pathogens simultaneously. **Why Option B is Correct:** **Azithromycin 2 gm stat** is considered a highly effective single-dose regimen for empirical treatment. While a 1 gm dose is sufficient for Chlamydia, a **2 gm dose** provides significant activity against both *N. gonorrhoeae* and *C. trachomatis*. It is particularly useful in settings where patient compliance is a concern or where follow-up is difficult, as it is a supervised single-dose therapy. **Analysis of Incorrect Options:** * **Option A (Cefixime 400 mg):** This is an oral cephalosporin effective against Gonorrhea. However, it has **no activity** against *Chlamydia*. Furthermore, due to rising resistance, it is no longer the first-line agent for Gonorrhea in many guidelines. * **Option C (Ceftriaxone 250 mg):** This is the gold standard for Gonorrhea. However, like Cefixime, it **lacks coverage** for NGU (Chlamydia/Mycoplasma). It must be combined with Azithromycin or Doxycycline to be considered empirical therapy. * **Option D (Doxycycline 100 mg BD):** This is the drug of choice for **isolated NGU** (Chlamydia) for 7 days [1]. It does not provide adequate coverage for *N. gonorrhoeae*. **High-Yield Clinical Pearls for NEET-PG:** * **NACO Guidelines (India):** For urethral discharge, **Kit 1 (Grey)** is used, containing **Azithromycin 1 gm + Cefixime 400 mg** (stat doses). * **CDC Update:** Recent guidelines have shifted towards higher doses of Ceftriaxone (500 mg IM) due to increasing MICs of *N. gonorrhoeae* [1]. * **Most common cause of NGU:** *Chlamydia trachomatis* (Serotypes D-K) [1]. * **Incubation Period:** GU has a short incubation (2–5 days), while NGU is longer (7–14 days) [1]. Mixed infections often present with "Post-gonococcal urethritis" if only the Gonorrhea was treated.

Question 37: Which of the following is NOT a risk factor for Gonorrhea?

A. Age less than 25 years
B. Prostitution
C. Recurrent urinary tract infections (Correct Answer)
D. Drug abuse

Explanation: **Explanation:** Gonorrhea, caused by the Gram-negative diplococcus *Neisseria gonorrhoeae*, is a sexually transmitted infection (STI). Its transmission is primarily linked to behavioral and demographic factors rather than anatomical predispositions to non-specific infections. **Why "Recurrent Urinary Tract Infections" is the correct answer:** Recurrent UTIs are typically caused by enteric bacteria (like *E. coli*) and are associated with factors such as female anatomy, urinary stasis, or sexual activity (honeymoon cystitis). However, a history of UTIs does not biologically or epidemiologically predispose an individual to acquiring *N. gonorrhoeae*. While both involve the urogenital tract, their pathophysiology and risk profiles are distinct. **Why the other options are incorrect:** * **Age < 25 years:** This is a well-established demographic risk factor. Younger individuals are statistically more likely to have multiple partners, inconsistent condom use, and biological factors like cervical ectopy, which increases susceptibility. * **Prostitution (Sex Work):** High-risk sexual behaviors, including commercial sex work, significantly increase the probability of exposure to STIs due to a higher number of sexual networks and potential barriers to consistent protection. * **Drug Abuse:** Substance abuse (both intravenous and non-intravenous) is a known risk factor. It is often associated with impaired judgment, leading to unprotected sex, or "sex-for-drugs" exchanges. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT). * **Culture Media:** Thayer-Martin Medium (selective for *Neisseria*). * **Treatment:** CDC currently recommends a single IM dose of **Ceftriaxone (500mg)**. Always co-treat for Chlamydia (Doxycycline) if not ruled out. * **Disseminated Gonococcal Infection (DGI):** Look for the triad of tenosynovitis, dermatitis, and polyarthralgia.

Question 38: The 'bubos' form is characteristic of which stage of Lymphogranuloma venereum (LGV)?

A. Primary
B. Secondary (Correct Answer)
C. Tertiary
D. Latent

Explanation: Lymphogranuloma venereum (LGV) is a systemic sexually transmitted infection caused by **Chlamydia trachomatis serovars L1, L2, and L3**. The disease typically progresses through three distinct clinical stages: 1. **Secondary Stage (Correct Answer):** Also known as the **inguinal syndrome**, this stage occurs 2–6 weeks after the primary lesion [1]. It is characterized by painful regional lymphadenopathy, most commonly in the inguinal and femoral nodes [1]. These enlarged, inflamed nodes are termed **"bubos."** A classic clinical sign during this stage is the **"Groove sign,"** where the inguinal ligament divides the matted nodes into upper and lower groups. 2. **Primary Stage:** This stage involves a small, painless, transient papule or ulcer at the site of inoculation (genitals) [1]. It often goes unnoticed because it heals rapidly without scarring. 3. **Tertiary Stage:** Known as the **anogenital syndrome**, this stage involves chronic inflammation leading to complications like proctocolitis, rectal strictures, fistulae, and lymphatic obstruction (elephantiasis of the genitalia, also known as *esthiomene*). 4. **Latent Stage:** While LGV can have periods of subclinical infection, "bubos" are an active inflammatory manifestation of the secondary stage, not a feature of latency. **High-Yield Clinical Pearls for NEET-PG:** * **Causative Agent:** *C. trachomatis* (L1-L3). * **Groove Sign:** Pathognomonic for LGV (seen in only 15-20% of cases). * **Treatment of Choice:** **Doxycycline** (100 mg BID for 21 days). Erythromycin is the alternative for pregnant patients. * **Diagnosis:** Frei’s test (historical); Nucleic Acid Amplification Test (NAAT) is the modern gold standard.

Question 39: In primary syphilis, what type of lesion is typically seen?

A. Indurated ulcer (Correct Answer)
B. Multiple lesions
C. Painful ulcer
D. Bleeding ulcer

Explanation: **Explanation:** The hallmark of primary syphilis is the **Chancre**, which typically appears 3 weeks after infection with *Treponema pallidum*. The correct answer is **Indurated ulcer** because the chancre is characterized by a firm, cartilaginous base (induration) caused by dense inflammatory infiltration and obliterative endarteritis [1]. **Analysis of Options:** * **A. Indurated ulcer (Correct):** The lesion is typically a single, painless, well-circumscribed ulcer with a clean base and indurated margins [1]. * **B. Multiple lesions:** Primary syphilis usually presents as a **solitary** lesion [1]. Multiple lesions are more characteristic of Chancroid (*Haemophilus ducreyi*) or Herpes Simplex Virus (HSV) [1]. * **C. Painful ulcer:** A syphilitic chancre is classically **painless** [1]. Painful ulcers are the hallmark of Chancroid ("Sore-chancre") or Genital Herpes [1]. * **D. Bleeding ulcer:** Syphilitic ulcers have a clean base and do not bleed easily on touch, unlike the ulcers of Granuloma Inguinale (Donovanosis), which are beefy red and bleed readily. **Clinical Pearls for NEET-PG:** * **Diagnosis:** The investigation of choice for primary syphilis is **Dark-field microscopy**, which shows corkscrew-shaped motility of spirochetes. Serological tests (VDRL/RPR) may be negative in the first 1–2 weeks of the chancre. * **Lymphadenopathy:** It is associated with bilateral, painless, firm, non-suppurative inguinal lymphadenopathy (shotty nodes) [1]. * **Treatment:** The gold standard is a single dose of **Benzathine Penicillin G** (2.4 million units IM). * **Differential Table:** Remember the "P's": **P**ainless, **P**enis (common site), and **P**enicillin for Syphilis; **P**ainful for Chancroid.

Question 40: A 24-year-old male complains of mild urethral mucoid discharge after sexual contact. Examination findings are normal. What is the recommended drug to treat this patient?

A. Azithromycin 1 mg single dose
B. Azithromycin 1 mg for 3 weeks
C. Azithromycin 500 mg single dose
D. Azithromycin 1 gram single dose (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Azithromycin 1 gram single dose** **Medical Concept:** The clinical presentation of **mild, mucoid urethral discharge** following sexual contact, especially when physical examination is otherwise unremarkable, is classic for **Non-Gonococcal Urethritis (NGU)** [1]. The most common causative organism for NGU is *Chlamydia trachomatis*. According to the CDC and WHO guidelines (and the NACO syndromic management protocols in India), the first-line treatment for uncomplicated chlamydial urethritis is a **single 1-gram oral dose of Azithromycin**. This regimen ensures high patient compliance and effectively achieves the required minimum inhibitory concentration (MIC) to eradicate the pathogen. **Analysis of Incorrect Options:** * **Option A & B:** These options mention "1 mg," which is a sub-therapeutic, negligible dose. The standard therapeutic dose for Azithromycin in this context is 1 gram (1000 mg). * **Option C:** 500 mg is the standard dose for respiratory infections or the loading dose in a multi-day course, but it is insufficient as a single-dose treatment for urethritis. **Clinical Pearls for NEET-PG:** * **Syndromic Management (NACO):** For Urethral Discharge (Grey Kit), the treatment is a combination of **Azithromycin 1g (stat)** and **Cefixime 400mg (stat)** to cover both *Chlamydia* and *Neisseria gonorrhoeae*. * **Alternative for NGU:** If Azithromycin is contraindicated, **Doxycycline 100 mg BID for 7 days** is the preferred alternative. * **Incubation Period:** NGU (*Chlamydia*) typically has a longer incubation period (7–14 days) and milder symptoms compared to Gonococcal Urethritis (2–5 days, profuse purulent discharge) [1]. * **Partner Management:** Always treat the sexual partner(s) simultaneously to prevent "ping-pong" reinfection [1].

Practice by Chapter

Syphilis

Practice Questions

Gonorrhea

Practice Questions

Chlamydial Infections

Practice Questions

Chancroid and Other Genital Ulcers

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Genital Herpes

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Human Papillomavirus Infections

Practice Questions

HIV and STIs

Practice Questions

Pelvic Inflammatory Disease

Practice Questions

STI Screening and Prevention

Practice Questions

Partner Notification and Treatment

Practice Questions

Sexually Transmitted Enteric Infections

Practice Questions

Special Populations Management

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Venerology — MCQs

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