Venerology — MCQs

Venerology Indian Medical PG Practice Questions and MCQs

Question 81: What is the characteristic of a primary chancre?

A. Painless punched out ulcer (Correct Answer)
B. Painless ulcer with overhanging edges
C. Painless ulcer with irregular raised edges
D. Painful punched out ulcer

Explanation: The primary chancre is the hallmark lesion of **Primary Syphilis**, caused by the spirochete *Treponema pallidum*. **1. Why Option A is Correct:** A primary chancre typically appears 3 weeks after exposure. Its classic description is a **painless, indurated (firm), and "punched-out" ulcer** with a clean base. The lack of pain is due to the absence of an acute inflammatory response, and the "punched-out" appearance refers to its well-defined, regular margins [1]. **2. Analysis of Incorrect Options:** * **Option B (Overhanging edges):** This is characteristic of **Chancroid** (*Haemophilus ducreyi*). Unlike syphilis, chancroid presents with multiple, very painful ulcers with undermined or overhanging edges. * **Option C (Irregular raised edges):** This description is more suggestive of **Granuloma Inguinale (Donovanosis)** or potentially a malignant ulcer. Donovanosis presents as beefy-red, painless, expanding ulcers with exuberant granulation tissue. * **Option D (Painful punched out ulcer):** While the shape is correct, the presence of pain excludes a typical syphilitic chancre [1]. Painful ulcers are usually associated with **Herpes Simplex Virus (HSV)** or **Chancroid** [2]. **Clinical Pearls for NEET-PG:** * **Induration:** The base of a syphilitic chancre feels like a "button" or "cartilage" when palpated (Hunterian Chancre). * **Lymphadenopathy:** Primary syphilis is associated with **painless, non-suppurative, rubbery** bilateral inguinal lymphadenopathy. * **Diagnosis:** The gold standard for primary syphilis is **Dark Ground Microscopy (DGM)** to visualize motile spirochetes. Serological tests (VDRL/RPR) may be negative in the first 1–2 weeks of the chancre's appearance. * **Treatment:** The drug of choice is **Benzathine Penicillin G** (2.4 million units IM, single dose).

Question 82: Rectal stricture is a common manifestation of which of the following conditions?

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

Explanation: **Explanation:** **Lymphogranuloma inguinale** (also known as **Lymphogranuloma Venereum or LGV**) is caused by *Chlamydia trachomatis* serotypes L1, L2, and L3. The correct answer is B because rectal stricture is a classic late-stage complication of the **genito-anorectal syndrome** seen in LGV. In women and MSM (men who have sex with men), the infection can spread via lymphatic drainage to the perirectal and pelvic lymph nodes. This leads to chronic inflammation, proctocolitis, and lymphatic obstruction. Over time, the resulting fibrosis and scarring lead to the formation of **rectal strictures**, fistulae, and "esthiomene" (chronic hypertrophic ulceration of the external genitalia). **Analysis of Incorrect Options:** * **A. Syphilis:** Caused by *Treponema pallidum*. While it can cause proctitis in the secondary stage, it typically presents with a painless chancre (primary) or a generalized rash; it does not typically lead to fibrotic rectal strictures. * **C. Granuloma inguinale (Donovanosis):** Caused by *Klebsiella granulomatis*. It presents with painless, beefy-red, highly vascular ulcers (pseudobuboes). It involves the skin and subcutaneous tissues rather than deep pelvic lymphatics. * **D. Chancroid:** Caused by *Haemophilus ducreyi*. It presents with painful, soft ulcers and painful inguinal lymphadenopathy (suppurative buboes), but it does not cause chronic rectal fibrosis. **NEET-PG High-Yield Pearls:** * **Groove Sign of Greenblatt:** Pathognomonic for LGV; it is the depression between inflamed inguinal and femoral lymph nodes separated by the inguinal ligament. * **Donovan Bodies:** Safety-pin appearance in macrophages, diagnostic for Granuloma inguinale. * **School of Fish appearance:** Characteristic Gram stain finding for Chancroid. * **Frei Test:** A historical skin test used for LGV diagnosis (now replaced by NAAT).

Question 83: What condition typically presents with multiple painful bleeding ulcers and inguinal bubo?

A. Chancre
B. Granuloma inguinale
C. Lymphogranuloma Venereum
D. Chancroid (Correct Answer)

Explanation: ### Explanation **Chancroid** is caused by the Gram-negative coccobacillus *Haemophilus ducreyi*. It is classically characterized by the "Four Ps": **P**ainful, **P**urulent, **P**olymicrobial (multiple), and **P**unch-out ulcers. These ulcers are soft and bleed easily upon manipulation (friable). A hallmark feature is the development of a painful, unilateral **inguinal bubo** (suppurative lymphadenopathy) which may rupture spontaneously [1]. **Analysis of Incorrect Options:** * **Chancre (Syphilis):** Caused by *Treponema pallidum*. It typically presents as a **painless**, single, indurated (hard) ulcer with clean base and painless lymphadenopathy. * **Granuloma Inguinale (Donovanosis):** Caused by *Klebsiella granulomatis*. It presents as chronic, **painless**, beefy-red velvety ulcers that bleed on touch [1]. There is no true lymphadenopathy; instead, it causes "pseudobuboes" (granulomatous nodules). * **Lymphogranuloma Venereum (LGV):** Caused by *Chlamydia trachomatis* (L1-L3). The initial ulcer is small, **painless**, and transient (often missed) [1]. It is followed by painful inguinal lymphadenopathy with the characteristic "Groove sign." **Clinical Pearls for NEET-PG:** * **School of Fish Appearance:** Classic Gram stain finding for *H. ducreyi*. * **Railroad Track Appearance:** Another description for the parallel arrangement of *H. ducreyi*. * **Treatment of Choice:** Azithromycin (1g orally, single dose) or Ceftriaxone. * **Differential Tip:** If the ulcer is **P**ainful, think **H**erpes or **H**aemophilus (**P**ainful **H**oles). If **P**ainless, think Syphilis or Donovanosis.

Question 84: What is the recommended dose of benzathine penicillin for early syphilis?

A. 3-4 million units intravenously
B. 2.4 million units intramuscularly as a single injection (Correct Answer)
C. 2.4 million units intramuscularly daily, plus probenecid 500 mg orally for 14 days
D. 2.4 million units intramuscularly weekly for three doses

Explanation: The treatment of syphilis is based on the stage of the infection and the duration of the disease. *Treponema pallidum* is highly sensitive to penicillin, and the goal is to maintain sustained treponemicidal levels in the blood. **Why Option B is Correct:** For **Early Syphilis** (which includes Primary, Secondary, and Early Latent syphilis of <1 year duration), the standard of care is a **single dose of 2.4 million units of Benzathine Penicillin G (BPG)** administered intramuscularly. Because *T. pallidum* divides slowly (every 30–33 hours), the long-acting repository form of benzathine penicillin provides the necessary low-level, sustained blood concentration required to eradicate the organism in early stages. **Analysis of Incorrect Options:** * **Option A:** Intravenous penicillin (Aqueous Crystalline Penicillin G) is reserved for **Neurosyphilis** to ensure adequate penetration into the cerebrospinal fluid (CSF). * **Option C:** This regimen (IM Penicillin + Probenecid) is an alternative treatment for **Neurosyphilis** (specifically Procaine Penicillin), not early syphilis. * **Option D:** This is the regimen for **Late Latent Syphilis** (>1 year duration), syphilis of unknown duration, or Tertiary syphilis (without neuro-involvement). It requires three weekly doses to ensure prolonged exposure. **High-Yield NEET-PG Pearls:** * **Drug of Choice:** Penicillin remains the gold standard for all stages of syphilis. * **Jarisch-Herxheimer Reaction:** An acute febrile reaction occurring within 24 hours of starting treatment (most common in secondary syphilis); it is managed with NSAIDs, not by stopping penicillin. * **Penicillin Allergy:** In non-pregnant patients with early syphilis and a penicillin allergy, **Doxycycline (100 mg BID for 14 days)** is the preferred alternative. * **Pregnancy:** Penicillin is the *only* recommended treatment. If the patient is allergic, they must undergo **desensitization**.

Question 85: A painful vaginal ulcer with inguinal lymphadenopathy and a "school of fish" appearance on microscopy are characteristic of which sexually transmitted infection?

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

Explanation: ### Explanation **Correct Answer: D. Chancroid** **Why it is correct:** Chancroid is caused by the Gram-negative coccobacillus ***Haemophilus ducreyi*** [1]. It is characterized by the clinical triad of **painful** genital ulcers (often multiple with ragged edges), inflammatory **inguinal lymphadenopathy** (buboes), and a specific microscopic arrangement [1]. On Gram stain, the organisms align in parallel rows, described classically as a **"school of fish"** or "railroad track" appearance. **Why the other options are incorrect:** * **Syphilis (Treponema pallidum):** Presents with a **painless**, indurated ulcer (chancre) [1]. Microscopy via dark-field illumination shows corkscrew-shaped motile spirochetes, not a school of fish pattern. * **Lymphogranuloma venereum (LGV):** Caused by *Chlamydia trachomatis* (L1-L3). It features a transient, **painless** papule/ulcer followed by painful "Groove sign" lymphadenopathy [1]. It is an obligate intracellular organism. * **Granuloma inguinale (Donovanosis):** Caused by *Klebsiella granulomatis*. It presents as **painless**, beefy-red velvety ulcers that bleed on touch [1]. Microscopy reveals **Donovan bodies** (safety-pin appearance) within macrophages. **High-Yield Clinical Pearls for NEET-PG:** * **Painful vs. Painless:** Remember **"H. ducreyi makes you cry"** (Painful = Chancroid and Herpes; Painless = Syphilis, LGV, and Donovanosis). * **Buboes:** In Chancroid, lymphadenopathy is painful and may suppurate (unilateral). * **Treatment:** A single dose of **Azithromycin (1g)** or Ceftriaxone (250mg IM) is the first-line management. * **Culture:** Requires special media (e.g., Mueller-Hinton agar with vancomycin) and is difficult to grow.

Question 86: Lymphogranuloma venerum is characterized by all of the following except?

A. Primary lesions heal without scarring.
B. Commonly develop systemic infection.
C. Metronidazole is an effective treatment. (Correct Answer)
D. Groove sign is seen characteristically.

Explanation: **Lymphogranuloma Venereum (LGV)** is a sexually transmitted infection caused by **Chlamydia trachomatis serovars L1, L2, and L3**. ### Explanation of Options: * **Option C (Correct Answer):** Metronidazole is an antiprotozoal and anaerobic antibacterial agent; it has no activity against *Chlamydia*. The **first-line treatment for LGV is Doxycycline** (100 mg twice daily for 21 days). Erythromycin or Azithromycin are alternatives. * **Option A:** The primary lesion is typically a small, painless papule or ulcer that is transient and often goes unnoticed. It **heals rapidly without leaving a scar**, which distinguishes it from the scarring seen in Syphilis or Chancroid. * **Option B:** LGV is a systemic disease. Beyond local lesions, patients frequently present with **systemic symptoms** such as fever, chills, malaise, and myalgia, especially during the secondary stage (lymphatic spread) [1]. * **Option C:** The **"Groove Sign" (Greenblatt’s sign)** is a pathognomonic clinical finding. It occurs when the inguinal ligament divides matted, enlarged inguinal and femoral lymph nodes, creating a visible depression or "groove" between the two groups of nodes [1]. ### NEET-PG High-Yield Pearls: * **Stages:** 1° (Primary ulcer) → 2° (Inguinal syndrome/Buboes) → 3° (Anogenital syndrome/Strictures). * **Esthiomene:** A chronic complication involving hypertrophic ulceration and elephantiasis of the female external genitalia due to lymphatic obstruction. * **Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the preferred diagnostic method. Frei’s test is a historical skin test (now obsolete). * **Proctocolitis:** Common in MSM (Men who have sex with men), presenting with rectal discharge, pain, and tenesmus [1].

Question 87: A patient presenting with vaginal discharge, whose husband is a long-haul truck driver, attends a sexually transmitted disease clinic. What is the recommended empirical treatment?

A. Azithromycin + metronidazole + fluconazole (Correct Answer)
B. Azithromycin
C. Metronidazole + fluconazole
D. Fluconazole

Explanation: ### Explanation The correct answer is **A. Azithromycin + metronidazole + fluconazole**. **1. Underlying Medical Concept:** This question tests the concept of **Syndromic Management of Sexually Transmitted Infections (STIs)**, a strategy advocated by the WHO and NACO (National AIDS Control Organisation) in India [1]. In a patient presenting with vaginal discharge, the goal is to provide immediate empirical treatment covering the most common causative organisms without waiting for laboratory confirmation. The standard "Vaginal Discharge Syndrome" (managed under **Kit 2 - Green Kit**) targets: * **Bacterial Vaginosis** and **Trichomoniasis**: Covered by **Metronidazole** (2g oral single dose). * **Candidiasis**: Covered by **Fluconazole** (150mg oral single dose) [2]. However, the clinical history mentions the husband is a "long-haul truck driver," identifying him as a high-risk group for STIs [1]. In such cases, or if there is clinical suspicion of **Cervicitis** (mucopurulent discharge or cervical motion tenderness), the treatment must also cover *Chlamydia trachomatis* and *Neisseria gonorrhoeae* [3]. This is managed under **Kit 1 (Grey Kit)**, which includes **Azithromycin** (1g oral single dose) and Cefixime. Therefore, a comprehensive empirical approach for this high-risk patient includes all three agents. **2. Why Incorrect Options are Wrong:** * **Option B (Azithromycin):** Only covers Chlamydia; misses common causes of vaginal discharge like Trichomonas and Candida. * **Option C (Metronidazole + fluconazole):** This is the standard Kit 2 treatment. While it covers common vaginal infections, it fails to address the high-risk epidemiological factor (husband's occupation) which necessitates coverage for cervicitis (Chlamydia). * **Option D (Fluconazole):** Only treats fungal infections (Candidiasis). **3. NEET-PG High-Yield Pearls:** * **NACO Color Coding:** * **Kit 1 (Grey):** Urethral/Cervical discharge (Azithromycin + Cefixime). * **Kit 2 (Green):** Vaginal discharge (Metronidazole + Fluconazole). * **Kit 3 (White):** Non-herpetic genital ulcer (Penicillin + Azithromycin). * **Kit 6 (Yellow):** Genital Herpes (Acyclovir). * **Whiff Test:** Positive (fishy odor) in Bacterial Vaginosis (KOH mount). * **Strawberry Cervix:** Classic sign of *Trichomonas vaginalis*.

Question 88: Du Bois sign seen in syphilis is:

A. Shortening of the little finger (Correct Answer)
B. Small patches are seen on the back
C. Tightening of the fingers
D. All of the above

Explanation: **Explanation:** **Du Bois Sign** is a classic clinical sign associated with **Congenital Syphilis**. It refers to the **shortening of the little finger** (pinky finger) due to the premature separation or destruction of the epiphysis of the fifth metacarpal bone. This occurs as a result of syphilitic osteochondritis, a common skeletal manifestation in infants born with the infection. **Analysis of Options:** * **Option A (Correct):** Shortening of the little finger is the definitive definition of Du Bois sign. It is a high-yield morphological marker for late congenital syphilis. * **Option B (Incorrect):** Small patches on the back do not correspond to any named sign in syphilis. While secondary syphilis presents with a generalized maculopapular rash, it is not referred to as Du Bois sign. * **Option C (Incorrect):** Tightening of the fingers (sclerodactyly) is characteristic of systemic sclerosis (Scleroderma), not syphilis. **High-Yield Clinical Pearls for NEET-PG:** To master Congenital Syphilis, remember the **Hutchinson’s Triad**: 1. **Hutchinson’s teeth** (notched incisors). 2. **Interstitial keratitis** (leading to blindness). 3. **Eighth nerve deafness** (sensorineural hearing loss). **Other Skeletal Signs in Syphilis:** * **Higoumenakis sign:** Unilateral thickening of the inner third of the clavicle. * **Wimberger’s sign:** Focal erosion of the medial aspect of the proximal tibial metaphysis. * **Saber Shin:** Anterior bowing of the tibia due to periostitis. * **Clutton’s joints:** Symmetrical painless swelling of the knees.

Question 89: Genito-ulcerative (non-herpetic) diseases are coded under which color in the Standard Treatment Guidelines (STG) kits?

A. Grey
B. Blue
C. White (Correct Answer)
D. Red

Explanation: ### Explanation The National AIDS Control Organization (NACO) in India utilizes a **Syndromic Management** approach for Sexually Transmitted Infections (STIs). This method uses color-coded kits to provide immediate, standardized treatment based on clinical presentation rather than waiting for laboratory confirmation. **1. Why White is Correct:** The **White Kit** is specifically designed for **Genital Ulcerative Disease (Non-Herpetic)**. It is used when a patient presents with a non-vesicular ulcer [1]. * **Contents:** Injection Benzathine Penicillin (2.4 million units) and Tablet Azithromycin (1g). **2. Analysis of Incorrect Options:** * **Grey (Option A):** Used for **Urethral Discharge, Cervical Discharge, and Anorectal Discharge**. It contains Azithromycin (1g) and Cefixime (400mg). * **Blue (Option B):** Used for **Vaginal Discharge** (Bacterial Vaginosis and Trichomoniasis). It contains Metronidazole (2g) and Secnidazole (2g) or Clindamycin. * **Red (Option D):** Used for **Genital Ulcerative Disease (Herpetic)**. It contains Acyclovir (400mg) to treat Herpes Simplex Virus (HSV-2) [1]. **3. Clinical Pearls for NEET-PG:** * **Green Kit:** Used for **Vaginal Discharge** (specifically Candidiasis). Contains Fluconazole (150mg) [1]. * **Yellow Kit:** Used for **Lower Abdominal Pain** (Pelvic Inflammatory Disease). * **Black Kit:** Used for **Inguinal Bubo**. Contains Azithromycin and Doxycycline. * **High-Yield Tip:** If a genital ulcer is painful and soft, think **Chancroid** (*H. ducreyi*); if painless and hard, think **Syphilis** (*T. pallidum*). Both are covered by the **White Kit**.

Question 90: A young long-distance lorry driver presents with a painless penile ulcer 9 days after sexual intercourse with a professional sex worker. What is the likely diagnosis?

A. Herpes Genitalis
B. Chancre (Correct Answer)
C. Chancroid
D. Traumatic ulcer

Explanation: The clinical presentation points toward **Primary Syphilis**, characterized by the **Chancre**. [1] ### 1. Why Chancre is the Correct Answer The diagnosis is based on three classic features described in the stem: * **Painless nature:** The hallmark of a syphilitic chancre is that it is typically painless, indurated (hard), and clean-based. * **Incubation Period:** The ulcer appeared 9 days after exposure. The incubation period for *Treponema pallidum* is typically 9–90 days (average 3 weeks), making 9 days a perfect fit. * **Risk Factors:** Long-distance lorry drivers are a classic high-risk group mentioned in NEET-PG vignettes for Sexually Transmitted Infections (STIs). ### 2. Why Other Options are Incorrect * **Herpes Genitalis:** Caused by HSV-2, these ulcers are characteristically **multiple, superficial, and very painful**. [1] They are preceded by vesicles. * **Chancroid:** Caused by *Haemophilus ducreyi*, these ulcers are **painful** ("Soft Chancre") with ragged edges and a necrotic base. * **Traumatic Ulcer:** These usually have an immediate onset following trauma and lack the specific induration of a chancre. ### 3. Clinical Pearls for NEET-PG * **Investigation of Choice:** The gold standard for a primary chancre is **Dark Ground Microscopy (DGM)** to visualize spirochetes. Serology (VDRL/RPR) may be negative in the first 1–2 weeks of the ulcer. * **Lymphadenopathy:** Syphilis presents with **painless, rubbery, non-suppurative** regional lymphadenopathy. In contrast, Chancroid presents with painful, suppurative "buboes." * **Treatment:** The drug of choice is **Benzathine Penicillin G** (2.4 million units IM single dose).

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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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Sexually Transmitted Enteric Infections

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Special Populations Management

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Venerology — MCQs

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