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Difficulty: MediumInfectious Diseases

Match each clinical presentation of genital ulcer disease to the most appropriate first-line pharmacotherapy.

  • A 25-year-old man with a single, painless, indurated penile ulcer with a clean base and bilateral non-tender inguinal lymphadenopathy.Intramuscular benzathine penicillin G
  • A 22-year-old woman with multiple extremely painful vulvar vesicles on an erythematous base that have ulcerated, accompanied by dysuria and tender inguinal lymphadenopathy.Oral acyclovir, valacyclovir, or famciclovir
  • A 28-year-old man with a deep, exquisitely painful penile ulcer with ragged, undermined edges and a purulent base, accompanied by a unilateral, tender, fluctuant inguinal lymph node.Oral azithromycin or intramuscular ceftriaxone
  • A 32-year-old man with a unilateral, painful, fluctuant inguinal mass (bubo) who recalls a small, transient, painless genital ulcer that resolved spontaneously 3 weeks ago.Oral doxycycline for 21 days

Answer

The correct matches pair Primary Syphilis with Benzathine penicillin G, Genital Herpes with oral antivirals, Chancroid with Azithromycin or Ceftriaxone, and Lymphogranuloma Venereum with a 21-day course of Doxycycline.
Each classic genital ulcer presentation corresponds to a specific organism and a guideline-directed treatment regimen. A painless, indurated ulcer with non-tender nodes is typical for primary syphilis (Treponema pallidum), requiring intramuscular benzathine penicillin G. Painful vesicles or shallow ulcers point to genital herpes (HSV), treated with oral antivirals. Deep, painful ulcers with a purulent base and tender nodes suggest chancroid (Haemophilus ducreyi), treated with azithromycin or ceftriaxone. A painless transient ulcer followed by painful inguinal buboes indicates lymphogranuloma venereum (Chlamydia trachomatis L1-L3), which necessitates a 21-day course of oral doxycycline.

Step-by-Step Solution

1
Evaluate the clinical characteristics of the genital ulcer (painful vs. painless).
Painful ulcers suggest genital herpes (HSV) or chancroid. Painless ulcers suggest primary syphilis, lymphogranuloma venereum (LGV), or granuloma inguinale.
Pain is the most important initial differentiating factor in the clinical diagnosis of genital ulcer disease.
2
Assess the characteristics of the associated regional lymphadenopathy.
Non-tender lymphadenopathy points to syphilis. Tender lymphadenopathy points to HSV or chancroid. Painful, fluctuant buboes appearing weeks after a transient initial ulcer point to LGV.
Lymph node involvement patterns are highly specific to the causative pathogen and help confirm the diagnosis.
3
Match the identified clinical syndrome with the current guideline-directed first-line antimicrobial therapy.
Syphilis requires benzathine penicillin G, HSV requires antivirals, chancroid requires azithromycin or ceftriaxone, and LGV requires a 21-day course of doxycycline.
Empiric treatment must rapidly and specifically target the most likely organism to prevent disease transmission and complications.

Key Concept

Identifying the etiology of genital ulcer diseases based on clinical features (painful vs. painless, presence and type of lymphadenopathy) is essential for selecting the correct first-line empiric antimicrobial therapy.
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Topics

Infectious Diseases

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