A Man with Penile Ulcerations The 5-Minute STI Clinical Case Study

Case 28 year-old heterosexual male with a 5-day history of penile ulcerations and painful inguinal lymphadenopathy Also complains of dysuria, headaches and general malaise Sexual history – New sex partner since 6 weeks – Inconsistent condom use for vaginal sex – 12 lifetime sexual partners – No concurrent partnerships – No history of other STI’s, specifically no history of genital or labial herpes

Case Physical Exam: – Multiple, partly crusted ulcerations and intact blisters on penis shaft and foreskin – Swollen foreskin – Bilateral tender lymphadenopathy – Scant urethral discharge

Question 1 Your clinical impression is that the patient likely has genital herpes. Which of the below statements is/are true: a. The lesion represents a primary herpetic infection b. The lesion represents a first episode infection c. The most likely cause is HSV type 1 d. The most likely cause is HSV type 2 (Check all that apply)

Question 2 What laboratory test is the most sensitive and specific to determine the herpetic etiology of these lesions? a. Viral isolation by culture and sub-typing b. Tzanck smear c. Herpes serology d. PCR

Question 3 A Gram-stained smear shows >5 white blood cells per high-power field - What is the most likely cause of the patient’s urethritis? a. Chlamydia trachomatis b. Mycoplasma genitalium c. Neisseria gonorrhoeae d. None of the above

Question 4 How should this patient be treated? a. Acyclovir 400 mg orally 3 times a day for 7 days b. Azithromycin 1 g in a single oral dose c. Ceftriaxone 250 mg single intramuscular injection d. Metronidazole 500 mg 2 times a day for 7 days (Check all that apply)

Question 5 With regards to counseling, what is the most important message for this patient? a. His partner should have a serological test to determine whether she has been infected with HSV b. He should be taking acyclovir prophylactically to avoid recurrences c. Consistent condom use is the only way to avoid HSV transmission to his partner if she is not already infected

Additional Clinical Slides

Primary HSV-2 infection vulva

Woman with recurrent HSV-2 Infection inner-thigh

Chronic HSV-2 ulcer in patient with advanced HIV infection

Herpes zoster

Herpes zoster (same patient as previous slide)

Disclaimer Copyright case study and clinical photos: –Dr. Kees Rietmeijer, Denver STD/HIV Prevention Training Center This case study and individual clinical slides can be used for educational purposes with reference to source and/or inclusion of the DMHC logo