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13-year-old female presents with vaginal mucosa inflammation, ulcerative lesions
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A previously healthy 13-year-old female had the recent onset of a low-grade fever with some dysuria and vaginal itching with pain. She is not sexually active, denies trauma or abuse, has never had a urinary tract infection and noted no other complaints. However, further history revealed that she may have had a previous episode of a similar complaint within the last year that lasted about 5 days, but she was not evaluated or treated.
On exam, the patient was found to be a healthy-appearing adolescent female, with normal vital signs. The only positive finding on her complete exam included some inflammation of the vaginal mucosa along with several discrete ulcerative lesions (Figure 1). Lab tests included a negative herpes PCR and negative Mycoplasma titers.
Figure 1. Inflammation of the vaginal mucosa with discrete ulcerative lesions.
Source: Green P
Case Discussion
This patient was diagnosed with idiopathic aphthosis (D), which, like aphthous stomatitis, has no known or consistent identifiable cause, although it has been associated with Mycoplasma infection in some patients. The diagnosis is based on history and clinical features, supported by a history of recurrence, even if the patient has a history of oral aphthosis. Treatment is symptomatic with a topical anesthetic, acetaminophen, sitz baths and time; oral steroid therapy is recommended in some severe cases. If the diagnosis is uncertain, a biopsy of the edge of one of the lesions may be performed to rule out some “look-alikes.”
Figure 2. Inflammation of the mucous membranes.
Source: Brien JH
Figure 3. Inflammation of the mucous membranes.
Source: Brien JH
Figure 4. X-ray of patient with recent M. pneumoniae infection.
Source: Brien JH
One must be sure to at least consider the possibility of trauma/abuse, as well as herpes simplex virus. If the patient is really not sexually active or abused, herpes would be very unusual, and with a negative PCR, it can usually be taken off the table.
Behçet syndrome — named after Hulusi Behçet, an early 20th century Turkish dermatologist — is a fairly rare autoimmune small-vessel vasculitis. It can result in similar genital ulcerations, but also characteristically has oral ulcerations and eye involvement (uveitis) as well, forming the classic triad. Other organ systems also can be involved. Diagnosis is made by these clinical findings without any other cause found. As noted, it is rare in this country, but more common in the Middle East and Asia, sometimes referred to as the Silk Road syndrome or disease. There has been an association with HLA-B51. Treatment is directed toward symptomatic relief with anti-inflammatory agents, usually under the guidance of a rheumatologist.
Lastly, atypical Stevens-Johnson syndrome was featured in the September 2014 column. Essentially, this condition is characterized by inflammation of the mucous membranes (Figures 2-3), with or without ulcerations, but, unlike Stevens-Johnson syndrome, there is little to no associated skin rash or lesions seen. It has been observed that there is a fairly strong association with current or recent M. pneumoniae infection, (Figure 4 in the same patient as in Figures 2-3). If suspected, treatment of the Mycoplasma infection may be helpful; otherwise, only symptomatic support is all that is needed. Please refer to that column for more details.
I would like to thank Pam Greene, MD, Ob/Gyn staff at McLane Children’s Hospital, for her help with providing material and guidance for this case. – James H. Brien, DO
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.