Case 4: Vulvitis in a nonsexually active adolescent girl

A 15-year-old girl presented with a five-day history of significant swelling and pain of the vulva. Several days previously she experienced flu-like symptoms (headache, photophobia, decrease in oral intake and vomiting). She was taking no medications and had no allergies. Her medical history was unremarkable. Her immunizations were up to date. Onset of menses was 12 years of age. The patient was not sexually active and there was no history of sexually transmitted infections. She denied use of cigarettes, alcohol or illicit substances. On examination, vitals included a temperature of 36.2°C, heart rate 115 beats/min, blood pressure 98/54 mmHg and respiratory rate 20 breaths/min. She appeared tired and pale, with infra-orbital dark circles. Head and neck, respiratory and cardiovascular examinations were within normal limits. Bowel sounds were present with mild diffuse abdominal tenderness on palpation. There was significant bilateral swelling and erythema of the labia minora, on the right side more than the left. Thick yellow discharge was present, which appeared to be vaginal in origin. The area was very tender to palpation. There also appeared to be petechiae on the right side, just inside the vagina. The patient was admitted for oral rehydration, pain control and further investigations. A Foley catheter was placed due to extreme pain on voiding. Cefixime (320 mg daily) had been initiated in the emergency room and was continued for a possible urinary tract infection, and 2000 mg valacyclovir every 12 h was added for possible herpes simplex infection. Several cases over the past 10 years have documented reports of young women experiencing ulcus vulvae acutum, consisting of a nonvenereal painful vulvar ulceration (1,2). Nonvenereal infectious causes of this condition have been described, including Epstein-Barr virus infection (most common), cytomegalovirus, Mycoplasma, HIV and influenza. In the present case, multiple cultures were obtained, including negative vaginal and urinary cultures. Serologies for chlamydia, gonorrhea, herpes simplex virus (immunoglobulin [Ig] G and IgM), Epstein-Barr virus and cytomegalovirus (IgG and IgM) were all negative. Culture for parvovirus was also negative. Viral culture obtained during the first emergency room visit was positive for influenza A but negative for influenza B. Blood cultures were also negative. Additional investigations included a biopsy of vaginal tissue, revealing only fibrinopurulent debris. A pelvic ultrasound was also normal. After consultation with infectious diseases, Mycoplasma serology was sent and remained pending during her admission but was subsequently positive for IgM. Supportive care including sitz baths, anti-inflammatories, and topical hydrocortisone and clotrimazole, were administered. The patient’s vulvar swelling, erythema and pain began to improve on postadmission day 3, after starting the hydrocortisone cream. By day 7, her symptoms had largely resolved and the patient was discharged. Because our patient had both a positive influenza A culture and Mycoplasma serology, it was difficult to definitively conclude which was the causative agent. However, Mycoplasma serology may stay positive for up to two months, and testing for influenza is recommended within four days of symptoms to ensure highest yield while the virus is actively shedding. Most of the case reports reviewed revealed that patients had a prodromal illness before the vulvitis. Given this timeline, we believe our patient’s condition was likely secondary to influenza virus. As well, our patient’s prodromal symptoms appeared to align clinically with an influenza infection because there was no nasal congestion nor cough. Only a few case reports have suggested an association with influenza A virus to vulvar ulcerations. Common themes throughout these reports included the young age of the patients and the lack of sexual activity. As well, most patients experienced a prodromal flu-like illness. In consideration of a differential diagnosis in the presented patient, Behçet disease has also been reported as a cause of noninfectious vulvar ulcers. Our patient did not have recurrent genital ulcers, nor any skin manifestations associated with that particular disease. She denied any problems with her vision. A pathergy test was not completed during her stay, which can be used to support a diagnosis of Behçet disease. Treatment of ulceration is generally supportive. Pain control may be achieved using oral or topical analgesics. In some cases, pain may be severe, and require hospitalization and placement of a Foley catheter. Topical steroids may be of benefit. Other adjunctive therapies, such as zinc oxide and sitz baths, may also be helpful (2). Oral antibiotics may be indicated if superinfection or immunosuppression are present. Oseltamivir could be considered for a viral etiology. However, given the timeline of the flu-like illness preceding the ulceration, there would have been little benefit in adding an antiviral agent. Influenza A is a documented cause of vulvitis, particularly if preceded by prodromal flu-like illness. Treatment of these types of vulvitis is mainly supportive. The treatment of viral vulvitis is mainly supportive but includes pain control and topical treatments.

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