Case 1: Fever and a genital ulcer in a recent immigrant

A 16-year-old girl presented to the emergency department of a community hospital with an eight-day history of fever. On the first day of illness, she noted mild upper respiratory tract symptoms that resolved within 24 h. During the following five days, she felt generally well with the exception of nocturnal fevers. Three days before presentation, she developed a painful ulcer on her left labium majus. She had normal bowel movements until the day of presentation when she had one loose, nonbloody bowel movement. She had been taking acetaminophen for two to three days as well as a first-generation cephalosporin for seven days, which the family had purchased in India. The patient denied any recent or remote sexual activity. The family had immigrated from India three weeks before the onset of her illness. Her medical and family history were unremarkable. She denied any sexual activity. Physical examination revealed a well-appearing adolescent with a temperature of 39.5°C as well as a single circular 2 cm × 2 cm white-topped ulcer on her left labium majus. The external genitalia were otherwise normal. The rest of a complete examination was unremarkable. Investigations in the emergency department included a normal complete blood count, negative malarial smear and mild trans-aminitis with an aspartate aminotransferase level of 105 U/L and an alanine aminotransferase level of 117 U/L. Herpes simplex virus and bacterial studies were performed on a swab of the lesion. A rapid plasma reagin test was performed to screen for syphilis, and blood cultures were drawn. She was discharged home with a plan for outpatient follow-up. Further investigation revealed the diagnosis. A stool culture was positive for Salmonella typhi. The patient’s blood culture, wound cultures and other investigations were all negative. She was treated with a seven-day course of oral ciprofloxacin and her condition quickly improved along with resolution of the vulvar ulcer. Typhoid fever is a result of infection with Salmonella enterica serovar Typhi. Each year, there are more than 20 million cases of the disease worldwide. Typically, after an incubation period of one to two weeks, patients experience fever, headache and abdominal pain. If left untreated, the fever plateaus at approximately 40°C with a relative bradycardia. Diarrhea, delirium and hepatosplenomegaly can arise in the second week of illness. Classically, several complications may occur in the third week including intestinal hemorrhage/perforation, encephalitis, endocarditis and metastatic abscesses. Genital ulcers have rarely been reported as one such metastatic site (1). The mechanism of ulcer formation is unknown but thought to be via bacterial emboli, direct inoculation by urine or feces, or possibly, as a result of endotoxin production. Genital ulcers resulting from typhoid fever are rare when blood cultures are negative. In the present patient, the use of a first-generation cephalosporin at home may have resulted in a negative blood culture result. Although ciprofloxacin is not approved for paediatric use, it is commonly used for treatment because multidrug-resistant S typhi is common in many parts of the world. Amoxicillin, trimethoprim-sulfamethoxazole, chloramphenicol, azithromycin and cefixime are other oral choices for outpatient therapy. More severe illnesses should be treated with parenteral ceftriaxone. Relapse of typhoid fever occurs in approximately 5% to 10% of patients, usually within two months of the initial presentation, and is milder than the initial disease. After reculturing the patient, a second course of the original antibiotic can be prescribed pending sensitivity data. In a nonsexually active, immunocompetent female adolescent, the most commonly diagnosed causes of genital ulcers include primary Epstein-Barr virus (EBV) infection and aphthosis, such as in Behcet’s disease or Crohn’s disease. Other lesions are considered idiopathic when the history is noncontributory and investigations are negative (2). In these patients, nonspecific viral symptoms are common. Lesions are typically self-limited and heal without scarring. A prodrome of fever, fatigue, tonsillitis and lymphadenopathy is suggestive of primary EBV infection. Vulvar lesions in the context of EBV are usually self-limited and nonrelapsing (3). When lesions are recurrent and associated with painful oral ulcers, ocular lesions or joint pain, Behcet’s disease should be considered and a rheumatological evaluation sought. These ulcers are typically deep, painful and heal with scarring. Genital lesions associated with Crohn’s disease may predate gastrointestinal manifestations. In sexually active patients, the differential is broadened to include herpes simplex virus and chancroid, which both typically cause painful ulcers. Ulcers associated with syphilis are typically painless. The evaluation of an adolescent female presenting with genital ulcers should include a detailed history, including sexual history. An evaluation for oral ulcers and skin lesions is important in the physical examination. Viral and bacterial culture of lesions and serology for EBV should be considered. Pain control is an essential part of the management plan. In the present patient, a travel history along with fever and diarrhea prompted a stool culture, which led to a diagnosis of an uncommon but reported cause of genital ulcers in adolescent females. Common diseases (eg, typhoid fever) can present in an uncommon manner (eg, genital ulcers). Not all genital ulcers are a result of sexually transmitted infections.

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