LipschÜtz Ulcer -- The Uncommon Diagnosis of Exclusion

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Case report Patient is an 11 year-old female with a history of recurrent oral ulcers and ADHD, with initial symptoms of a fever, sore throat and headache a week prior. A few days later, after symptom resolution, she developed pruritic labial swelling and grey vaginal discharge followed by two painful ulcerations on her labia minora. She was prescribed amoxillin clavulanate and referred to a gynaecologist where vaginal cultures and ulcer swabs were performed. She also received a dose of azithromycin and was started on valacyclovir. She had no improvement, developed significant dysuria and urinary retention, prompting admission. History was negative for abuse and no past history of genital lesions. Ulcers were approximately 2 cm, bilateral and symmetric with an overlying greyish exudate and associated swelling of the labia minora. Therapeutic modalities tried due to working diagnosis of Behçet’s, per rheumatology, included prednisone and topical flocinonide initially and then IV pulse methylprednisone, all with no improvement. With a negative ophthalmological exam for uveitis and negative autoimmune serology as well, this was ruled out. Of note patient was later found to be HLA B51 positive. ID modalities included CMV and EBV testing and initiating IV Acyclovir pending HSV. Positive results of elevated EBV IgM narrowed the diagnosis to Lipschütz ulcers or ulcus valvae acutum. This is an uncommon self-limited genital ulceration in nonsexually active adolescent females. Ulcers are deep with a violaceous border and necrotic base covered with a grey exudate. It is a diagnosis of exclusion and proposed criteria for diagnosis of Lipschütz ulcer in a young female with a recent viral illness includes first episode of acute genital ulceration, age <20, presence of deep, well-delimited, painful ulcerations on the labia, characteristic bilateral ‘kissing pattern’, absence of sexual contact, and exclusion of other known causes of genital ulceration. In this particular case, the evidence of acute EBV infection supported the diagnosis of Lipschütz ulcer in the setting of a primary EBV infection. This association has been reported in the past in limited case reports, particularly in gynaecology literature. It is considered rare but may be an overlooked diagnosis and should prompt early recognition and a systematic work-up to rule in this self-limited disease.


Diagnosis | Medicine and Health Sciences

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