Fever, Genital Pain, and Genital Ulcers

Abstract

A previously healthy 11-year-old female presented to the emergency department (ED) with complaints of fever, vomiting, and genital pain. Her symptoms began 4 days ago. She had fevers of up to 105°F for which she had been intermittently taking acetaminophen and ibuprofen. She had also experienced 6 episodes of nonbilious, nonbloody emesis. Three days prior to presentation, she began having sharp pain localized to the genital area. The day before her ED visit, she went to her pediatrician's office where a urinalysis and urine culture was performed. She was sent home with a presumptive diagnosis of a urinary tract infection. The same evening the patient complained of further pain in her genital area and her mother noted nonspecific staining of her underwear. Consequently, her mother brought the patient to the ED the following day.The patient had not attained menarche. She did not complain of dysuria, urgency, frequency, abdominal/ flank pain, vaginal discharge, joint pain, mouth pain/ ulcers, or rash. Two weeks ago she had shaved her pubic region, but was uncertain of having sustained any cuts to the area. She denied being sexually active. As per the history, there was no trauma and no suspicion or concern regarding sexual abuse.On presentation she was awake, alert, and in no acute distress. She was afebrile, with normal vital signs. Her abdomen was soft, nontender with no organomegaly. Her genitourinary exam revealed a 1.5-cm well-demarcated irregular ulcerated lesion on the inner aspect of her right labia minora and an adjacent 1-cm ulcerated lesion on the opposing surface of her left labia minora, both very painful to the touch. There was no active discharge or bleeding. Her hymen appeared intact and normal for age. Her perineal area appeared normal. There was no other skin or mucosal lesions. There were no signs of trauma or child abuse. There was no inguinal or other lymphadenopathy. The rest of her systemic examination was unremarkable.In the ED, initial workup revealed a white blood cell count of 14 000/µL (14.0 × 10 9 /L) with 65% neutrophils and 24% lymphocytes. Basic electrolytes panel was normal. C-reactive protein was elevated at 52.9 mg/L. Urinalysis showed a pH of 6.0, 1+ ketones, 2+ blood, 2+ leukocyte esterase, negative nitrites, <2 red blood cells, and 10 to 20 white blood cells. Urine pregnancy test was negative. A pelvic and renal ultrasound was unremarkable. A dose of ceftriaxone was administered for a possible urinary tract infection. Laboratory screening tests for sexually transmitted infections were requested, and the patient was admitted for further workup. Final DiagnosisLipschütz ulcers (acute genital ulcers) Hospital CourseSubsequent workup including Chlamydia, gonorrhea, and herpes simplex virus (HSV 1 and 2) culture and DNA amplification from the lesion, and serology test for syphilis, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and HIV were all negative. Cultures from the lesion, urine, and blood are also negative; hence, antibiotics were discontinued. Ophthalmologic exam was negat...