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A 19yo man was seen in the ED 2 weeks ago with a painless lesion to his penis. He is sexually active with men, has had 2 recent partners, and “sometimes forgets” to use condoms. At that time testing for HIV, RPR, gonorrhea, and chlamydia urine NAT were performed at the time and he was treated empirically with IM bicillin for presumed chancre of syphilis and empiric IM ceftriaxone for gonorrhea. All of the labs were subsequently negative. He now returns with bilateral tender inflamed inguinal adenopathy. His penile lesion resolved after a few days.
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October 16, 2018 at 4:11 pm
A) Doxycycline PO for 21 days. The patient has symptoms consistent with lymphogranuloma venerum, caused by certain serotypes of Chlamydia trachomatis. LGV is seen more often in men who have sex with men and HIV-infected men. Other STIs in the differential for a penile sore that are less likely in this case are: chancre of syphilis which is usually painless and is treated with bicillin (unlikely since RPR negative), herpes simplex virus (unlikely since lesion resolved rapidly and was not very painful), and chancroid (painful, usually evolves into a 1-2cm ulcer, caused by H. ducreyi and should have been treated by the ceftriaxone and azithromycin). LGV may also present with proctitis. Diagnosis is mainly clinical, and recommended treatment is doxycycline for 21 days, with erythromycin as a second-line choice, and sometimes aspiration of the inguinal buboes if indicated.