Case: Vaginal Rash
Case Study: 20-Something Female With Vaginal Rash and Pain
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“I’m feeling really sore in my genital area and have this new rash too. Do you think I could have herpes?”
Case: Susan, a 27-year-old single woman presents to your office with a chief complaint of increasing pain from “tears” in the vaginal area. She last had sexual relations a week ago with a partner who wore a condom, although it broke during intercourse. She does not recall seeing any penile ulcers or other unusual skin lesions on her partner. She denies any sexual abuse or violence. She reports that her partner, who is in the military, was ‘recently’ vaccinated for smallpox, but does not recall his wearing a bandage or dressing at the vaccination site.
Past medical history is negative for genital ulcers or sexually transmitted infections. She reports no hematuria or dysuria. She tested negative for HIV approximately 3 months ago. Review of systems negative, except for seasonal allergies and a history of eczema since childhood.
Medications: Antihistamines for seasonal allergies; topical corticosteroids as required to treat eczema flares.
Physical examination: Afebrile. Vital signs normal.
Skin: There is some redness, swelling, and crusting over the hands, knees, and feet.
GYN: Two shallow ulcerations of the labia minor along with mild bilateral labial erythema and induration, as well as vaginal discharge. No inguinal lymphadenopathy was noted, and examination findings were normal for the cervix, uterus, adnexa, and anus. A primary diagnosis of sexually transmitted infection was made, with no specific treatment administered pending viral culture results. A secondary diagnosis of vulvovaginal candidiasis was made and Susan was instructed to use over-the-counter miconazole.
Serologic tests for syphilis and hepatitis B virus were not performed. A viral swab specimen from the left labial lesion was submitted to the state laboratory for possible herpes virus infection.
Susan returns to the office in 4 days complaining of increased redness, swelling, and burning of the labia minora. Tests for gonorrhea and Chlamydia trachomatis infection had been negative.
How Would You Proceed?
Published on August 3, 2010
Updated on August 10, 2010
Discussion
It is possible that Susan has a vaginal cellulitis as the result of vulvar vaccinia, contracted from a partner who had been vaccinated for smallpox within several days of sexual contact. The newly vaccinated, smallpox vaccination produces a localized skin infection from live vaccinia virus, which confers immunity to smallpox. When proper precautions are taken—ie, application of an occlusive bioadhesive dressing over the vaccination site—there is typically no viral transfer to intimate contacts.[1] However, when the site is uncovered, unvaccinated people with exfoliative skin conditions—such as eczema—are at risk of inadvertent autoinoculation with vaccinia when exposed to a newly vaccinated person.[2]
Routine smallpox vaccination ended in 1972; therefore, Susan is too young to have been vaccinated against smallpox. In conjunction with her lifelong history of eczema and recent contact with a newly vaccinated partner, her symptoms should raise a high index of suspicion for vaccinia.
A reasonable course of treatment would include discontinuing the OTC antifungal agent and prescribing a 7-day course of an oral cephalosporin 500 mg twice daily. At 10-day follow-up, the patient’s labial redness, induration, and pain resolved, and the ulcers healed completely within 10 days.
Of note is that the state laboratory ruled out the presence of herpes simplex virus, but was unable to identify what virus she did have. The sample was sent to the CDC, where follow-up cloning and sequencing of the blood sample was able to identify a viral isolate consistent with vaccine-strain vaccinia virus.
References
- Talbot TR, Ziel E, Doersam J, et al. Risk of vaccinia transfer to the hands of vaccinated persons after smallpox immunization. Clin Infec Dis. 2004;38:536-541.
- Cono J, Casey CG, Bell DM; Centers for Disease Control and Prevention. Smallpox vaccination and adverse reactions. Guidance for clinicians. MMWR Recomm Rep. 2003;52(RR-4):1-28. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5204a1.htm.
I s she allergic to miconazole? Is this a Bartholin cyst ? Is thi s Herpes?
I would check to see if the herpes culture was back
If the culture was postive prescribed acyclovir
I would stop the miconazole
Ask have she used any other otc products or treatments, or has she had sexual intercourse since her last visit here. Ask if she has any more vaginal discharge, itching, or odor? Any pain with urination?
Vaginal exam – vaginal cultures,bv, trich, yeast.
Order a urine because this was not ordered before. Also cbc, syphyllis, hepatitis, and hiv
Of course no sex until further noticed
Prescribed something for the pain .
Warm sitz bath
Referred to Gyn or get her an appointment asap