{ 'id': 'Q-3', 'question': 'Which one of the following organisms causes

lymphogranuloma venereum?', 'options': ['Haemophilus ducreyi', 'Klebsiella

granulomatis', 'Herpes simplex virus', 'Chlamydia', 'Treponema pallidum'],
'answer': 'D', 'explanation': "STI: ULCERS Genital herpes is most often caused by
the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1).
Primary attacks are often severe and associated with fever whilst subsequent
attacks are generally less severe and localised to one site Syphilis is a sexually
transmitted infection caused by the spirochaete Treponema pallidum. Infection is
characterised by primary, secondary and tertiary stages. A painless ulcer (chancre)
is seen in the primary stage. The incubation period= 9-90 days Chancroid is a
tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers
associated with unilateral, painful inguinal lymph node enlargement. The ulcers
typically have a sharply defined, ragged, undermined border. Lymphogranuloma
venereum (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of
three stages stage 1: small painless pustule which later forms an ulcer stage 2:
painful inguinal lymphadenopathy stage 3: proctocolitis LGV is treated using
doxycycline. Other causes of genital ulcers • Behcet's disease • carcinoma •
granuloma inguinale: Klebsiella granulomatis* *previously called Calymmatobacterium
granulomatis" },
{ 'id': 'Q-9', 'question': 'A 23-year-old medical student is seen in a
genitourinary medicine clinic for a painless lesion on the glans of his penis. He
describes a 2-week history of the lesion that started as a small erythematous
papule and has now progressed to ulceration. This was associated with fevers,
sweats and general malaise. He has returned from his elective in the Caribbean and
admits to an episode of unprotected sex with a local resident. On examination there
was a 1x2cm painless ulcer on the glans of his penis. You note groove sign with
lymphadenopathy above and below the left inguinal ligament only. What organism is
cause of the patients presentation?', 'options': ['Treponema pallidum', 'Chlamydia
trachomatis', 'Haemophilus ducreyi', 'Klebsiella', 'Gonorrhoea'], 'answer': 'B',
'explanation': 'This patient is presenting with the classic features of
Lymphogranuloma venereum (LGV). This tropical sexually transmitted disease can be
caused by multiple serovars of Chlamydia Trachomatis. The bacterium gains entry
through breaches in the epithelial/mucous membranes, travelling through the
lymphatics via macrophages to local nodes. It is endemic to Africa, India,
Caribbean, central America and southeast Asia. The disease presents in two stages:
Primary stage: Self-limiting painless genital ulcer at the site of inoculation 3-12
days later. Secondary stage: Presents 1-6 months later with unilateral painful
lymphadenitis/lymphangitis. The site of inoculation dictates symptomatology, if
rectally, then tenesmus, proctocolitis, strictures and fistulas can ensue.
Cervicitis and urethritis are also common features. Enlarged lymph nodes are known
as buboes, they are often painful and can lead to thinning of the overlying skin
causing abscesses. Groove sign is separation inguinal nodes by the inguinal
ligament and is characteristic of the disease. Diagnosis is achieved by enzyme
linked immunoassays or polymerase chain reaction of infected sample areas/pus.
Acute and convalescent sera can be used, but requires two samples 2 weeks apart.
Treatment involves antibiotics, either doxycycline or macrolides (azithromycin or
erythromycin) and potential surgical drainage/aspiration of the buboes or
abscesses. Complications of the disease include: genital elephantiasis, hepatitis,
infertility, pelvic inflammatory disease, arthritis and fitz hugh curtis syndrome.
Please see Q-3 for STI: Ulcers' },
{ 'id': 'Q-49', 'question': 'A 35-year-old homosexual man is referred
to the local genitourinary clinic following the development of a solitary painless
penile ulcer associated with painful inguinal lymphadenopathy. He has recently
developed rectal pain and tenesmus. What is the most likely diagnosis?A. Herpes
simplex infection', 'options': ['Syphilis', 'Granuloma inguinale', 'Chancroid',
'Lymphogranuloma venereum'], 'answer': 'E', 'explanation': 'Genital ulcers painful:
herpes much more common than chancroid painless: syphilis more common than
lymphogranuloma venereum Lymphogranuloma venereum usually involves three stages: 1
- small painless pustule which later forms an ulcer 2 - painful inguinal
lymphadenopathy 3 - proctocolitis Please see Q-3 for STI: Ulcers' },
{ 'id': 'Q-61', 'question': 'A 27-year-old bisexual man presents to
your GUM clinic with a 7-day history of rectal discharge, pain on passing stools
and tenesmus. On examination, he has tender inguinal lymphadenopathy and
proctoscopy reveals red mucosa with yellow discharge and some shallow ulcers. Which
one of the following organisms is most likely to be causative?', 'options':
['Enterococcus coli', 'Treponema pallidum', 'Haemophilus ducreyi', 'Neisseria
gonorrhoea', 'Chlamydia trachomatis'], 'answer': 'E', 'explanation': 'If a sexually
active patient presents with genital chlamydia and bowel symptoms, LGV
proctocolitis should be considered The presence of ulcers and significant rectal
symptoms in a sexually active man raises the question of lymphogranuloma venereum,
which is caused by a type of Chlamydia trachomatis. Rectal infection with
gonorrhoea could cause similar symptoms but would not be expected to cause ulcers.
Please see Q-3 for STI: Ulcers' },
{ 'id': 'Q-94', 'question': 'A 45-year-old man is diagnosed as having
primary syphilis. Six hours after receiving his first injection of benzylpenicillin
he complains of feeling generally unwell. On examination he appears flushed. His
blood pressure is 94/62 mmHg, pulse 96/min and temperature 37.9º. These symptoms
settle after around four hours. Which one of the following is most likely to
explain this finding.', 'options': ['Arunan-Leadbetter reaction', 'Jarisch-
Herxheimer reaction', 'Concurrent infectious mononucleosis infection', 'Allergic
reaction to benzylpenicillin', 'Undiagnosed tertiary syphilis'], 'answer': 'B',
'explanation': 'SYPHILIS: MANAGEMENT Management • intramuscular benzathine
penicillin is the first-line management • alternatives: doxycycline • the Jarisch-
Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia
after first dose of antibiotic. It is thought to be due to the release of
endotoxins following bacterial death and typically occurs within a few hours of
treatment.' },
{ 'id': 'Q-95', 'question': 'A 34-year-old man presents with a
widespread maculopapular rash and mouth ulcers. Two months ago he presented to the
local GUM clinic after developing a painless penile ulcer. At the time he was noted
to have inguinal lymphadenopathy. Which one of the following organisms is most
likely to be responsible?', 'options': ['Lymphogranuloma venereum', 'Herpes simplex
virus type 2', 'Mycoplasma genitalium', 'Haemophilus ducreyi', 'Treponema
pallidum'], 'answer': 'E', 'explanation': "This patient has symptoms of secondary
syphilis. SYPHILIS Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by primary, secondary
and tertiary stages. The incubation period is between 9-90 days Primary features •
chancre - painless ulcer at the site of sexual contact • local non-tender
lymphadenopathy • often not seen in women (the lesion may be on the cervix)
Secondary features - occurs 6-10 weeks after primary infection • systemic symptoms:
fevers, lymphadenopathy • rash on trunk, palms and soles • buccal 'snail track'
ulcers (30%) • condylomata lata (painless, warty lesions on the genitalia Classical
palm lesions of secondary syphilisMore generalised rash of secondary syphilis
Tertiary features • gummas (granulomatous lesions of the skin and bones) •
ascending aortic aneurysms • general paralysis of the insane • tabes dorsalis •
Argyll-Robertson pupil Features of congenital syphilis • blunted upper incisor
teeth (Hutchinson's teeth), 'mulberry' molars • rhagades (linear scars at the angle
of the mouth) • keratitis • saber shins • saddle nose • deafness" },
{ 'id': 'Q-109', 'question': 'A 24-year-old man attends your GUM clinic
for results of his recent tests. He frequently engages in unprotected sex with
multiple partners. You note he had a mildly raised Venereal Disease Research
Laboratory (VDRL) test at 1:8. He did however have a negative EIA and TPPA test.
You suspect it could be a false positive test [Link] of the following would
be useful at determining a cause?', 'options': ['HIV test', 'Rheumatoid factor',
'Serum electrophoresis', 'Varicella serology', 'Mycoplasma serology'], 'answer':
'A', 'explanation': "False positive VDRL/RPR: 'SomeTimes Mistakes Happen' (SLE, TB,
malaria, HIV) The answer is HIV test. The VDRL test is very sensitive for syphilis
infections and titres can be used to track treatment and progression. It is,
however, prone to many false positives. This is defined by a positive VDRL in the
absence of a positive EIA/TPPA (which, in contrast, stay positive lifelong after
infection). False positives are usually due to a reaction of antibodies to the
cardiolipin-lecithin-cholesterol reagent in the RPR/VDRL tests. Systemic lupus
erythematous, HIV, antiphospholipid syndrome and TB infection are classic causes of
this. Other Treponemal infections like yaws and pinta can also cause false
positives, but this would not occur with atypical bacteria such as Mycoplasma.
SYPHILIS: INVESTIGATION Treponema pallidum is a very sensitive organism and cannot
be grown on artificial media. The diagnosis is therefore usually based on clinical
features, serology and microscopic examination of infected tissue Serological tests
can be divided into • cardiolipin tests (not treponeme specific) • treponemal
specific antibody tests Cardiolipin tests • syphilis infection leads to the
production of non-specific antibodies that react to cardiolipin • examples include
VDRL (Venereal Disease Research Laboratory) & RPR (rapid plasma reagin) •
insensitive in late syphilis • becomes negative after treatment Treponemal specific
antibody tests • example: TPHA (Treponema pallidum HaemAgglutination test) •
remains positive after treatment Causes of false positive cardiolipin tests •
pregnancy • SLE, anti-phospholipid syndrome • TB • leprosy • malaria • HIV
Treponema pallidum, the bacteria that cause syphilis. Note the spiral shape of the
organism. Credit: NIAID" },
{ 'id': 'Q-132', 'question': 'A 28-year-old man who has recently
emigrated from Nigeria presents with a penile ulcer. It initially started as a
papule which later progressed to become a painful ulcer with an undermined ragged
edge. Examination of the testes was unremarkable but tender inguinal
lymphadenopathy was noted. What is the most likely diagnosis?', 'options':
['Chancroid', 'Lymphogranuloma venereum', 'Syphilis', 'Herpes simplex infection',
'Granuloma inguinale'], 'answer': 'A', 'explanation': "Genital ulcers • painful:
herpes much more common than chancroid • painless: syphilis more common than
lymphogranuloma venereum + granuloma inguinale A diagnosis of chancroid is more
likely than lymphogranuloma venereum as the ulcer is painful. Whilst herpes simplex
is obviously more common the description of the ulcer is very characteristic of
chancroid. Painful inguinal lymphadenopathy is present in around 50% of patients.
STI: ulcers Genital herpes is most often caused by the herpes simplex virus (HSV)
type 2 (cold sores are usually due to HSV type 1). Primary attacks are often severe
and associated with fever whilst subsequent attacks are generally less severe and
localised to one site Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by primary, secondary
and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The
incubation period= 9-90 days Chancroid is a tropical disease caused by Haemophilus
ducreyi. It causes painful genital ulcers associated with unilateral, painful
inguinal lymph node enlargement. The ulcers typically have a sharply defined,
ragged, undermined border. Lymphogranuloma venereum (LGV) is caused by Chlamydia
trachomatis. Typically infection comprises of three stages • stage 1: small
painless pustule which later forms an ulcer • stage 2: painful inguinal
lymphadenopathy • stage 3: proctocolitis LGV is treated using doxycycline. Other
causes of genital ulcers • Behcet's disease • carcinoma • granuloma inguinale:
Klebsiella granulomatis* *previously called Calymmatobacterium granulomatis" },
{ 'id': 'Q-150', 'question': 'Which one of the following tests is most
likely to remain positive in a patient with syphilis despite treatment?',
'options': ['Wassermann reaction', 'Rapid plasma reagin (RPR)', 'Venereal disease
research laboratory (VDRL)', 'Blood culture', 'Treponema pallidum haemagglutination
test (TPHA)'], 'answer': 'E', 'explanation': 'Syphilis: investigation please
see' },
{ 'id': 'Q-171', 'question': 'A 34-year-old man presents with a
widespread maculopapular rash and mouth ulcers. Two months ago he presented to the
local GUM clinic after developing a painless penile ulcer. At the time he was noted
to have inguinal lymphadenopathy. Which one of the following organisms is most
likely to be responsible?', 'options': ['Lymphogranuloma venereum', 'Herpes simplex
virus type 2', 'Mycoplasma genitalium', 'Haemophilus ducreyi', 'Treponema
pallidum'], 'answer': 'E', 'explanation': "This patient has symptoms of secondary
syphilis. Syphilis Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by primary, secondary
and tertiary stages. The incubation period is between 9-90 days Primary features •
chancre - painless ulcer at the site of sexual contact • local non-tender
lymphadenopathy • often not seen in women (the lesion may be on the cervix)
Secondary features - occurs 6-10 weeks after primary infection • systemic symptoms:
fevers, lymphadenopathy • rash on trunk, palms and soles • buccal 'snail track'
ulcers (30%) • condylomata lata (painless, warty lesions on the genitalia )
lassical palm lesions of secondary syphilisMore generalised rash of secondary
syphilis Tertiary features • gummas (granulomatous lesions of the skin and bones) •
ascending aortic aneurysms • general paralysis of the insane • tabes dorsalis •
Argyll-Robertson pupil Features of congenital syphilis • blunted upper incisor
teeth (Hutchinson's teeth), 'mulberry' molars • rhagades (linear scars at the angle
of the mouth) • keratitis • saber shins • saddle nose • deafness" },
{ 'id': 'Q-195', 'question': 'A 54-year-old homosexual man presents to
the emergency department with fever and malaise 24 hours after being treated for
syphilis with intramuscular benzathine penicillin in his local GUM clinic. He has a
florid maculopapular rash over his arms, legs and torso which he tells you has been
present for the last 2 weeks. The patient informs you he has no sexual contacts for
the last 2 months and his last HIV test was performed 3 days ago when he tested
positive for syphilis and was negative. Observations are normal and there are no
other findings on systemic examination. What would be the most appropriate response
to this presentation?', 'options': ['Repeat HIV test, viral load and CD4 count',
'Admit for CT head, lumbar puncture and observation', 'Reassure the patient and
discharge him', 'Repeat syphilis serology and repeat treatment if this is
positive', 'Refer to dermatology for outpatient biopsy'], 'answer': 'C',
'explanation': 'The Jarisch-Herxheimer reaction is a known phenomenon following
syphilis treatment that does not require any specific treatment or investigations A
flu-like reaction, known as the Jarisch-Herxheimer reaction, is a known phenomenon
following syphilis treatment with Benzathine penicillin that is usually self
limiting to 24-48 hours that it is important to inform patients about prior to
treatment. As examination was normal and there is no history of neurological
symptoms there is no need to investigate for neurosyphilis. Syphilis serology will
very likely still be positive 1 day after treatment and there is no indication to
repeat this. Syphilis: management Management • intramuscular benzathine penicillin
is the firstline management • alternatives: doxycycline • the Jarisch-Herxheimer
reaction is sometimes seen following treatment. Fever, rash, tachycardia after
first dose of antibiotic. It is thought to be due to the release of endotoxins
following bacterial death and typically occurs within a few hours of treatment.' },
{ 'id': 'Q-207', 'question': 'A 38-year-old man presents to the
genitourinary clinic with multiple, painless genital ulcers. A diagnosis of
granuloma inguinale is made. What is the causative organism?', 'options':
['Klebsiella granulomatis', 'Chlamydia', 'Herpes simplex virus', 'Treponema
pallidum', 'Haemophilus ducreyi'], 'answer': 'A', 'explanation': "Granuloma
inguinale - Klebsiella granulomatis STI: ulcers Genital herpes is most often caused
by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type
1). Primary attacks are often severe and associated with fever whilst subsequent
attacks are generally less severe and localised to one site. There is typically
multiple painful ulcers. Syphilis is a sexually transmitted infection caused by the
spirochaete Treponema pallidum. Infection is characterised by primary, secondary
and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The
incubation period= 9-90 days. Chancroid is a tropical disease caused by
Haemophilusducreyi. It causes painful genital ulcers associated with unilateral,
painful inguinal lymph node enlargement. The ulcers typically have a sharply
defined, ragged, undermined border. Lymphogranuloma venereum (LGV) is caused by
Chlamydia trachomatis. Typically infection comprises of three stages • stage 1:
small painless pustule which later forms an ulcer • stage 2: painful inguinal
lymphadenopathy • stage 3: proctocolitis LGV is treated using doxycycline. Other
causes of genital ulcers • Behcet's disease • carcinoma • granuloma inguinale:
Klebsiella granulomatis* *previously called Calymmatobacterium granulomatis" },
{ 'id': 'Q-210', 'question': 'Which of the following is least
recognised as a cause of a false positive VDRL test?', 'options': ['Pregnancy',
'SLE', 'Oral contraceptive pill', 'Tuberculosis', 'HIV'], 'answer': 'C',
'explanation': 'Syphilis: investigation Treponema pallidum is a very sensitive
organism and cannot be grown on artificial media. The diagnosis is therefore
usually based on clinical features, serology and microscopic examination of
infected tissue Serological tests can be divided into • cardiolipin tests (not
treponeme specific) • treponemal specific antibody tests Cardiolipin tests •
syphilis infection leads to the production of nonspecific antibodies that react to
cardiolipin • examples include VDRL (Venereal Disease Research Laboratory) & RPR
(rapid plasma reagin) • insensitive in late syphilis • becomes negative after
treatment Treponemal specific antibody tests • example: TPHA (Treponema pallidum
HaemAgglutination test) • remains positive after treatment Causes of false positive
cardiolipin tests • pregnancy • SLE, anti-phospholipid syndrome • TB • leprosy •
malaria • HIVTreponema pallidum, the bacteria that cause syphilis. Note the spiral
shape of the organism. Credit: NIAID' },
{ 'id': 'Q-260', 'question': "A 54-year-old man presents to a sexual
health clinic with positive serology for syphilis, which was found during routine
work up for an insurance medical. He travels a great deal for work and states he
has on occasion paid for sex with male sex workers in Thailand. He has never had a
syphilis test before and is very shocked as he feels well and is completely
asymptomatic. He is reluctant to have treatment for his syphilis as he feels very
well and asks you how he can have syphilis if he doesn't have symptoms. Which of
the following should you advise him?", 'options': ['Asymptomatic (latent) infection
implies late disease', 'Symptomatic syphilis requires repeated antibiotic
treatments; latent disease requires a one off treatment only', 'Spontaneous
clearance of Treponema pallidum does not occur', 'Only symptomatic patients need
treatment for syphilis', 'Almost all patients with syphilis will describe a chancre
as their first symptom'], 'answer': 'C', 'explanation': "Latent syphilis (i.e
asymptomatic syphilis) can occur at an early and a late stage and requires the same
antibiotic treatment Syphilis can be present without any symptoms at either an
early or a late stage; these are called 'early latent' (less than 2 years since
last negative syphilis test) and 'late latent' (more than 2 years since last
negative test). Whether the syphilis is latent or causing symptoms does not alter
the treatment; this is only affected by whether syphilis has not been tested for in
the last 2 years, in which case further doses arerequired, or if neurosyphilis is
suspected. Many patients with syphilis are unaware of having had a chancre and this
is sometimes picked up incidentally on clinical examination. There is no known
clearance of Treponema pallidum without antibiotic treatment Please see Q-171" },