Lipschutz's genital ulceration: a manifestation of Epstein-Barr virus primary infection

Lipschütz's acute vulvar ulcer: a systematic review

In previously healthy subjects, vulvar ulcers are mostly caused by sexually transmitted microorganisms. Lipschütz's acute vulvar ulceration, first reported in 1912, is a non-sexually acquired condition characterized by sudden onset of a few genital ulcers. We systematically review presentation, underlying causes, and disease duration of Lipschütz's ulceration. A comprehensive source of Excerpta Medica, National Library of Medicine, and Web of Science databases was performed. Reports including cases of apparently previously healthy females affected by Lipschütz's ulceration were selected. A predefined database was used to extract data on demographics, history, clinical and microbiological findings, and treatment.The search disclosed 158 cases. Almost 90% of cases were ≤ 20 years of age and sexually inactive. Lesions were usually one to about three, painful, ≥ 10 mm large, well-delimited, with a fibrinous and necrotic center and a symmetric distribution. Voiding disorders and enlarged inguinal lymph nodes were observed in a large subset of cases. Canker sores were noted in 10% of patients. Lipschütz's vulvar ulceration occurred concomitantly with an infectious disease in 139 cases. Infectious mononucleosis syndrome (N = 40) was the most frequently detected well-defined infection, followed by mycoplasma species infections (N = 11). The disease resolved after ≤ 3 weeks.Conclusions: Lipschütz's ulceration mainly affects both sexually inactive and, less frequently, sexually active subjects ≤ 20 years of age, presents with ≤ 3 vulvar ulcers, resolves without recurrences within 3 weeks and is temporarily associated with an infection, most frequently a flu-like illness or an infectious mononucleosis syndrome. What is Known: • Lipschütz's acute vulvar ulceration is a non-sexually acquired condition, which is characterized by a sudden onset of a few necrotic and painful genital ulcers. • The condition tends to resolve spontaneously and is usually triggered by an infection. What is New: • The condition mainly affects subjects ≤ 20 years of age, tends to resolve within 3 weeks, and is usually temporarily associated with a flu-like illness or an infectious mononucleosis syndrome. • Systemic corticosteroids do not reduce disease duration.

Lymphocytic Arteritis in Epstein-Barr Virus Vulvar Ulceration (Lipschütz Disease): A Report of 7 Cases

Epstein-Barr virus (EBV) infection can rarely present as painful genital ulcers, mostly in young female adolescents. Typically diagnosed by clinical findings, EBV vulvar ulceration (EBVVU) is rarely biopsied. Herein, the authors report the histopathology in 8 biopsies from 7 EBVVU patients, all serologically confirmed for acute (4/7) or reactivated-chronic (3/7) EBV infection. The 7 women all presented with 1 or more painful, punched-out vulvar ulcers. Only patients with acute EBV infection showed other clinical findings: fever and/or atypical lymphocytosis affected 75% (3/4); lymphadenopathy in 50%; and malaise/fatigue, dysuria and/or hepatomegaly in 25%. All reactivated-chronic EBVVU had a solitary ulcer, and 2 had history of a similar episode of vulvar ulceration (aphthosis). Histopathologically, lymphocytic arteritis was identified in 88% (7/8); a submucosal scar was found in the eighth specimen. Other histopathologies included venulitis (62%), endarteritis obliterans (38%), thrombosis (25%), neutrophilic sebaceous adenitis (25%), and mucosal lymphoid hyperplasia (12%). Dense angiocentric CD3 CD4 T-cell lymphocyte-predominant infiltrates were found, regionally or diffusely. In 2 specimens, neutrophils compromised half of the infiltrate. Minor components of CD8, CD20, and CD30 lymphocytes, CD123 plasmacytoid monocytes, CD68 macrophages, and plasma cells were present. Small-vessel endothelium and smooth muscle adjacent to the ulcers faintly expressed cytoplasmic EBV latent membrane protein-1 (LMP1). In situ hybridization for early EBV mRNA (EBER) identified rare solitary or scattered clustered positive lymphocytes in 38%. Polymerase chain reaction for EBV DNA was positive in one EBER positive biopsy. EBV infection has been documented in muscular vessel vasculitis. Based on the aforementioned, EBVVU appears to be the consequence of localized lymphocytic arteritis.

A New Diagnostic Way for Behcet's Disease: Skin Prick with Self-Saliva

Behcet's disease (BD) is a mysterious multisystemic disorder characterized by recurrent involvement of mucocutaneous (including recurrent aphthous stomatitis; RAS), ocular, intestinal, vascular, and/or nervous system organs. Previously, the positivity of "pathergy test", which is one of the diagnostic examinations, was reported to be related to the possession of HLA-B51 gene in BD patients, even though the positivity is low and different from the countries. Here, instead of the ordinal pathergy test, we would like to propose the prick with self-saliva as a new diagnostic way for patients with RAS of BD based on the genetic intrinsic factors including HLA-B51 and extrinsic triggering factors. BD patients are considered to acquire the hypersensitivity against oral streptococci through the innate immune mechanism in the oral cavity. Bes-1 gene and 65 kD of heat shock protein (HSP-65) derived from oral S. sanguinis are supposed to play important roles as extrinsic factors in BD pathogenesis. Although the prick positivity was not related to the possession of HLA-B51 gene, the method is suggested to be a significant way for BD diagnosis. The results also suggest that BD symptoms are due to the vascular immune responses by monocytes expressed oral streptococcal agents of the patients.

Chronic active Epstein-Barr virus infection-associated hydroa vacciniforme-like eruption and Behçet's-like orogenital ulcers

The cutaneous manifestations of chronic active Epstein-Barr virus (EBV) infection can be diverse. Among them, hydroa vacciniforme-like eruption is one of the best-known features. Although rare, mucosal ulcers have been reported to be associated with EBV as a result of primary infection or immune suppression. We describe a 65-year-old female with recurrent necrotic papulovesicles on the face and both arms for 2 years. She also complained of recurrent oral and genital mucosal ulcers developing simultaneously with skin eruptions. They appeared periodically during the spring and summer and were triggered or aggravated by sun exposure. Skin biopsies from the face and genitalia showed identical findings with dense lymphocytic infiltrations. In addition, in situ hybridization revealed EBV-positive lymphoid cells in both specimens. To our knowledge, this is the first case of serologically and pathologically proven chronic active EBV infection presenting hydroa vacciniforme-like eruption and orogenital ulcers at the same time in one patient.

[Vulvar inflammatory dermatoses]

Vulvar skin disease is a common reason for consultation. The vulva, like the rest of the skin, can be affected by numerous diseases of various etiologies, but its particular anatomic and physiologic characteristics create additional diagnostic and therapeutic difficulties. The study of vulvar disease is emerging as a new branch of dermatology. In this article, we examine the characteristics of the normal vulva, and perform a brief, structured review of vulvar inflammatory dermatoses, which comprise a heterogeneous group of diseases in which a broad, multidisciplinary approach is essential.

Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.

Three cases of Lipschutz vulval ulceration

A Lipschütz ulcer or 'ulcus vulvae acutum' is an acute simple ulceration of the vulva or vagina of non-venereal origin which can be associated with lymphadenopathy. Three cases are described with accompanying clinical photographs. Two cases refer to adolescents, one an infant, all without any history of sexual contact. The cases serve to illustrate a little known but potentially important differential diagnosis of vulval ulceration.

Genitourinary manifestations of epstein-barr virus infections

Epstein-Barr virus (EBV) is best known as the organism responsible for the syndrome of acute infectious mononucleosis. Transmission of EBV most commonly occurs through oral secretions. EBV has also been isolated from the female genital tract, where its role is poorly understood. This article reviews the available literature and data regarding EBV in the female genital tract and discusses areas of consensus and controversy. The primary manifestation of EBV seems to be vulvar ulcers, which are underrecognized. Diagnosis relies on appropriate serologic testing. Management includes local care and may require pain and corticosteroid medications. Although EBV is present elsewhere in the female genital tract, its pathogenic role in the cervix, uterus, fallopian tubes, and ovaries is poorly understood.

Reactive nonsexually related acute genital ulcers: review of cases evaluated at Mayo Clinic

BACKGROUND

Reactive nonsexually related acute genital ulcers (RNSRAGU) occur in pubertal girls after an acute systemic infection.

OBJECTIVE

We sought to characterize RNSRAGU by reviewing the medical records of patients with this disorder.

METHODS

We searched our medical index database from 1997 to 2007 for RNSRAGU cases. Questionnaires were mailed to identified patients.

RESULTS

The study included 10 patients; 5 responded to the questionnaire. The mean age at onset was 11.5 years. Vulvar ulcers were preceded by viral gastroenteritis (n = 3), viral upper respiratory tract infection (n = 3), streptococcal pharyngitis (n = 1), influenza (n = 1), and other nonspecific febrile illnesses (n = 2). Seven patients had oral involvement also; 6 had at least one recurrence; and 3 were hospitalized for pain control. Analgesics and topical corticosteroids were the most common treatments. Ulcerations resolved within several weeks in all patients.

LIMITATIONS

Retrospective study design, small study size, and 50% questionnaire response rate are limitations.

CONCLUSIONS

Although rare, RNSRAGU should be considered when genital ulceration follows an acute systemic illness.

Lipschütz acute vulval ulcers associated with primary cytomegalovirus infection

A previously healthy 16-year-old girl presented with painful acute genital ulcers that appeared in the context of a primary cytomegalovirus infection. Complementary examinations ruled out both venereal disease and other usual causes of genital ulcerations, and the lesions resolved in < 2 weeks with no sequelae or later recurrences. Cytomegalovirus disease should be considered in the screening of acute vulval ulcers.

Epstein-Barr virus-associated genital ulcers: an under-recognized disorder

Infectious mononucleosis is the best-known syndrome associated with primary Epstein-Barr virus infection. Although a variety of cutaneous and mucosal manifestations are recognized in infectious mononucleosis, genital ulcers have only rarely been described. We describe an otherwise healthy 14-year-old girl in whom painful genital ulcers developed during an episode of serologically-confirmed primary Epstein-Barr virus infection. Clinical, serologic, and histopathologic evaluation failed to disclose evidence of any other etiologic explanation for her lesions. The patient remains well, without recurrence. To date, only 13 instances of genital ulceration in females attributable to Epstein-Barr virus infection have been reported.

Genital ulcers caused by Epstein-Barr virus

In North America, the most common cause of vulvar ulcers is infection with herpes simplex virus. However, Epstein-Barr virus can also cause vulvar ulcers, and may be underrecognized. Unlike herpes simplex virus, Epstein-Barr virus is not necessarily sexually transmitted. Therefore, it is particularly important to include in the differential diagnosis of genital ulcers for patients for whom a diagnosis of a venereal infection has important psychosocial consequences. We report three cases of acute primary Epstein-Barr virus infection in which the presenting symptoms were vulvar ulceration.

Genital ulceration as a presenting manifestation of infectious mononucleosis

This article describes a case of infectious mononucleosis (IM) in a 16-year-old female adolescent who presented with fever, sore throat, cervical lymphadenopathy and genital ulcerations. Initially, this patient was thought to have herpes simplex viral infection secondary to the characteristic multiple genital ulcers. Seven cases (including this case) have reported an association between Epstein-Barr virus (EBV) infection and genital ulcerations. IM as a cause of genital ulcerations should be included in the differential diagnosis.