Clinical Pearls. Painful Inguinal Swelling. Chief Complaint: Painful inguinal swelling

Transcription

1 Painful Inguinal Swelling, Norton 305 Clinical Pearls Painful Inguinal Swelling Valerie C. Norton, MD Chief Complaint: Painful inguinal swelling History of Present Illness: A 24-year-old man presents to the ED with 4 days of painful inguinal swelling. He denies noticing any other genital lesions or ulcers and denies penile discharge, fever, and dysuria. He admits to engaging in unprotected sex with several female partners. He was treated 3 months prior for urethritis, receiving antibiotics to treat both Neisseria gonorrhoeae (GC) and Chlamydia frachornatis (chlamydia) infections. He had a negative HIV test at that time. He is otherwise healthy. Physical Examination: The patient is in no distress and has normal vital signs. Physical examination is normal with the exception of the genitalia and the left inguinal adenopathy, as seen in Figure 1. There are multiple, enlarged left inguinal lymph nodes, which are matted, tender, and centrally fluctuant. There are a few small, nonulcerative, excoriated papules on the scrotum, pubis, and right inner thigh. The examination reveals no ulcer, chancre, vesicle, wart, discharge, or other genital lesion. Laboratory: Urinalysis is negative. Penile cultures are taken for GC and chlamydia. Blood is sent for rapid plasma reagin (RPR) and lymphogranuloma venereum (LGV) titers. I (The laborarory results appear on page 322.) I FIGURE 1. The patient's genitalia on arrival to the ED. From Vanderbilr University hfedical Center; Naslwille, TN, Deparrinerzr of Emergency Medicine (VCN). Phorographic critique: Michael A. Morris, L'nii.ersiy of Arhnsas for Medical Sciences, Lirtle Rock. AR. Secrion ediror: Lawrence B. Stack, MD. Deparrmenr of Emergenci' -. Medicine, Vanderbilt Universiiy Medical Centel; Nashville, TN. Received: June 16, 1996; revision received: August 14, 1996: accepred: August : updared: Sepreinber Address for correspondence and reprirtrs: Valerie C. Norton, MD, Deparrrnerir of Emergency Medicine, Vanderbilr University Medical Center; rford House, Nashville, TN Fax: ; valerie. mcrnail. vanderbilt. edu

2 322 ACADEMIC EMERGENCY MEDICINE APR 1997 VOL 4/NO 3 budget. That level of funding has been sustained in subsequent budget years. Basically, it allows local groups to define their traffic safety problems with their community data, build their coalitions, implement local countermeasures, and assess the benefits to their community through evaluation. We ve got a large constituency who have been involved in traffic safety for many years. They re discovering that EPs are one of the most enjoyable, dedicated, committed, and knowledgeable groups that they ve seen. So the Safe Communities program is a real opportunity to teach your residents how to provide populationbased care. If you re trying to learn how to do population-based care, this is a tool and a way for residents to get experiential learning. In closing, it has been a wonderful experience having the opportunity to do public service. My success is your success. You are the keepers of the House of Medicine as we move into a changing age. You know I became a little bit upset with some in the House of Medicine during preparations for the National Highway System bill. That bill addressed speed limits, motorcycle helmets, and seat belts. When I called several famousname clinics to get their support, their answer was that traffic safety was not their issue. Well, it is your issue! Either you are the shepherd of the flock, or this is the silence of the lambs. As you hand the tools of medicine to the next generation, you should consider using motor vehicle safety or similar injury prevention issues as a way to advance the specialty in the era of population-based medicine. I d like to thank you for all you ve done for me and for giving me the opportunity to share with you my recent life experiences. A special thanks to 2 of the author s staff members, Liz Neblett and Joan Harris, who helped prepare slides and other materials used in this presentation. REFERENCE 1. National Highway Traffic Safety Administration. Report to Congress, Benefits of Safety Belts and Motorcycle Helmets. Report #DOT HS , Washington DC, Feb Key words: highway safety; federal administration; NHTSA; injury prevention; automobile; crash; collision; motor vehicle. Clinical Pearls (cont. from page 305) Results: Culture results were negative for GC and chlamydia. The LGV titer was positive at 1:8, and the RPR was also positive. It was unknown whether the positive RPR represented a new case, or whether the patient had been previously treated for syphilis. The patient was empirically treated for LGV and chancroid at the time of the ED visit, with a single shot of ceftriaxone (250 mg IM) and a 3-week course of doxycycline (100 mg PO bid). He was referred back to his public health clinic to assess the positive RPR. (The correcf diagnosis and discussion apear on page 326.)

3 326 ACADEMIC EMERGENCY MEDICINE APR 1997 VOL 4/NO 4 any other drug to facilitate date or acquaintance rape may be abated. REFERENCES 1. Bureau of the Census, United States Department of Commerce. Projections : Current Population Report. Washington. DC: US Government Printing Office, Publication P Schwartz IL. Sexual violence against women: Prevalence, consequences, societal factors, and prevention. Am J Prev Med. 1991; National Victim Center and Crime Victims Research and Treatment Center. Rape in America: A Report to the Nation. Arlington. VA: National Victim Center, Federal Bureau of Investigation. Crime in the United States- 1995: Uniform Crime Reports. Washington, DC: Federal Bureau of Investigation, United States Department of Justice, Calhoun SR, Wesson DR, Galloway GP, Smith DE. Abuse of flunitrazepam (Rohypnol) and other benzodiazepines in Austin and South Texas. J Psychoactive Drugs. 1996; 28:l Doheny K. What the date rape drugs do. Los Angeles Times. Vol 115 (Oct 8, 1996):El. 7. Bullock C. Rophie used as date rape drug. Emergency Med News 1996; 18: Mattila MAK, Larni HM. Flunitrazepam: a review of its pharmacological propenies and therapeutic use. Drugs. 1980; 20: Girl s death linked to date rape drug. Los Angeles Times. Vol 1 15 (Sept 11, 1996): A Korttila K, Saarnivaara L. Tarkkanen J, Himberg JJ, Hytonen M. Comparison of diazepam and flunitrazepam for sedation during local anaesthesia for bronchoscopy. Br J Anaesth. 1978; 50: George KA, Dundee JW. Relative amnestic actions of diazepam, flunitrazepam and lorazepam in man. Br J Pharmacol. 1977; 4: Linnoila M. Erwin CW. Brendle A, Logue P. Effects of alcohol and flunitrazepam on mood and performance in healthy young men. J Clin Pharmacol. 1981; 21: Rall TW. Hypnotics and sedatives; ethanol. In: Goodman Gilrnan A, Rall TW, Nies AS, Taylor P (eds). Goodman and Gilman s The Pharmacological Basis of Therapeutics 8th ed. New York: McGraw-Hill, 1993, pp Ledray LE. Date rape drug alert. J Emerg Nurs. 1996; 22: Drummer OH, Syrjanen ML. Cordner SM. Deaths involving the benzodiazepine flunitra- zepam. Am J Forens Med. Pathology. 1993; 14~ Dwyer BJ. Rape: psychological, medical, and forensic aspects of emergency management. Emerg Med Rep. 1995; 16: Physicians Desk Reference 51st ed. Montvale, NJ: Medical Economics Company, 1996; pp Greenberg MI. Rohypnol (AKA Rophies ) draws national attention as date rape drug. Emerg Med News. 1997; 19:18-9, Hoffmann-La Roche. Inc. Hoffmann-La Roche Offers Law Enforcement Testing Capability in Fight against Rohypnol Misuse. Nutley, NJ: Hoffinann-LaRoche Inc., Jun Hoffmann-La Roche, Inc. Flunitrazepam (Rohypnol) Testing: Basic Facts. Nutley, NJ: Hoffmann-LaRorhe, Inc., Hoffmann-La Roche, Inc. Hoffmann-La Roche Takes Action to Stop Rohypnol Diversion and Misuse. Nutley, NJ: Hoffmann- LaRoche, Inc., Sept Drug-induced Rape Prevention and Punishment Act of Washington, DC: US House of Representatives No. 4137; Controlled Substances: Flunitrazepam. Sacramento: California Senate Bill No. 2164, Hayden; Clinical Pearls (cont. from page 322) Diagnosis: 1 ) Lymphogranuloma venereum; 2) late primary, latent, or previously treated syphilis. Discussion: Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by a strain of Chlamydia trachomatis. After a 3-day to 3-week incubation period, LGV initially manifests itself with the transient appearance of a small, painless vesicle, ulcer, or papule. The initial lesion may look like a syphilitic chancre, or a solitary herpes ve~icle.~ The lesion may appear anywhere on the genitals and frequently goes unnoticed. In most studies, only 5% to 25% of patients with LGV can recall having a genital sore prior to the onset of inguinal aden~pathy.~ The patient usually does not seek medical care until painful swelling of the inguinal lymph nodes occurs 2 to 6 weeks later. The lymphadenopathy is usually unilateral, with a matted, fluctuant appearance, and frequently goes on to become suppurative. A crease along the inguinal ligament may be seen when there are swollen nodes above and below it, giving rise to the term groove sign, which is characteristic of LGV.i.2 The groove sign occurs in ~33% of patients and was not present in this patient. The groups of swollen nodes are termed buboes and may be confused with syphilitic buboes or the adenopathy asso- ciated with chancroid or genital herpes. It is not uncommon for the nodes to form spontaneous cutaneous fistulas with chronic purulent drainage. Recipients of anal intercourse may develop a hemorrhagic proctitis due to LGV. The patient also often has a fever and high white blood cell count in the acute phase, and may rarely show signs of meningoencephalitis. Complications include genital strictures, chronic fistulae, and elephantiasis due to blockage of lymphatic drainage of the ipsilateral leg. -3 Lymphogranulorna venereum is rare in the United States, with most cases arising in the South. It is endemic in the Third World, and should be kept in mind when seeing patients with genital ulcers or lymphadenopathy who have traveled to developing countries. The key to the diagnosis is keeping it in mind when seeing patients with inguinal adenopathy, particularly when fluctuant or suppurative. Serum LGV titers are widely available and can aid in making the definitive diagnosis. Serum complement fixation is most commonly done, though some laboratories also have a microimmu- nofluorescence test a~ailable.~ Depending on the laboratory, titers ranging from 1:8 to 1:64 or higher are consid-

4 Painful Inguinal Swelling, Norton 327 I TABLE 1 Characteristics of Sexually Transmitted Diseases Causing Inguinal Lymphadenopathy , ,...,.,._...,,.... Disease Skin Lesion Lymph Nodes Diagnostic Tests Treatment * Lymphogranuloma Small, painless, often un- Fluctuant, may rupture, Serum LGV titer Doxycycline 100 mg PO venereum (LGV) noticed usually unilateral bid X 3 weeks Chancroid Painful, deep ulcer, larger Fluctuant, may rupture, Culture, DNA probe rarely Ceftriaxone 250 mg IM or than in LGV usually unilateral available azithromycin 1 g PO Syphilis Painless chancre, larger Indurated, nonfluctuant, RPR,? VDRL, FTAt dark- Depends on stage; benzathan in LGV usually bilateral field microscopy thine penicillin 2.4 MU IM if <1 year Herpes simplex vi- Crops of painful vesicles/ Indurated, nonfluctuant, Viral culture, Tzanck Acyclovir 500 mg PO tid rus type 2 ulcers usually bilateral smear X 10 days for primary infection *See text for details of alternative therapies. TRPR = rapid plasma reagin; FTA = fluorescent treponenial antibody. ered positive. Standard chlamydia DNA probes also may be obtained from the cervix, urethra, or rectum, and if positive may provide supporting evidence for the presence of a sexually transmitted disease (STD). However, there is no commercially available culture or DNA probe for the LGV strain of chlamydia, and it is unknown how many patients with LGV also will have positive results with a standard chlamydia probe.' Differential Diagnosis: Syphilis is the primary concern in the differential diagnosis of a painless genital ulcer associated with lymphadenopathy. Syphilis is increasing in frequency in the United States, especially in the HIV-positive population and those with other STDs. In the United States, about 10-20% of genital ulcers are attributable to syphilis.'-4 (Table 1 provides a description of the characteristics of STDs causing painful lymphadenopathy.) Like LGV, primary syphilis begins with a painless genital chancre, though much more prominent and noticeable than the initial lesion of LGV. Also like LGV, syphilis can be associated with indurated, swollen inguinal lymph nodes that can persist for months. Unlike the fluctuant nodes found in LGV, however, the nodes seen in syphilis are usually nonfluctuant and do not become matted together,' and are bilateral in 70% of cases.4 LGV titers and serologic testing for syphilis enable differentiation in most cases. In the few cases where the diagnosis is in doubt, the patient should receive treatment for both diseases. Of note, the course of PO doxycycline typically given for LGV is an acceptable alternative treatment for syphilis of <I year's duration.' Chancroid is another STD that can cause genital ulcers and painful lymphadenopathy, and is also being seen with increased frequency in this country, according to some report^.^.'.^ It causes about 5% of genital ulcers in America and is somewhat more common than LGV, though still rare. Unlike the trivial ulcer of LGV, chancroid ulcers are usually larger, often multiple, and quite painful, with purulent bases and undermining of the edges. However, the lymphadenopathy of chancroid is quite similar to that of LGV, as the nodes are unilateral, fluctuant, and very tender, and often rupture spontaneously.'-4 Chancroid is caused by Hemophilus ducreyi, which may be cultured; however, the culture is not available at most institutions and the diagnosis is often made empirically.' -3.5 Multiple treatment options are available, including single-dose therapy with 250 mg of ceftriaxone IM or 1 g of azithromycin PO.^ The most common cause of genital ulcers is herpes simplex virus type 2 (HSV-2). This entity is unlikely to be confused with LGV due to the multiplicity of ulcers, the painful nature and characteristic vesicular appearance of the ulcers, and the recurrent nature of the attacks suffered by most patients with HSV-2. HSV-2 can, however, cause enlarged, painful, indurated lymph nodes, which may be confused with LGV if typical herpetic ulcers are not present at the time of examination. Unlike the unilateral, fluctuant nodes of LGV, the lymph nodes seen with HSV-2 are indurated and more often bilateral.'.'.4 HSV-2 is a much more common STD than LGV and is thought to account for SO-70% of the genital ulcers seen in the United States. Granuloma inguinale, or donovanosis, is often discussed along with the diseases mentioned above, but is in fact a very different entity. It is caused by Calymmatobacterium granulomatis and is very rare in the United States. It manifests as a painless, granulomatous ulceration and erosion of the genital area, which can progress to become extremely large and disfiguring. It does not cause lymphadenopathy except in the presence of superinfection, though occasionally a deep, subcutaneous extension of the granuloma may be mistaken for a bubo.' Granuloma inguinale is also treated with several weeks of doxycycline. Other nonsexually transmitted entities also should be considered when evaluating a patient with regional lymphadenopathy. Streptococcal or staphylococcal skin infections of the lower extremities may cause a reactive inguinal lymphadenitis; a good examination of the lower extremities is important to look for evidence of cellulitis

5 328 ACADEMIC EMERGENCY MEDICINE APR 1997 VOL 4/NO 4 or skin lesions that may serve as portals of entry. Cat scratch disease can cause extensive, fluctuant inguinal lymphadenopathy that may be similar to that seen in LGV. Hidradenitis suppurativa also can occur in the inguinal region and may result in spontaneously draining nodes that may look like LGV. Lymphoma and primary tuberculosis also can cause inguinal lymphadenopathy, though usually of a nonfluctuant nature.. Management: LGV is usually amenable to standard treatment regimens for Chlamydia trachomatis, with the exception that treatment must be continued for at least 3 weeks. Most experts recommend doxycycline 100 mg PO bid for 3 weeks.6 Pregnant patients may be treated with erythromycin 500 mg PO qid for 3 weeks. Another alternative is sulfisoxazole 500 mg PO qid for 3 weeks. Patients with rectal LGV may require more prolonged courses of treatment. Compliance with a 3-week course of therapy is often a problem in this patient population, making careful follow-up mandatory. Performing incision and drainage of the buboes is contraindicated because it does not shorten the course of the disease and may in fact promote the development of chronic cutaneous fist~las.~.~,~ Needle aspiration is controversial; some authors believe it is also contraindicated for the same reason, while others believe it does no harm and may provide material for culture or prevent spontaneous rupture Since serum titers are widely available, it seems reasonable to avoid aspirating buboes unless they are tensely swollen and uncomfortable to the patient, because these will often spontaneously rupture in any case. Clinical Pearls: 1. Swollen, tender; inguinal adenopathy in a sexually active patient should bring to mind the diagnoses of LGC: chancroid, syphilis, and HSV-2. LGV and chancroid lymph nodes are more Jiuctuant and suppurative than those of syphilis and HSV-2, but this distinction may not be apparent early on. 2. Chancroid, syphilis, and HSV-2 are almost always preceded by typical genital ulcers, but the tiny ulcer of LGV often goes unnoticed. 3. Sexually active patients with tender inguinal adenopathy should undergo serum testing for LGC: syphilis, and HIK Other STD testing should be done as indicated. Many institutions do not have a test available for chancroid. 4. Since test results will not be available at the time of the visit, the most logical approach to treatment is to initiate empiric therapy for LGV syphilis, and chancroid simultaneously. A single dose of ceftriaxone, 250 n7g IM, will treat chancroid and incubating syphilis, and a 3-week course of doxycycline, 100 mg PO bid, Miill treat not only LGG: but also primary, latent, and early secondary syphilis. 5. Performing incision and drainage of the nodes is contraindicated. Photograph Critique (by Michael A. Moms): Successful clinical photographs share several common characteristics: 1) standardized patient positioning and posing; 2) careful image cropping that highlights the pathology and gives the viewer enough landmarks to pinpoint the body location; 3) good control of the background (no shadows, elimination of distracting elements such as instruments, clothing, blood, etc.) so that the patient s pathologic condition is the dominant element in the image; 4) use of a lighting technique that illuminates the subject and demonstrates the condition; 5) careful selection of the plane of focus and sufficient depth of field to clearly demonstrate the pathology. Figure 1 (p. 305) has all of these characteristics and is an excellent clinical photograph. Patient positioning and posing represent a standard AP view. The image is cropped so that the area of interest is centered and ample identifying landmarks are included in the image. The background is minimal and clean. Lighting technique is good; note the highlight (glare) in the center right of the image-which does a superb job of illustrating the inguinal swelling. Focus plane and depth of field are sufficient to keep the entire area of interest in acceptable focus. I REFERENCES 1. Goens JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum, and granuloma inguinale. Am Family Physician. 1994; 49: Martin DH, Mroczkowski TF. Dermatologic manifestations of sexually transmitted diseases other than HIV. Infect Dis Clin North Am. 1994; 8: Elgart ML. Sexually transmitted diseases of the vulva. Dermatol Clin. 1992; 10: Hawkes CA, McAllister K. Cutaneous lesions of the male genitalia. In: Harwood-Nuss A (ed). The Clinical Practice of Emergency Medicine. Philadelphia: J. B. Lippincott, 1991, pp Joseph AK, Rosen T. Laboratory techniques used in the diagnosis of chancroid, granuloma inguinale, and lymphogranuloma venereum. Dermatol Clin. 1994; 12:l Sanford JP, Gilbert DN, Sande MA. Guide to Antimicrobial Therapy (ed. 26). Dallas: Antimicrobial Therapy, 1996, pp 16, 30, Stapczynski JS. Cellulitis. In: Callaham ML (ed). Current Practice of Emergency Medicine, ed. 2. Philadelphia: B. C. Decker, 1991, pp Highet AS, Hay FU, Roberts SOB. Bacterial Infections. In: Champion RH, Burton JL, Ebling FJG (eds). Textbook of Dermatology, ed. 5. London: Blackwell Scientific Publications, 1992, pp ,..,.,..,..., Key words: medical photography; groin node; lymphogranuloma venereum; inguinal adenopathy.