|Year : 2007 | Volume
| Issue : 2 | Page : 106-107
Ramesh M Bhat, Shireen Furtado
Department of Dermatology, Fr. Muller Hospital, Kankanady, Mangalore, India
Ramesh M Bhat
Department of Dermatology, Fr. Muller Hospital, Kankanady, Mangalore - 575 002
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Lipschütz first identified an acute disease with ulceration of the external genital organs of young women. The syndrome has been termed acute vulvar ulcer or ulcus vulvae acutum. The following typical case history of a 19-year-old girl is a good illustration of this interesting clinical entity.
Keywords: Acute vulvar ulcer, Lipschütz ulcer, ulcus vulvae acutum
|How to cite this article:|
Bhat RM, Furtado S. Lipschutz ulcer. Indian J Sex Transm Dis 2007;28:106-7
| Introduction|| |
In 1913, Lipschütz, an Austrian dermatologist, identified an acute disease comprising fever, ulceration of the external genitalia and lymphadenopathy, occurring in young women.  This acute non-venereal vulvar ulcer is now also known as 'ulcus vulvae acutum'.  It has been described as occurring predominantly in young girls of 14-20 years, 70% of the cases being virgins. In most cases, the ulcer is located on the inner aspect of labia minora, labia majora, introitus, external urethral orifice or posterior commissure. , The appearance of these ulcers is alarming, and not surprisingly these patients are commonly over investigated.
| Case Report|| |
A 19-year-old unmarried female presented to us with high-grade fever of sudden onset and painful ulcers on the genitalia. Genital lesions initially started as painful swelling progressing to form very painful 'wounds' impeding walking and urination. The patient gave no history of trauma or sexual contact. This was the first episode, and she did not complain of oral ulcers.
On examination, the patient was febrile. Vulva was slightly swollen and erythematous. A total of three ulcers were seen [Figure - 1]. Two ulcers, each of about 10 mm in diameter, were seen on the right and left labium majus. One ulcer, around 20 mm, involved the labia minora and extended up to the introitus. The ulcers were extremely tender to touch and had sharp edges and yellow base with minimum slough. The hymen was intact. Inguinal lymph nodes were bilaterally palpable, non-tender and firm in consistency. Oral mucosa was normal; no ulcers were seen [Figure - 2].
Routine investigations were done. Complete blood counts revealed neutrophilic leukocytosis and elevated ESR (50 mm/h). Pus cells were present in urine, and urine culture sensitivity showed the organism to be Escherichia More Details coli . Pathogens isolated from the genital ulcers were yeast-like budding cells, microscopically. On culture, candidial growth was seen. Pathergy test was done and found to be negative. Mantoux test was positive. However, AFB in sputum was negative and chest X-ray was normal. Serological investigations for HIV, VDRL, HBsAg, RA factor and ANA were negative. Skin biopsy revealed mixed inflammatory infiltrate.
The patient was treated with Azithromycin (500 mg od) for 3 days and Metronidazole (400 mg tid) for 5 days. She was then started on Dapsone (100 mg od). Inj. Betamethasone (8 mg) was given intramuscularly for 3 days. External treatment (sitz bath) with potassium permanganate, povidone iodine dressings and povidone iodine ointment was advised. Pain disappeared after a week, dysuria remaining the most persisting complaint. By the second day of treatment, the ulcers began to colliquate.
| Discussion|| |
The clinical entity of hyperacute genital ulceration generally occurs in young women, predominantly virgins.  Lipschütz assumed that the disease is caused by autoinoculation with Bacillus crassuss (Doderlein's lactobacillus), while other physicians of his generation ascribed the disease to poor hygiene of young women. , In some cases, Epstein-Barr virus and Ureaplasma were identified. Recently, genital ulceration very similar to acute vulvar ulcer has been observed in HIV-positive women. These ulcers healed after Zidovudine therapy. ,, It usually affects labia minora and introitus. Sometimes, it may be visible in labia majora, where it would heal leaving minor scars. 
The cause and pathogenesis of the disease still remains unknown, and few hypotheses are discussed in literature.  Histopathology is of no diagnostic value. 
Based on clinical course and morphologic findings, three main forms of the course of the disease can be identified: (1) gangrenous form, (2) chronic form (pseudo-veneric Lipschütz ulcer, Scherber's pseudo-tuberculotic form) and (3) miliary form.
The disease should be differentiated from venereal (syphilis, ulcus molle) and non-venereal infections (herpes simplex, herpes zoster, miliary ulcerative tuberculosis). Of the non-infectious diseases, Behηet's syndrome, various aphthous ulcers, ano-vaginal fistula, Reiters and myeloproliferative diseases should be primarily considered. 
Lipschütz ulcer, despite its characteristic symptoms, is very rare and often misdiagnosed.
| References|| |
|1.||Lipschutz B. Through a strange Geschwürsform of the female genitalia (ulcer Vulvae Acutum). Arch Dermatol Syphilis (Berlin) 1913;114:363-95. |
|2.||Zeitsch.f. Geburtsh. U. Gynak. Womans Clin 1947;128:307-26. |
|3.||Berlin C. The pathogenesis of the so-called ulcus vulvae acutum. Acta Derm Venereol 1965;45:221-2. [PUBMED] |
|4.||Gottron HA, Sch φnfeld W. Dermatologie und Venerologie. Georg Thieme: Verlag - Stuttgart; 1965. |
|5.||Brown ZA, Stenchever MA. Genital ulceration and infectious mononucleosis. Am J Obstet Gynecol 1977;127:673-4. [PUBMED] |
|6.||Portinoy J, Aronheim GA, Chibu F, Clecner B, Joncas JH. Recovery of Epstein-Barr virus from genital ulcers. N Engl J Med 1984;311:966-8. |
|7.||Covino JM, McCormack WM. Vulvar ulcer of unknown etiology in a human immunodeficiency virus-infected woman, response to treatment with zidovudine. Am J Obstet Gynecol 1990;163:115-8. |
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|9.||Josey WE. Anovaginal fistula presenting as a vulvar ulcer: A report of two cases in postmenopausal women. J Reprod Med 1988;33:857-8. [PUBMED] |
[Figure - 1], [Figure - 2]
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