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Simple cases
Case 25
32-year-old patient from New Guinea presents with an interpreter because of a sore in the right groin.
History
Are you having pain?
No.
No. The lack of pain in a lesion which looks as if it should hurt helps with the diagnosis.
How long has this lesion been present?
For 3-4 months.
The time course of a disease often gives clues to the etiology.
How did this start?
At first there was a swelling in my groin. Then it started draining, and now the whole thing has gotten larger.
The clinical evolution of a lesion often gives clues to the etiology.
Have you seen a doctor for this?
No.
Information about previous tests and treatments might help.
Have you have fever, night sweats or weight loss?
No.
Some patients with chronic infections develop systemic findings.
Did you have an injury at this spot before the swelling started?
No.
Many infections have a protal of entry, so it is smart to ask.
Have you had any other problems?
I broke my arm ten years ago.
One must take a history but it doesn't always help.
Lesion
Choose the right efflorescences:
An erosion is a superficial non-scarring defect.
There is a bizarre ulcer with fibrinous debris and islands of re-epithelization.
No vesicle or blister is seen.
A fissure is a long thin defect, not seen here.
Diagnosis
Choose the right diagnosis:
Uncommon sexually transmitted disease, usually seen in tropical lands, but occasionally epidemics in focal areas in Western lands. Caused by Calymmatobacterium granulomatis.
Herpes simplex can cause big ulcers, especially in HIV-infected patients, but otherwise the lesions are more superficial.
Burns usually spare the body folds, and there is no history.
Hidradenitis suppurativa involves the groin and axillae. Individual lesions look like boils and heal with fistulas and scarring.
Artifact is a diagnosis of exclusion, but this lesion really does not appear self-induced. Often such lesions are a bit too linear or rectangular, if made with an instrument, or look splattered if made with a caustic.
Therapy
Choose the right therapy(ies):
This the is recommended regimen for granuloma inguinale, which responds well. Healing with scarring is anticipated.
Surgical treatment is not indicated. The antiobiotic regimen is that for neurosyphilis and is not indicated here.
This is another possible approach.
There is no good topical therapy for granuloma inguinale. In addition, the peroxide would be so painful that the patient would not complete the treatment.
