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Picture of the Month—Quiz Case FREE

Cynthia Marie Carver DeKlotz, MD; Ilona J. Frieden, MD
[+] Author Affiliations

Author Affiliations:Washington Hospital Center/Georgetown University School of Medicine, Washington, DC (Dr DeKlotz); and Department of Dermatology, School of Medicine, University of California, San Francisco (Dr Frieden).

Section Editor: Samir S. Shah, MD
Section Editor: Albert C. Yan, MD

Arch Pediatr Adolesc Med. 2008;162(1):86. doi:10.1001/archpediatrics.2008.6-88.
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A 12-year-old girl was referred for evaluation of vulvar ulcers. Ten days prior to her visit, she developed a fever lasting for 3 days. On the third day of her fever, she developed dysuria and was seen by her pediatrician, who treated her for a presumed urinary tract infection. Within a few days, however, she developed severe vulvar pain and was seen at a local emergency department where viral cultures of an ulcer for herpes simplex and urine cultures were obtained. Results of both were negative, and she was treated empirically with valacyclovir hydrochloride, prednisone, and trimethoprim/sulfamethoxazole.

One week after the onset of symptoms, her pain was beginning to improve, but she continued to experience mild dysuria. She denied any sexual activity, history of vulvar trauma, gastrointestinal complaints, or other constitutional symptoms.

Examination of her external genitalia was notable for vulvar ulcerations with a fibrinous exudative discharge but no erythema. Specifically, she had a large, tender, deep, irregularly shaped ulceration on the right posterior inner labia minora with a superimposed pseudomembrane and smaller, shallow ulcers present on the left labia minora (Figure 1). The remainder of her physical examination was unremarkable; she was healthy appearing and had no hepatosplenomegaly, lymphadenopathy, or oral mucous membrane lesions.

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Figure 1.

Close-up photograph demonstrates bilateral vulvar ulcerations.

Graphic Jump Location


Place holder to copy figure label and caption
Figure 1.

Close-up photograph demonstrates bilateral vulvar ulcerations.

Graphic Jump Location




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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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