Case and Research Letters
Comment on: Nonsexually Transmitted Acute Ulcer of the Vulva Associated With Influenza A Virus Infection
Úlcera vulvar aguda de transmisión no sexual asociada a infección por virus influenza A
I. López-Lerma
, M. Serra-Torres, V. García-Patos Briones
Corresponding author
Department of Dermatology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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López-Lerma, M. Serra-Torres, V. García-Patos Briones" "autores" => array:3 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "López-Lerma" "email" => array:1 [ 0 => "Ilopez@aedv.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Serra-Torres" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "García-Patos Briones" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Department of Dermatology, Hospital Universitari Vall d’Hebron, Barcelona, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Úlcera vulvar aguda de transmisión no sexual asociada a infección por virus influenza A" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter published by Esteve-Martínez et al<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on nonsexually transmitted acute ulcer of the vulva, or ulcus vulvae acutum, associated with influenza A virus infection, and would like to congratulate the authors on their concise and thorough review of this condition.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree with their conclusion that it is important to be familiar with this type of vulvar ulcer and its association with influenza A virus infection,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> and would like to draw readers’ attention to fact that this ulcer can also occur in elderly patients, regardless of whether or not they report having had sexual relationships. One interesting case we saw recently was that of a 20-year-old woman with necrotizing genital ulcers that had required debridement in the gynecology department at our hospital.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient, with no relevant past history, reported that she had experienced fever and generalized joint pain 11 days before being seen in the dermatology department. She had been prescribed treatment with antipyretic medication and a single dose of oral levofloxacin by her primary care physician. Four hours after ingestion, the patient noted vulvar discomfort and an inflamed area. In the next 24<span class="elsevierStyleHsp" style=""></span>hours, she also developed pharyngeal discomfort and a worsening general state of health, leading her to visit the emergency department, where a polymerase chain reaction (PCR) assay confirmed influenza A subtype H1N1 infection. The patient was admitted and treated with oseltamivir. During her stay in hospital, several deep, bilateral genital ulcers with necrotic-looking borders were noticed. Several swab specimens were obtained for standard culture, <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> culture, and PCR testing for <span class="elsevierStyleItalic">Chlamydia trachomatis</span>, herpes simplex virus types 1 and 2, and samples were taken for serology. Empirical treatment was initiated with ceftriaxone (single dose), oral acyclovir, and amoxicillin-clavulanic acid. The ulcers, however, continued to deteriorate and it was decided to debride the area. In view of the worsening condition of the patient, and the negative results for the viral cultures, the PCR tests, and serology for syphilis and human immunodeficiency virus (HIV), her physicians decided to request dermatologic evaluation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">At the time of this evaluation, there was marked vulvar edema and the posterior region of the right labia minora had been resected, leaving an ulcerated area with a clean base. On the left side of the vulva, there was a 1.5-cm exudative ulcer with a fibrinous base. The lesions were painful and accompanied by bilateral enlarged inguinal lymph nodes of less than 1<span class="elsevierStyleHsp" style=""></span>cm. Topical treatment with absorbent dressings and fusidic acid was prescribed. The ulcers improved and began to heal within a few days; 3 weeks later, they had healed completely. Serology was negative for HIV I and II, syphilis, and cytomegalovirus. Epstein-Barr virus serology was negative for immunoglobulin (Ig) M antibodies and positive for IgG antibodies. No antinuclear antibodies were detected.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis we considered included other causes of acute genital ulcer such as sexually transmitted diseases, lesions caused by trauma, complex aphthosis, and ulcerative lesions associated with autoimmune diseases or inflammatory bowel disease.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> In our case, the final diagnosis was ulcus vulvae acutum in association with H1N1 influenza A virus infection, although we cannot rule out the possibility that the drugs taken by the patient during her illness contributed to the aggressive course of the disease and the necrotic appearance of the lesions. There have been several reports of acute genital ulcers associated with influenza virus infection in the last 3 years, but it is not known whether this association is due to new mutations of the virus or to the concomitant ingestion of drugs. Prospective studies will help to determine whether the prevalence and course of ulcus vulvae acutum in patients with influenza differ depending on whether they receive oseltamivir or purely symptomatic treatment. Familiarity with this disease in emergency and dermatology departments will improve the management of these patients and prevent unnecessary interventions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: López-Lerma I, et al. Ùlcera vulvar aguda de transmisión no sexual asociada a infección por virus influenza A. Actas Dermosifiliogr.2011;102:832-833.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Úlcera vulvar aguda de trasmisión no sexual asociada a infección por virus influenza A" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Esteve-Martínez" 1 => "J. López-Davia" 2 => "A. García-Rabasco" 3 => "I. Febrer-Bosch" 4 => "V. 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Flaig" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2340/00015555-0979" "Revista" => array:7 [ "tituloSerie" => "Acta Derm Venereol" "fecha" => "2011" "volumen" => "91" "paginaInicial" => "55" "paginaFinal" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21031278" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0161642009009087" "estado" => "S300" "issn" => "01616420" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010200000010/v1_201304241244/S1578219012000261/v1_201304241244/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010200000010/v1_201304241244/S1578219012000261/v1_201304241244/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219012000261?idApp=UINPBA000044" ]
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| 2021 January | 51 | 41 | 92 |
| 2020 December | 49 | 36 | 85 |
| 2020 November | 34 | 45 | 79 |
| 2020 October | 46 | 26 | 72 |
| 2020 September | 53 | 37 | 90 |
| 2020 August | 39 | 44 | 83 |
| 2020 July | 53 | 30 | 83 |
| 2020 June | 36 | 56 | 92 |
| 2020 May | 33 | 47 | 80 |
| 2020 April | 47 | 50 | 97 |
| 2020 March | 39 | 96 | 135 |
| 2020 February | 11 | 179 | 190 |
| 2020 January | 4 | 110 | 114 |
| 2019 December | 8 | 52 | 60 |
| 2019 November | 4 | 20 | 24 |
| 2019 October | 0 | 21 | 21 |
| 2019 September | 4 | 22 | 26 |
| 2019 August | 4 | 13 | 17 |
| 2019 July | 4 | 18 | 22 |
| 2019 June | 4 | 16 | 20 |
| 2019 May | 7 | 19 | 26 |
| 2019 April | 3 | 35 | 38 |
| 2019 March | 4 | 34 | 38 |
| 2019 February | 0 | 32 | 32 |
| 2019 January | 2 | 10 | 12 |
| 2018 December | 5 | 7 | 12 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 1 | 0 | 1 |
| 2018 May | 0 | 1 | 1 |
| 2018 April | 0 | 25 | 25 |
| 2018 March | 2 | 19 | 21 |
| 2018 February | 152 | 32 | 184 |
| 2018 January | 156 | 39 | 195 |
| 2017 December | 105 | 20 | 125 |
| 2017 November | 110 | 27 | 137 |
| 2017 October | 86 | 19 | 105 |
| 2017 September | 76 | 17 | 93 |
| 2017 August | 118 | 35 | 153 |
| 2017 July | 96 | 23 | 119 |
| 2017 June | 106 | 48 | 154 |
| 2017 May | 84 | 25 | 109 |
| 2017 April | 80 | 30 | 110 |
| 2017 March | 62 | 57 | 119 |
| 2017 February | 77 | 28 | 105 |
| 2017 January | 69 | 24 | 93 |
| 2016 December | 121 | 12 | 133 |
| 2016 November | 107 | 16 | 123 |
| 2016 October | 73 | 22 | 95 |
| 2016 September | 93 | 21 | 114 |
| 2016 August | 91 | 19 | 110 |
| 2016 July | 62 | 11 | 73 |
| 2016 June | 17 | 11 | 28 |
| 2016 May | 10 | 16 | 26 |
| 2016 April | 7 | 27 | 34 |
| 2016 March | 8 | 14 | 22 |
| 2016 February | 8 | 13 | 21 |
| 2016 January | 7 | 11 | 18 |
| 2015 December | 10 | 5 | 15 |
| 2015 November | 15 | 6 | 21 |
| 2015 October | 12 | 6 | 18 |
| 2015 September | 13 | 2 | 15 |
| 2015 August | 14 | 8 | 22 |
| 2015 July | 47 | 10 | 57 |
| 2015 June | 43 | 8 | 51 |
| 2015 May | 83 | 25 | 108 |
| 2015 April | 77 | 15 | 92 |
| 2015 March | 50 | 14 | 64 |
| 2015 February | 29 | 9 | 38 |
| 2015 January | 36 | 17 | 53 |
| 2014 December | 49 | 24 | 73 |
| 2014 November | 34 | 13 | 47 |
| 2014 October | 48 | 14 | 62 |
| 2014 September | 36 | 10 | 46 |
| 2014 August | 52 | 20 | 72 |
| 2014 July | 50 | 19 | 69 |
| 2014 June | 54 | 17 | 71 |
| 2014 May | 83 | 17 | 100 |
| 2014 April | 54 | 13 | 67 |
| 2014 March | 86 | 18 | 104 |
| 2014 February | 44 | 14 | 58 |
| 2014 January | 64 | 14 | 78 |
| 2013 December | 52 | 12 | 64 |
| 2013 November | 14 | 10 | 24 |
| 2013 October | 12 | 14 | 26 |
| 2013 September | 10 | 7 | 17 |
| 2013 August | 16 | 9 | 25 |
| 2013 July | 13 | 19 | 32 |
| 2013 June | 10 | 16 | 26 |
| 2013 May | 20 | 3 | 23 |
| 2013 April | 14 | 18 | 32 |
| 2013 March | 23 | 11 | 34 |
| 2013 February | 58 | 12 | 70 |
| 2013 January | 48 | 11 | 59 |
| 2012 December | 29 | 4 | 33 |
| 2012 July | 1 | 0 | 1 |
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