Ulcus vulvae acutum Lipschütz in aninfant: case report

MD Nathália Gomes Meireles, MD Ricardo Iannarella, MD Ludmila Frutuozo Silveira, MD Lívia Vargas Fabbri, MD Christiano Simões Hallack, MS Wellington De Oliveira Maia, MS Emanuela Heiderick Gouvêa

Constantino Ottaviano Clinical Hospital of Teresópolis, Teresópolis, Brazil

Objective:

Lipschutz ulcers or Lipschütz ulcus vulvae acutum (UVAL) are acute reactive genital ulcers that is not associated with sexual intercourse. This disease is difficult to diagnose and the pathophysiology is not completely elucidated, the reason why it is diagnosed by excluding other pathologies. The Symptoms include painful genital ulcer, fever, fatigue and lymphadenitis. Also, it is described associations with viral infections like Epstein-Barr (EBV) or cytomegalovirus (CMV). 

 Case report:

Female patient, 1 year old, toddler. She was admitted in pediatrics at Constantino Ottaviano Clinical Hospital of Teresópolis due to a fever started 3 days before, associated with rapidly progressing vulvar lesions. Physical examination by the gynecology hospital team revealed ulcerated vulvar lesions, painful on mobilization in the region of the distal and proximal right labia majora, vaginal furcula and labia minora on the left side. The lesions presented a dirty bottom, with purulent-looking secretion, measuring around 4 centimeters each. Furthermore, on examination there was enlarged lymph nodes in the bilateral inguinal region. Laboratory tests did not suggest an infectious condition. Methylprednisolone was prescribed with significant improvement in the genital lesions and the toddler was discharged with oral prednisolone prescription as an outpatient. The biopsy report showed the sample consisted of fibrinoleukocyte crust. The cuts showed fibrin, red blood cells and polymorphonuclear cells. Focal positivity for cytokeratins (ae1/ae3) in residual superficial epithelial cells, positivity for cd3 in T lymphocytes and Negative for cd20. The findings for fungi and bacteria using special staining were negative. 

The clinical follow up was successful and the lesions were healed with no remaining scars. 

Discussion:

The clinical case described is appealing because the patient presented a rare case of Lipschtz vulvar ulcer as toddler and hospitalization was necessary to optimize treatment and clinical follow-up. Also, intravenous corticosteroid therapy was significant in the clinical results. Clinical examination was decisive in the diagnosis, once the biopsy was negative and in most cases it does not elucidate clearly de pathology. It is important to highlight the hypothesis of sexual violence has to be excluded. 

Conclusion: 

The case report describes a clinical case of Lipschutz vulvar ulcer in a one year old child, which is a rare association. It’s a challenge in clinical practice not only to diagnose but also to identify the causal factors and determine the treatment. More research and studies are necessary to clarify the best approach in this pathology