A 13-year-old girl is brought to your office by her father because she has had vaginal discomfort for 2 days. She also has had a fever up to 104°F and a small perineal rash. She was seen the previous day in the emergency department (ED) for the same symptoms. The ED evaluation included urinalysis, urine pregnancy test, and complete blood count with differential. Results were reportedly normal, with the exception of a left shift without leukocytosis. Slightly indurated and “pebble-like” lesions were noted on the perineal exam. DNA probes for gonorrhea and chlamydia were obtained. The patient was given acyclovir for presumed new-onset herpes simplex and was instructed to continue acetaminophen and ibuprofen for fever. The patient and her father are now seeking follow-up care.
Q: What are some causes of vaginal pain with fever? How would you proceed with the evaluation?
A: ______________________________________________________________ ______________________________________________________________
Other medical history
- Enuresis, recurrent perioral rash around age 7 with annual recurrences
- No chronic infections or illness
- Premenarchal
- Negative trauma history, including abuse
- Bike riding 2 days earlier but no falls
- Taking acyclovir as prescribed by ED; acetaminophen/ibuprofen for fever
- No known allergies
Family and social history
- Parents alive and well; no siblings
- Straight-A student
- Involved in JROTC (was on a retreat 2 weeks ago)
- No use of tobacco, alcohol, street drugs, or suspicious substances
- Denies any sexual activity
Physical examination
- Review of systems: Positive for chills, fever, dysuria, and perineal pain; otherwise negative
- Temperature 101.6°F, pulse 112, respiratory rate 22, blood pressure 110/70 mm Hg, weight 94 lb
- Alert female in no distress, normal neurologic exam
- HEENT: normal exam with clear oropharynx without lesions
- Skin/integument: no rashes, including arms, legs, hands, feet, and trunk
- Heart, lungs, and abdomen: tachycardia, otherwise normal
- Reproductive examination (chaperone present): Tanner stage III; perineal edema with marked purple ecchymoses located bilaterally at posterior introitus; multiple lacerations also noted as well as tenderness; some scabbed areas noted; no periurethral or perianal lesions or bruising; no vaginal discharge; speculum and bimanual exam were deferred due to pain.
Q: What is your presumptive diagnosis and plan?
A: ____________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
You are concerned about abuse. You interview the patient alone and she again denies any type of sexual encounter. She has never used tampons. She does report that she is a heavy sleeper and that she recently went on a retreat where she and a girlfriend slept in the same room. As far as she knows, there was no intruder. She tearfully says, “If anything happened, I can’t remember.”
You also interview the father alone. He says he and his wife “keep a tight rein” on their daughter. She has been out of their supervision only for the recent retreat. He is concerned that his daughter may have been given a “date-rape” drug and requests testing. His demeanor seems appropriate during the conversations both in the presence and absence of his daughter.
According to state law, you notify the Department of Social Services of unexplained perineal trauma. You also contact the local sexual abuse/rape experts in your area, who have arranged for an evaluation the following day. The father assists in making the arrangements for the evaluation while he is still in your office.
Department of Social Services forensic interview and medical examination
The next day, the patient and her family undergo a comprehensive evaluation by local medical and investigative professionals from the Department of Social Services.
The differential diagnosis for genital ulcers in a sexually inexperienced female includes sexual abuse, herpes simplex virus, Behçet’s disease, Epstein Barr infection, pilonidal disease, Crohn’s disease, and hidradenitis suppurativa. Definitive diagnosis can be difficult (TABLE 1).
One retrospective series reviewed the case of 9 adolescent females with vulvar ulcers and found that 6 had no formal diagnosis. Most important, the initial presentation should prompt healthcare professionals to take steps to ensure a patient’s safety.
After performing a physical examination, the abuse experts report that the patient’s presentation is consistent with Behçet’s disease. A genital culture was obtained, and the patient was given pain medication and azithromycin.
The expert also stated that the father’s reaction to the situation was appropriate and not that of an abusive father. Most perpetrators are very hostile and defensive, whereas this father was extremely concerned and cooperative. Still, a report to Child Protective Services had to be made because of the unexplained physical findings, especially in the genital area.
Further consideration
Additional information on Behçet’s disease is found in an article in the New England Journal of Medicine from 1999: “Behçet’s disease is an inflammatory disorder of unknown cause, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions.”