Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Mycoplasma pneumoniae as a cause of vulvar ulcers in a non-sexually active girl: a case report

  • Maria G. Koliou1, 2, 3Email author,
  • Talia Kakourou4,
  • Jan Richter5,
  • Christina Christodoulou5 and
  • Elpidoforos S. Soteriades3, 6
Journal of Medical Case Reports201711:187

https://doi.org/10.1186/s13256-017-1345-9

Received: 12 January 2017

Accepted: 2 June 2017

Published: 9 July 2017

Abstract

Background

Non-sexually active young females very rarely develop genital ulcers. Such ulcers pose a diagnostic challenge as well as physical and emotional distress for patients and family; therefore, the search for their etiology requires exhaustive investigation. Several viruses such as Epstein–Barr virus have been associated with this entity; however, Mycoplasma pneumoniae has rarely been linked to such ulcers in the literature. We present a case of vulvar ulcers in a non-sexually active young girl during the course of pneumonia caused by Mycoplasma pneumoniae.

Case presentation

A 10-year-old non-sexually active girl of cypriot origin presented at a hospital with fever, dry cough, and acute vulvar ulcers. Laboratory investigations as well as imaging studies revealed Mycoplasma pneumoniae as the cause of her pneumonia and acute vulvar ulcers.

Conclusions

Although a rare cause of vulvar ulcers, Mycoplasma pneumoniae should be considered in the differential diagnosis of acute vulvar ulcers coexisting with respiratory symptoms.

Keywords

Mycoplasma pneumoniae Acute vulvar ulcers Non-sexually active females Cyprus

Background

Non-sexually active young females very rarely develop genital ulcers. However, such ulcers pose a significant diagnostic challenge and they may cause physical and emotional distress for patients and families since they may raise suspicion of possible sexual abuse and/or venereal etiology. Therefore the search for the etiology of genital ulcers requires exhaustive investigation. Despite the above challenges, a definite diagnosis of the cause of such ulcers often cannot be identified.

In 1913, Lipschütz described vulvar ulcers in adolescent and virgin females where no specific cause was detected [1]. Since this first description, several additional possible causes have been reported in the literature. In most cases, symptoms consistent with a viral illness precede the development of the ulcers and the differential diagnosis includes infectious agents [2]. Several case reports and case series have associated these vulvar ulcers in non-sexually active females with viral infections such as Epstein–Barr virus [3], cytomegalovirus (CMV), influenza A virus, mumps virus [4, 5], and in some cases with autoimmune disorders such as Behçet’s disease [6] or trauma [7]. Herpes simplex virus (HSV) has been associated with such ulcers, most commonly in sexually active patients. Mycoplasma pneumoniae has rarely been linked with these ulcers in the medical literature [8, 9].

Mycoplasma species represent the smallest bacterial cells discovered. Several species are pathogenic in humans, the main one being M. pneumoniae, which is mainly responsible for respiratory tract infections. Extrapulmonary manifestations, such as dermatologic, can also occur with or without concurrent respiratory infection in up to 25% of human Mycoplasma infections. These include nonspecific erythematous maculopapular rashes, Stevens–Johnson syndrome, Henoch–Schönlein purpura, and mucositis [10].

In this report we describe the case of a young non-sexually active girl who developed acute vulvar ulcers during the course of pneumonia caused by M. pneumoniae.

Case presentation

A 10-year-old girl of cypriot origin was referred to hospital because of fever and ulcers in the genital area. Three days before admission she started having fever, sore throat, and mild dry cough. A quick pharyngeal test for group A streptococcal antigen was found negative. On day 3 after the onset of fever, she developed intense pain and burning in her genital area for which she was admitted to our hospital.

On admission, she had fever and cough but no diarrhea or abdominal pain. On examination, painful ulcers of variable depth and diameter with elevated violaceous borders located inside the labia majora were noted (Fig. 1). No oral ulcers or swollen lymph nodes were detected. She was not sexually active and had no previous history of similar ulcers. She was initially treated with intravenously administered antibiotics and local wound care with antiseptics.
Fig. 1

Genital ulcers of the patient

Cultures from the lesions were negative for bacteria. Polymerase chain reaction (PCR) in the tissue for HSV was also negative. Antibodies against HSV1 and HSV2, antinuclear antibodies, anti-double-stranded deoxyribonucleic acid (dsDNA), antineutrophil cytoplasmic antibodies (ANCA)-proteinase (PR3), and ANCA-myeloperoxidase (MPO) were all negative. Four days after admission the lesions significantly improved with local treatment, but her fever and cough persisted. A chest X-ray revealed a right-sided pneumonia (Fig. 2). Orally administered azithromycin was added as a treatment agent and 2 days later she became afebrile. Mycoplasma immunoglobulin M (IgM), as measured by a semi-quantitative enzyme-linked immunosorbent assay (ELISA) method on day 11 after onset of symptoms, was found to be highly positive. Three weeks later, Mycoplasma IgM titer was also found positive but at a lower titer. Real-time PCR for M. pneumoniae in nasopharyngeal secretions was positive and strongly positive in two consecutive sputum specimens. However, PCR for Mycoplasma in the tissue specimen from the genital lesions was found negative.
Fig. 2

Chest X-ray revealing right lower lobe pneumonia

For the detection of the bacteria, a duplex real-time PCR assay was employed targeting the Community Acquired Respiratory Distress Syndrome (CARDS) toxin gene of M. pneumoniae and the major outer membrane protein gene of Chlamydia pneumoniae. In addition, the respiratory samples were tested for a panel of respiratory viruses without yielding a positive result: influenza A and B, respiratory syncytial virus (RSV), rhinovirus, parainfluenza viruses 1 to 4, adenovirus, human metapneumovirus, human bocavirus, enterovirus, and human coronaviruses 229E, OC43, and NL63. During a 2-year follow-up after hospital discharge, she had no recurrence of the ulcers.

Discussion

M. pneumoniae has been linked to acute vulvar ulcers in a few previous reports in the literature. In most of these reports the diagnosis was established by measuring IgM-specific antibodies against the Mycoplasma. In our case, both serology and molecular methods were used in order to diagnose acute M. pneumoniae infection.

A culture of M. pneumoniae, despite being the gold standard method for diagnosis, usually has a mean incubation period of 10 to 14 days and low sensitivity. Therefore, clinical diagnosis relies mainly on serology and in recent years also on molecular methods. Detection of anti-Mycoplasma IgM antibody usually indicates acute infection. In adults, IgM antibodies may not develop and only an immunoglobulin G (IgG) response can be detected, especially in cases of re-infection [11]. However, this is not the case in children where past infection by M. pneumoniae is unlikely and therefore measurement of IgM is considered a quite reliable method for diagnosis.

The direct detection of M. pneumoniae nucleotide sequences from clinical specimens such as sputum, nasopharyngeal aspirate, or pharyngeal swab, has been proven to be a very sensitive and specific approach, which offers a rapid diagnosis of infection [12, 13]. However, in some cases, detection of M. pneumoniae from respiratory tract secretions may only indicate carriage [10]. The utilization of a combined approach of serology with PCR techniques, if available, may surpass the limitations of either technique when used alone.

The diagnosis of M. pneumoniae infection in our case was based on both positive IgM antibodies and the detection of the genetic material of the pathogen by real-time PCR. A possible causative mechanism for these extrapulmonary manifestations is the immune-mediated damage against host tissue caused by the variety of cross-reactive antibodies, which are generated as a result of M. pneumoniae infection [10]. However, in some cases M. pneumoniae has been isolated directly from the lesions [14]. In these cases, direct damage of the tissue by the pathogen is implicated. In our case, neither Mycoplasma nor any other pathogen was isolated directly from the skin lesions, therefore the immune-mediated effect may be the most probable explanation.

When these ulcers develop in an adolescent, the investigation should be based on a careful and non-offensive sexual history. The differential diagnosis should include infections that may or may not be sexually transmitted such as HSV, syphilis, chancroid, and human immunodeficiency virus (HIV) as well as Epstein–Barr virus, CMV, influenza A virus, and M. pneumoniae. In cases of recurrent genital manifestations combined with or without oral ulcers, the possibility of systematic autoimmune diseases such as Behçet’s or aphthosis should also be considered [15].

In most cases of vulvar ulcers in non-sexually active females, the disease is usually self-limited and local care is sufficient. Systemic use of anti-bacterial drugs or anti-viral drugs does not appear to alter the course of the disease [2]. This was also obvious in our case where her skin lesions significantly improved with local care while the M. pneumoniae infection was still active and required the administration of antimicrobial treatment such as azithromycin.

Conclusions

M. pneumoniae is a rare cause of acute genital ulcers in non-sexually active young females. It should be considered in the differential diagnosis especially if the ulcers are accompanied or preceded by symptoms from the respiratory tract. Despite the fact that vulvar ulcers in non-sexually active young females are a benign and self-limited condition, investigation of the cause of illness should exclude potential sexually transmitted diseases and could reassure both the patient and the family.

Abbreviations

ANCA: 

Antineutrophil cytoplasmic antibodies

CARDS: 

Community Acquired Respiratory Distress Syndrome

CMV: 

Cytomegalovirus

dsDNA: 

Double-stranded deoxyribonucleic acid

ELISA: 

Enzyme-linked immunosorbent assay

HIV: 

Human immunodeficiency virus

HSV: 

Herpes simplex virus

IgG: 

Immunoglobulin G

IgM: 

Immunoglobulin M

MPO: 

Myeloperoxidase

PCR: 

Polymerase chain reaction

PR3: 

Proteinase 3

RSV: 

Respiratory syncytial virus

Declarations

Acknowledgements

Not applicable.

Funding

There was no funding for this case report.

Availability of data and materials

Data are available from the corresponding author on reasonable request.

Authors’ contributions

MGK conceived of the idea for the case report. TK contributed to the differential diagnosis. JR and CC performed the molecular studies. MGK and ESS wrote the first draft of the manuscript. All authors contributed to the preparation of the final manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethics approval and consent to participate

Not applicable.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Paediatrics, Archbishop Makarios III Hospital
(2)
University of Cyprus, School of Medicine
(3)
Cyprus Institute of Biomedical Sciences
(4)
First Pediatric Department, University of Athens School of Medicine
(5)
Department of Molecular Virology, Cyprus Institute of Neurology and Genetics
(6)
Harvard School of Public Health, Department of Environmental Health, Environmental and Occupational Medicine and Epidemiology (EOME)

References

  1. Lipschütz B. Uber eine eigenartige Geschwόrsform des weiblichen Genitales (Ulcus vulvae acutum). Arch Dermatol Syph (Berlin). 1913;114:363–96.View ArticleGoogle Scholar
  2. Rosman IS, Berk DR, Bayliss SJ, White AJ, Merritt DF. Acute genital ulcers in nonsexually active young girls: case series, review of the literature, and evaluation and management recommendations. Pediatr Dermatol. 2012;29(2):147–53.View ArticlePubMedGoogle Scholar
  3. Sisson BA, Glick L. Genital ulceration as a presenting manifestation of infectious mononucleosis. J Pediatr Adolesc Gynecol. 1998;11(4):185–7.View ArticlePubMedGoogle Scholar
  4. Lehman JS, Bruce AJ, Wetter DA, Ferguson SB, Rogers 3rd RS. Reactive nonsexually related acute genital ulcers: review of cases evaluated at Mayo Clinic. J Am Acad Dermatol. 2010;63(1):44–51.View ArticlePubMedGoogle Scholar
  5. Martín JM, Godoy R, Calduch L, Villalon G, Jordá E. Lipschütz acute vulval ulcers associated with primary cytomegalovirus infection. Pediatr Dermatol. 2008;25(1):113–5.View ArticlePubMedGoogle Scholar
  6. Morgan ED, Laszlo JD, Stumpf PG. Incomplete Behcet’s syndrome in the differential diagnosis of genital ulceration and postcoital bleeding. A case report. J Reprod Med. 1988;33(10):844–6.PubMedGoogle Scholar
  7. Cebesoy FB, Balat O, Inaloz S. Premenarchal vulvar ulceration: is chronic irritation a causative factor? Pediatr Dermatol. 2009;26(5):514–8.View ArticlePubMedGoogle Scholar
  8. Vieira-Baptista P, Machado L, Costa AR, Beires J, Martinez-de-Oliveira J. Mycoplasma pneumoniae: a rare cause of vulvar ulcers or an undiagnosed one? J Low Genit Tract Dis. 2013;17(3):330–4.View ArticlePubMedGoogle Scholar
  9. Kos L, Galbraith SS, Lyon VB. Vaginal ulcerations with acute mycoplasma infection. J Am Acad Dermatol. 2007;56(5 Suppl):S117–8.View ArticlePubMedGoogle Scholar
  10. Waites KB, Talkington DF. Mycoplasma pneumoniae and its role as a human pathogen. Clin Microbiol Rev. 2004;17(4):697–728.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Baum SG. Mycoplasma pneumoniae and Atypical pneumonia. In: Mandel GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. Philadelphia: Churchill Livingstone, Elsevier; 2010. p. 2481–9.Google Scholar
  12. Van Kuppeveld FJ, Johansson KE, Galama JM, Kissing J, Bölske G, Hjelm E. 16S rRNA based polymerase chain reaction compared with culture and serological methods for diagnosis of Mycoplasma pneumoniae infection. Eur J Clin Microbiol Infect Dis. 1994;13(5):401–5.View ArticlePubMedGoogle Scholar
  13. Ramirez JA, Ahkee S, Tolentino A, Miller RD, Summersgill JT. Diagnosis of Legionella pneumophila, Mycoplasma pneumoniae, or Chlamydia pneumoniae lower respiratory infection using the polymerase chain reaction on a single throat swab specimen. Diagn Microbiol Infect Dis. 1996;24(1):7–14.View ArticlePubMedGoogle Scholar
  14. Stutman HR. Stevens-Johnson syndrome and Mycoplasma pneumoniae: evidence for cutaneous infection. J Pediatr. 1987;111(6 Pt 1):845–7.View ArticlePubMedGoogle Scholar
  15. Delgado-García S, Palacios-Marqués A, Martínez-Escoriza JC, Martín-Bayón TA. Acute genital ulcers BMJ Case Rep. 2014. doi: https://doi.org/10.1136/bcr-2013-202504.

Copyright

© The Author(s). 2017

Advertisement