Case report

Ulcer of Lipschutz, a rare and unknown cause of genital

ulceration

A. Moise, P. Nervo, J. Doyen, F. Kridelka, J. Maquet, G. Vandenbossche

Hospital Notre Dame des Bruyères, CHU, Obstetrics and Gynecology, Rue de Gaillarmont 600, 4032 Chênée, Belgium.

Correspondence at: gautiervdb@hotmail.com

Abstract
Acute genital ulcers are painful and distressing to women. Lipchutz Ulcer is an uncommon disease that typically
occurs in sexually inactive young women. The main differential diagnosis are sexually-transmitted or non-infectious
diseases which cause genital or oro-genital ulcerations. This article aims to review the diagnosis of acute genital
ulcers and, through a rare case of acute genital ulcerations, to discuss diagnostic procedures.
Key words: genital ulceration, acute ulceration, young women, Lipchutz ulcer, diagnosis.

Clinical history

A 13-year-old girl of Caucasian origin presented

to the paediatric emergency room reporting acute
vulvodynia, preceded by prodromal influenza-like
symptoms (fever, tiredness, malaise) present for the
past 48 hours.
The patient had no relevant medical history, nor
recurrent buccal or genital apotheosis. She didn’t
receive any regular medication. She was sexually
inactive, and hadn’t applied any cream or anything
else on the vulva. There was no trauma nor history
of sexual abuse.
This is the first time she had experienced such
symptoms.
The patient had an antalgic gait. Gynecologic
examination showed her labia minor with two
centimetric, fibrinous, soft ulcerations on their
inner aspect. These lesions had a symmetrical
appearance, known as « kissing lesions » (Figure
1). Furthermore, there was no abnormal leucorrhoea
nor sign of trauma, but small adenopathies were
palpated in the inguinal areas.
Intense pain caused stress for both the adolescent
and her mother. Nevertheless, the patient didn’t
Figure 1: Symmetric ulcerations of inner labia minor known
present other clinical, extra-genital signs (no as «  kissing lesions  », two deep, centimetric and fibrinous
neurologic, cutaneous, ocular or gastrointestinal ulcerations.
symptoms).

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 Investigations (Behcet, IBD like Crohn disease…), trauma and
other causes of acute genital ulcerations need to be
Blood count, viral (HIV, HBV, HCV, EBV, CMV), excluded. Biopsy is often not required.
parasitic (toxoplasmosis) and treponemal (TPHA- Rosman et al. have developed an algorithm for
VDRL) serologies as well as samples for further evaluation and treatment of acute genital ulcerations
microbiological explorations (HSV PCR, anaerobic after HSV-infection exclusion (Figure 2) (Rosman
germs and mycosis cultures) have been performed. et al., 2012).
While results were pending, hospitalization in
a paediatric ward was required with up to step
II analgesic (paracetamol and tramadol) were
administered in association with local hygiene
(physiological serum) and wound care. An empirical
antiviral treatment (acyclovir per os 200 mg 5X/
day) was initiated and the bladder was catheterized.
Performed explorations only showed an isolated
inflammatory syndrome without hyperleukocytosis
(CRP up to 20 mg/L). Viral and bacterial tests were
negative and serologies didn’t bring any proof of
recent infection. In light of these results, acyclovir
was terminated. Ulcers eventually fully healed in a
few weeks.

Discussion

Acute vulvar ulceration, also referred to as a

Figure 2: Algorithm for evaluation and treatment of acute geni-
Lipschutz Ulcer, is a clinical diagnosis based on tal ulceration (AGU) in young women (Rosman et al., 2012)
both: (HSV = Herpes Simplex Virus, PCR = Polymerase chain reac-
— detailed history with acute painful genital tion, GI - gastrointestinal, EBV = Epstein-Barr Virus, CMV =
ulcerations associated to fever in a sexually inactive, Cytomegalovirus).
adolescent girl (Lipschütz, 1913)
— physical examination showing centimetric, Patient care consists of pain control including
fibrinous, soft necrotic ulcerations with red- topical and systemic analgesia and wound care.
violaceous border and inguinal adenopathies. Patient and parents should be reassured that the
Pathogenesis is unclear but a hypersensitivity disease is benign and its lack of recurrence. In
reaction secondary to viral or bacterial infection case of severe pain, hospitalization with bladder
with deposition of immune complex in the dermal catheterization might be required to avoid any
vessels causing micro-thrombosis, and eventually secondary urine retention (Bandow 2010).
leading to deep, necrotizing, painful, aphtoid lesions The main differential diagnosis of Lipschutz
is suspected. ulcerations are sexually transmitted diseases and
One hypothesis suggests a manifestation of EBV non-infectious diseases which cause genital or oro-
primary infection (Lorenzo en Robertson 2005). genital ulcerations.
The disease typically begins with prodromal The most common diseases in this regard are
influenza or mononucleosis-like symptoms followed (Robert, 2017):
by the onset of 1mm to 2,5cm, single or multiple - genital herpes
(in this case, they are symmetrical, described as - HIV infection
«  kissing lesions  »), vulvar ulcerations (Huppert, - syphilis
2010). - complex aphthosis
The ulcerations typically involve the labia minor - Behcet’s syndrome
but can extend to the labia major, perineum vestibule - Crohn’s disease
and lower vagina. There is no risk of transmission. - pyoderma gangrenosum
Spontaneous healing is complete in two to six - childhood vulval pemphigoid.
weeks (this feature being a retrospective diagnostic
argument), usually without scarring. Conclusion
The clinical diagnosis is one of exclusion. As
a matter of fact, sexually transmitted infections Lipchutz Ulcer is an uncommon disease that
(HSV, treponema pallidum), auto-immune diseases typically occurs in young, sexually inactive women.

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 The diagnosis is one of exclusion and other causes of References
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proper analgesia and wound care, this feature being welichen Genitales (Ulcus vulvae actum). Arch Dermatol
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Declaration of interest statement: Pract. 2005;18:67-8.
The authors declare to have no conflict of interest. Rosman IS, Berk DR, Bayliss SJ et al. Acute genital ulcers in
nonsexually active young girls: case series, review of the
literature, and evaluation and management recommendations.
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ULCER OF LIPSCHUTZ, A RARE AND UNKNOWN CAUSE OF GENITAL ULCERATION – VANDENBOSSCHE et al.
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