Vulvar Swelling, Plaques, and Nodules in a Young Adult Woman

Abstract

A 26-YEAR-OLD WOMAN PRESENTS WITH5WEEKS OF VULVAR SWELLING,PRURITUS, and progressively enlarging vulvar plaque accompanied by 2 months of occasional constipation and recurrent bloody, mucoid diarrhea. She has no history of anogenital warts and is monogamous with her husband. She has had no bloodtransfusions, contactwith trichloroaceticacid, spermicides,oranyother toxic agents or irritants. Physical examination reveals bilateral purple swelling of the labium majora and multiple moist, edematous, 1to 8-mm wart-like skin nodules on the perineal and perianal surfaces (FIGURE 1). A 2-mm ulcer is observed inside the right labium minus. Digital rectal examination shows bloody mucus mixed with loose stool. White blood cell count is normal (4 10/L), as is neutrophil count (2.07 10/L);hemoglobin level is slightlydecreased(10.2g/dL).Erythrocyte sedimentation rate is 71 mm/h (reference range, 0-20 mm/h), and C-reactive protein level is 28 mg/L (reference range, 0-5 mg/L). Bacterial and fungal swab cultures from the ulceration are negative. Vaginal and urethral swabs are negative, with moderately increased polymorphonuclear leukocytes. Results of serologic testing for Treponema pallidum and human immunodeficiency virus are negative. What Would You Do Next?