Lipschütz ulcers: uncommon diagnosis of vulvar ulcerations.

To cite: Mourinha V, Costa S, Urzal C, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015214338 DESCRIPTION Aetiological diagnosis of genital ulcers is still a challenge in clinical practice. The cause is mostly infectious, but it may otherwise be a presentation of a wide variety of pathologies, such as autoimmune (eg, Behçet’s disease), cancer or inflammatory processes. The Lipschütz ulcer is a non-sexually transmitted condition. It has been considered as an uncommon and probably underdiagnosed entity, although a recent study has reported that it may represent around 30% of vulvar ulcerations. It affects mainly adolescents and young adults, but there are reported cases in children. It presents as a sudden onset of painful vulvar ulcers, usually wider than 1 cm and deep, with a red border and a necrotic centre covered by grey exudate or grey-black eschar, sometimes preceded by unspecific nongynaecological symptoms. Bilateral ‘Kissing lesions’ are characteristic. The diagnosis is mainly clinical and made by exclusion after ruling out other causes of genital ulcerations. The aetiology is unknown, although some cases have suggested an association with acute Epstein-Barr virus (EBV) or other viral or bacterial infections. We report a case of a 22-year-old woman who presented at the emergency department, for painful extensive vulvar and lower vaginal ulcerations associated with greyish exudate and oedema (figures 1 and 2). It had started 3 days before, and the patient had been medicated with azithromycin, without improvement. She denied recent sexual intercourse, trauma and oral ulcerations, but referred a history of flu-like symptoms 1 week before. She was admitted for study and treatment, starting empiric treatment with doxycycline, acyclovir and analgesia (local and intravenous). Infectious (HIV, hepatitis C virus, hepatitis B virus, syphilis, herpes simplex virus, Varicella-Zoster virus, EBV and cultural tests) and autoimmune (antinuclear antibody, antiphospholipid antibodies, antineutrophil cytoplasmic antibody, C3 and C4 complement levels) tests