Case Report

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Genital ulceration associated with typhoid fever

Omar Mustapha, MD; Suha Kanj, MD; Georges Araj, PhD; Salman Mroueh, MD;
Ghassan Dbeibo, MD; Muhieddine Seoud, MD

lcus vulvae acutum is an acute

nonvenereal genital ulcer.1 Typhoid and paratyphoid fever are among
the infections that are associated with
this rare entity. We report genital ulceration that occurred simultaneously in 2
sisters in the setting of typhoid fever and
review the previously reported cases in
the literature.

C ASE R EPORT
Case 1
Our patient is a 14-year-old, sexually inactive girl who was admitted to the
American University of Beirut Medical
Center with fever and genital ulceration.
Five days before admission she had
spikes of high-grade fever, chills, and
vomiting. Two days later, swelling and
ulceration of the right labium minus was
noticed. On the following days, the fever
persisted, and the genital ulcer became
very painful. She had no diarrhea or constipation but complained of headache.
She had marked swelling of the right labium minus and a 3- to 5-cm genital ulcer that was red and purulent with central necrosis. The genitalia were very
tender. There was no inguinal adenopathy, and the rest of the physical examina-

We report on 2 sisters with genital ulceration as a major symptom of typhoid fever and
review the world literature for this rare entity.
Key words: typhoid fever, ulcer

tion was unremarkable. Her white blood

cell count was 5000 cells/mL, with 73%
segmented and 21% lymphocytes.
Erythrocyte sedimentation rate (ESR)
was 35 mm/h. Chest x-ray examination
was normal. Venereal disease research
laboratory was nonreactive. Treponema
pallidum hemagglutination assay results
were negative. On the day of admission,
the urine culture was negative, and the
swab cultures from the ulcer grew normal vaginal flora. Blood cultures grew
Salmonella typhi. The patients condition
responded promptly to ciprofloxacin.

Case 2
Two days after the admission of the first
sister, the older sister, a 17-year-old sin-

FIGURE 1

A typhoid genital ulcer

gle and sexually inactive girl, was admitted to the American University of Beirut
Medical Center with high-grade fever of
5 days duration and similar genital ulcerations. She also denied any diarrhea or
constipation but complained of headache. Except for a temperature of 39.5C,
her general physical examination was
unremarkable, with no organomegaly or
adenopathy. Pelvic examination revealed a large genital ulcer (very similar
to the 1 seen in her sister) and marked
swelling of the left labium minus (Figure
1). Laboratory investigations were
within normal limits (white blood cell
count, 7300 cells/mL, with 78% segmented and 17% lymphocytes). The biopsy specimen from 1 of the genital ulcers revealed nonspecific necrotic and
purulent inflammatory exudates that are
consistent with ulceration (Figure 2).
Two days after her admission, blood cultures grew S typhi. Widal test revealed an
FIGURE 2

Histology of a typhoid
genital ulcer

From the Department of Internal Medicine,

Division of Infectious Diseases (Drs
Mustapha and Kanj), the Department of
Pathology (Dr Araj), the Department of
Pediatrics (Drs Mroueh and Dbeibo), and
the Department of Obstetrics and
Gynecology (Dr Seoud), American
University of Beirut Medical Center, Beirut,
Lebanon.
Received Sept. 26, 2008; revised Nov. 4,
2008; accepted Nov. 18, 2008.
Reprints: Muhieddine Seoud, MD, American
University of Beirut Medical Center,
Department of Obstetrics and Gynecology,
Cairo St., 113-6044 Beirut, Lebanon.
mike@aub.edu.lb.
0002-9378/free
2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.11.036

e6

Typhoid genital ulceration.

Histologic section (hematoxylin and eosin stain)

from a typhoid genital ulceration that shows
extensive inflammation.

Mustapha. Genital ulceration associated with typhoid fever.

Am J Obstet Gynecol 2009.

Mustapha. Genital ulceration associated with typhoid fever.

Am J Obstet Gynecol 2009.

American Journal of Obstetrics & Gynecology MAY 2009

Case Report

www.AJOG.org

TABLE 1

Genital ulcers reported with enteric fever: review of the world literature
Study

Year of publication

Cases (n)

Age (y)

Type of infection

Diagnostic test

Outcome

Braun3

1950

36

Typhoid

Widal test

Cured

Sedallian

1950

12-21

Typhoid

Blood cultures

Cured

Visani

1952

NA

Typhoid

NA

NA

Buchman

1955

12

Typhoid

Blood cultures

Cured

Roberts and Barron

1958

15, 25

Typhoid

Blood cultures

Cured

Barone et al

1963

19

Typhoid

Widal test

Cured

Berlin

1965

12-13

Typhoid

Widal test

Cured

Van Joast

1971

17

Paratyphoid

Blood cultures

Cured

Pelletier et al

2003

25

Paratyphoid

Blood cultures

Cured

................................................................................................................................................................................................................................................................................................................................................................................
4
................................................................................................................................................................................................................................................................................................................................................................................
5
................................................................................................................................................................................................................................................................................................................................................................................
2
................................................................................................................................................................................................................................................................................................................................................................................
6
................................................................................................................................................................................................................................................................................................................................................................................
7
................................................................................................................................................................................................................................................................................................................................................................................
1
................................................................................................................................................................................................................................................................................................................................................................................
8
................................................................................................................................................................................................................................................................................................................................................................................
9
................................................................................................................................................................................................................................................................................................................................................................................

NA, not available.

Mustapha. Genital ulceration associated with typhoid fever. Am J Obstet Gynecol 2009.

S typhi H of 1:1600. The patient received

ciprofloxacin.
Both patients experienced defervescence within 3-4 days. In both sisters, the
genital ulcers took approximately 3
weeks to heal completely without scaring. Both sisters tested negative for the
human immunodeficiency virus. Both
sisters were still virginal on examination
and have had no history of repeated infections or previous vaginal candidiasis.
Follow-up examination after 6 months
revealed that both sisters were free of any
disease.
The family was asked detailed questions to attempt to identify a source of
infection. Both sisters admitted to eating
ice cream several days before the illness.
Both sisters slept in the same room and
exclusively used the same bathroom.
They were the only family members who
used a commode with a bottom highpressure jet-spray fountain to wash off
after urination and defecation. Culture
from this water showed heavy infestation
with enterobacteriacae at 100,000 colonies/mL, but no S typhi was recovered.
The mother and another sister used a
handheld low-pressure water spray jet to
wash off in another bathroom and were
not affected. No one else in the neighbor-

hood or in the same building was reported to have had typhoid fever. During
that time, we had an outbreak of typhoid
fever in the country, with many cases reported from several areas. The public
health authorities were notified.

C OMMENT
Genital ulcers that are associated with
enteric fever are rare in our modern
times. Except for an isolated report in
2003, the last reported patient to have
enteric fever was in 1971. In 1898, Keen
described 17 patients with typhoid ulcers
of the vulva and vagina (in Buchman).2
One year later, 2 patients were reported
by Lartigan (in Buchman).2 Table 1 summarizes the cases of genital ulcers that
have been associated with typhoid and
paratyphoid fever that have been reported in the world literature.1-9
The pathogenesis and mechanism of
the ulceration are unknown. Bacterial
emboli, direct inoculation by feces and
urine, and production of endotoxins are
possible mechanisms.2,9 Our article is
unique, because it describes genital ulcers that were associated with typhoid fever simultaneously in 2 sisters. The way
the 2 sisters (from a total of 4 female fam-

ily members) in the house were washing,

with the high-pressure, heavily infected
water that was directed to the genitalia,
could explain the genital involvement.
In conclusion, enteric fever should be
considered in the differential diagnosis
of acute genital ulcerations that occur in
nonsexually active girls.
f
REFERENCES
1. Berlin C. The pathogenesis of the so-called
ulcus vulvae acutum. Acta Dermato-Venereologica 1965;45:221-2.
2. Buchman MI. A typhoid ulcer of the external
genitals. Am J Obstet Gynecol 1955;70:435-7.
3. Braun H. Typhoid ulcer of the vulva. Z Haut
Gschlechtskr 1950;9:251-8.
4. Sedallian P. Ulcerations of the vulva in the
course of typhoid fever. Presse Med 1950;
58:1445.
5. Visani A. Vulvar ulcerations during typhoid.
Acta Med Ital Mal Infett Parassit 1952;7:10-2.
6. Roberts DW, Barron SL. Typhoid fever with
vulvovaginitis. Lancet 1958;2:1043-4.
7. Barone A, Persico M, Pellicano A. Acute ulcerations of the vulva during ileal typhoid. Arch
Gynecol Obstet 1963;68:385-94.
8. Van Joast T. An unusual case of vulvar ulcer
of acute onset. Ned Tijdschr Geneeskd
1971;115:1080-2.
9. Pelletier F, Aubin F, Puzenat E, et al. Genital
ulceration: a rare manifestation of paratyphoid
fever. Eur J Dermatol 2003;13:297-8.

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