Stage One

A 32-year-old woman was referred to the clinic from maxillofacial surgery. She had presented there with a wart on her tongue. At the time of her visit to the clinic three weeks later she had developed an ulcer on her vulva. This had been present for over a week and was painful. This photograph shows two distinct ulcers.

What is the differential diagnosis?

Large ulcer on left labia minora. Smaller ulcer at junction of right labia minora and majora (Angela Robinson)

Severe vulvitis showing typical adherent white plaques of candida (Angela Robinson)

Stage Two

On further questioning she revealed that she had visited her family practitioner a few times with vaginal discharge and feeling sore. She had been given treatment for candida but had not been examined. She thought she may have had ulcers on her vulva on two previous occasions, the first time three years previously.

She had lost some weight and more recently had developed night sweats.

Stage Three

She had been married for eight years and had only ever had one sexual partner, her husband. They were both originally from Rwanda. They had moved to the UK as asylum seekers and at that time she was pregnant. She had declined antenatal testing for HIV. Her son had been born healthy but had subsequently developed autistic behaviour.

Stage Four

After discussion with her husband she agreed to have an HIV test which was positive. At the time of diagnosis her:

  • CD4 count was 120/ml3
  • HIV viral load was 560,000 copies/ml
  • Syphilis serology was negative
  • Vulval ulcer swab was positive for HSV type 2.

She was commenced on Aciclovir 400mg x5 per day for 5 days. The ulcers healed in 10 days. She was subsequently prescribed aciclovir 400mg bd as HSV suppression for 6 months.

Stage Five

She started antiretroviral therapy once viral resistance tests had been completed. She began to increase in weight and feel better.

Her husband agreed to test and was found to be positive for HIV. Her son also was tested for HIV and was found to be negative.

With persistent or recurrent infection, do an HIV test.

Lessons

  1. Vulval candida infections are common but can be an indication of immunosuppression. With persistent or recurrent infection – do an HIV test.

  2. Vaginal discharge has many causes. Anogenital HSV, which is an HIV indicator condition, is often misdiagnosed as candida by inexperienced practitioners. Examine the patient.

  3. Women in a monogamous long term relationship may not consider themselves to be at risk of HIV.

  4. Although routine antenatal testing identifies HIV-positive women and available treatments have reduced the risk of mother-to-child transmission to under 0.4%, do not assume antenatal HIV testing has been offered or accepted.