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JAMA Clinical Challenge

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

Image of swelling, plaques, and nodules on the patient's vulva and perianal region

Shu-li Li, MD
Chunying Li, MD, PhD
A 26-year-old woman presents with 5 weeks 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 blood transfusions, contact with trichloroacetic acid, spermicides, or any other toxic agents or irritants. Physical examination reveals bilateral purple swelling of the labium majora and multiple moist, edematous, 1- to 8-mm wart-like skin nodules on the perineal and perianal surfaces (Figure). 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 × 109/L), as is neutrophil count (2.07 × 109/L); hemoglobin level is slightly decreased (10.2 g/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.

See the full article for an explanation and discussion.

Author Affiliations: Drs Li (lichying@fmmu.edu.cn) and Li are affiliated with the Department of Dermatology, Xijing Hospital, The Fourth Military Medical University, Xi’an, Shaanxi, China.