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Observation
December 2015

Possible Involvement of Mycoplasma fermentans in the Development of Nonsexually Acquired Genital Ulceration (Lipschütz Ulcers) in 3 Young Female Patients

Author Affiliations
  • 1Department of Dermatology, Kyorin University School of Medicine, Tokyo, Japan
JAMA Dermatol. 2015;151(12):1388-1389. doi:10.1001/jamadermatol.2015.2061

Nonsexually acquired genital ulceration (NSAGU), also known as Lipschütz ulcers, is clinically characterized by acute painful genital ulcerations in young women and girls.13 Although various causative pathogens have been documented in the development of NSAGU, the involvement of Mycoplasma fermentans has not previously been proven. We report herein the cases of 3 consecutive patients with NSAGU associated with a recent M fermentans infection. We describe 1 of these cases in detail.

Report of a Case

A girl in her teens presented with a painful genital ulcer. She had noticed high-grade fever, nasal discharge, and cervical lymphadenopathy 3 weeks prior to the appearance of the genital lesion, and cefcapene pivoxil hydrochloride had been administered by her family physician, with no improvement. On examination, she showed a severe aphtha, 25 mm in diameter, with marked edema on the left major labium. The ulcer had an overlying adherent gray-brown eschar (Figure). The patient had never had any sexual contact and had no history of genital herpes infection.

Figure.
Clinical Image of Acute Genital Ulcer in Case 1
Clinical Image of Acute Genital Ulcer in Case 1

A necrotic ulcer overlying adherent gray-brown eschar on the edematous major labium.

Laboratory findings revealed a leukocyte count of 5.3 × 109/L (normal, 3.5-9.0 × 109/L); C-reactive protein concentration, 1.2 mg/dL (normal, <0.3 mg/dL); and alanine aminotransferase level, 276 IU/L (normal, <3-30 IU/L). Serologic test results for hepatitis B and C viruses, human immunodeficiency virus, and Treponema pallidum were all negative. Enzyme-linked immunosorbent assay (Tokiwa Kagaku) revealed anti-IgM antibody titer against M fermentans to be 1.12 enzyme immunoassay units (EIU) (normal, 0.09-0.47 EIU), indicating recent infection.4 Bacterial cultures of the lesion revealed no significant isolates. Chest radiography showed no abnormalities. The patient was diagnosed with NSAGU, and the ulcer was treated with lidocaine hydrochloride gel. The ulcer disappeared within 3 weeks, and no recurrence was observed during 2 years of follow-up. The clinical characteristics and results of microbiological workup of this and 2 other cases are summarized in the Table.

Table.  
Characteristics of Young Female Patients With Nonsexually Acquired Genital Ulceration (Lipschütz Ulcers) Associated With Mycoplasma fermentans Infection
Characteristics of Young Female Patients With Nonsexually Acquired Genital Ulceration (Lipschütz Ulcers) Associated With Mycoplasma fermentans Infection
Discussion

Various infectious agents such as herpes simplex virus, Epstein-Barr virus (EBV), cytomegalovirus (CMV), mumps virus, and mycoplasma have been suggested to be involved in the initiation of NSAGU.13 In the present cases, elevated anti-IgG antibody titers for EBV and for mumps virus indicated prior infection in all cases. No EBV DNAs were detected in the peripheral leukocytes in all cases. Antibody titers for CMV revealed previous infection in case 2 and no infection in cases 1 and 3. However, our serologic search for anti–M fermentans IgM antibodies alone showed positive results in all patients, suggesting recent M fermentans infections. The consistent results obtained from 3 consecutive cases of NSAGU indicate a reliable association between M fermentans infection and NSAGU. To elucidate acute M fermentans infection, anti–M fermentans IgM antibody measurements were performed within 2 weeks after the onset of genital ulcers.

Mycoplasma fermentans has been found in the throat, peripheral blood leukocytes, and urine.5 Interest in M fermentans has recently increased in the clinical setting because of its possible roles in the pathogenesis of illnesses such as rheumatoid diseases, respiratory infections, and genitourinary tract infections.5 Suggesting association between M fermentans and mucosal ulcers, a previous study revealed that antibodies against M fermentans were detected in 32% of patients with malignant aphthosis.6Mycoplasma fermentans infection seems likely to be involved in the development of genital ulcers, although the exact mechanism remains unknown.

No standardized treatment has been defined for NSAGU because the condition is commonly self-limiting; however, in most cases the severe pain and acute urinary retention require rapid healing.2,3 A regimen of topical or oral corticosteroids in the acute phase, followed by prophylactic doxycycline has recently been recommended for NSAGU.2 Furthermore, administration of macrolides and tetracyclines during the prodromal stage of NSAGU, well-known effective antibiotics against mycoplasma species, could provide beneficial effects.

Clinicians need to consider the involvement of M fermentans infection in the occurrence of NSAGU. Further searches for M fermentans infection in patients with NSAGU would clarify this association.

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Article Information

Corresponding Author: Yoko Kano, MD, PhD, Department of Dermatology, Kyorin University School of Medicine, 6-20-2 Shinkawa Mitaka, Tokyo 181-8611, Japan (kano@ks.kyorin-u.ac.jp).

Published Online: September 2, 2015. doi:10.1001/jamadermatol.2015.2061.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by the Ministry of Health, Labor and Welfare and by the Ministry of Education, Culture, Sports, Science and Technology (Drs Kano and Shiohara).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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