Answer: In addition to information regarding sexual activity and cyclical recurrences, specific questions establish the following facts:
a. Onset is heralded by an aura of itching and burning 12 hours before a visible lesion.
b. Lesions have recurred at approximately the same site each time.
c. The patient clearly describes an evolution from a red welt to bumps, blisters, and crusts.
d. Evolution of each episode is about 10 days from start to finish.
e. Lesions are described as irritable and uncomfortable, but not painful. This history supports a diagnosis of herpes genitalis and does not fit the course of other venereal diseases.
2. You advise the patient that although the lesion present is in a late phase and is not diagnostic, the overall picture is consistent with genital herpes. He desires a definitive diagnosis if possible. What lab tests are indicated? Answer: Tzanck smear, biopsy, and viral cultures will have very low sensitivity on a crusted involuting lesion. Complement fixation titers are of no value in recurrent disease. Since Tzanck smears are inexpensive, an attempt is not unreason able; however, a negative smear at this stage offers no reassurance. The most specific and cost-effective test in this case is a rapid immunofluorescence (RIF) test for herpes performed on a smear of crusted material. A serologic test for syphilis should be done, and authorization requested for HIV titers. As testing by polymerase chain reaction becomes universally available and less expensive, it may replace RIF testing.
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