Introduction:  Genital ulceration presents frequently at GUM clinics, with herpes simplex (HSV) infection a common aetiology.  A diagnosis of HSV is distressing with possible implications for relationships and future pregnancies. It is therefore important to consider other causes if atypical presentation or negative HSV PCR from area of active ulceration.
Method:  Case review of uncommon aetiologies of ulceration.
Results: 
Case 1: 25 year old.  Prodromal sore throat and flu-like symptoms.  Examination revealed deep ulcers on vulva and oral mucosa without eye or skin involvement. CRP 120, ESR 80, ASOT titre 400, negative autoimmune screen, monospot negative.  Developed anterior uveitis and erythema nodosum 24 hours later.  Diagnosed with Behcet’s disease requiring prednisolone and mycophenolate mofitil.
Case 2: 28 year old. Prodromal sore throat and headache.  Sexual history atypical for HSV. Known Graves’ disease, on propylthiouracil.    On examination, patient looked unwell.  Shallow vulval ulceration noted. Neutrophils 0.1, ESR 31. Diagnosed with apthous ulceration secondary to neutropenia and admitted for neutropenic-sepsis treatment. Required thyroidectomy with pathology revealing papillary carcinoma.
Case 3: 13 year old referred by SARC. No history of sexual contact or features of child sexual exploitation. Prodromal flu-like illness. Of note, mother Influenza A positive. 
No response to empirical acyclovir. HSV PCR negative. Nasopharyngeal swab confirmed Influenza A. Case subsequently closed with SARC and Social Services.
Discussion:  This case series highlights less common but important causes of genital ulceration.  Full systemic history and clinical assessment remains essential in those where alternate diagnoses to HSV are being considered.

Unusual causes of genital ulceration presenting to Genitourinary Medicine clinic - a case series

The Joint Annual Conference of the British Association for Sexual Health and HIV & the Society for the Study of Sexually Transmitted Diseases in Ireland