Skin and Subcutaneous Tissue 1 out of 242
A 17-year-old male comes to the physician because of painful genital sores, malaise, and fever for 3 days. He is sexually active with 3 female partners and does not use condoms consistently. His temperature is 38.3°C (101°F). Physical examination shows tender lymphadenopathy in the left inguinal region and multiple, punched-out ulcers over the penile shaft and glans. Microscopic examination of a smear from the ulcer is most likely to show which of the following?
Bipolar-staining intracytoplasmic inclusionsBipolar-staining intracytoplasmic inclusions (Donovan bodies) would be seen in cases of granuloma inguinale, which is caused by Klebsiella granulomatis. Granuloma inguinale typically manifests as a single, painless, beefy red ulcer without lymphadenopathy or systemic signs of infection. Bipolar-staining intracytoplasmic inclusions are not a feature of HSV infection. Eosinophilic intracytoplasmic inclusionsEosinophilic intracytoplasmic inclusions can be seen in infections by rhabdovirus (e.g., Negri bodies in rabies) or poxvirus (e.g., molluscum contagiosum), both of which are large viruses that replicate in the cytoplasm. Molluscum contagiosum can manifest with genital lesions, but the lesions would be flesh-colored, pearly, dome-shaped, or umbilicated papules, unlike the punched-out ulcers in this patient. Rabies is a terminal CNS disease characterized by insanity and hydrophobia, and Negri bodies would occur only in neurons. Eosinophilic intracytoplasmic inclusions are not a feature of HSV infection. Basophilic intracytoplasmic inclusions
Reticulate bodies, which would appear as basophilic intracytoplasmic inclusions, are seen with infections by Chlamydia trachomatis. Lymphogranuloma inguinale, which is caused by C. trachomatis serotypes L1–L3, can manifest with multiple genital ulcers, tender inguinal lymphadenopathy, and systemic symptoms. However, the genital ulcers in lymphogranuloma venereum would be painless. Basophilic intracytoplasmic inclusions are not a feature of HSV infection. Eosinophilic intranuclear inclusions
Eosinophilic intranuclear inclusions on a smear of an ulcer or opened vesicle describe the Cowdry A inclusion bodies seen in infections by herpesviruses such as HSV-1, HSV-2, VZV, and CMV. These intranuclear inclusions are formed during herpesvirus replication within the nucleus. Another microscopic characteristic of herpesvirus infection is the formation of multinucleated giant cells as a result of the fusion of multiple infected cells (seen on Tzanck smear). HSV-2 can remain dormant in the sacral ganglia after the primary infection to cause recurrent genital herpes. Basophilic intranuclear inclusions
Basophilic intranuclear inclusions can be seen, e.g., in adenovirus infections, which typically manifest with pharyngitis, conjunctivitis, pneumonia, acute hemorrhagic cystitis, gastroenteritis, or myocarditis. Basophilic intranuclear inclusions are not a feature of HSV infection.
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