Multiple Genital Ulcer on a Male Patient Due to Fungal

Balanoposthitis Suspect of Candida Albicans Infection Mimicking

Genital Herpes: A Case Report

Wresti Indriatmi

1*,

, Giorgio Barnes Komala

Department of Dermatovenereology, Medical Faculty of Universitas Indonesia, Jakarta, Indonesia

*Corresponding author

Keywords : Genital ulcer, balanoposthitis, case report, candida albicans

Abstract: Genital ulcer can be caused by an infectious or non-infectious diseases. The appearance of genital ulcer can

mimick one to another causative etiologies, so it becomes difficult to differentiate. We report one case of

34-year-old male, uncircumcised, with a painful multiple genital ulcer, he only have a sexual intercourse

with his wife, but conduct an oral sex. So our working diagnosis was genital herpes and we treated the

patient with valacyclovir 500 mg, twice daily, for 7 days. But turns out, the result of the culture for

microorganism was shown an unspecified fungal colonies growth, instead of bacteria. And also, after one-

week treatment, the ulcer became more profound and felt itchy rather than pain. We changed our working

diagnosis to balanoposthitis due to fungal infection with a suspicion of Candida albicansand treated the

patient with fluconazole 150 mg, single dose, bifonazole 1% cream and hydrocortisone 1 % cream twice

daily. After 5 days with a new regimen of treatment, almost all the ulcer was healed, no itchy or pain

sensations. With this case report, we hope that as a clinicians, we can be more careful and thorough in

examining a patient with a genital ulcer. A KOH examinations can be a consideration for an additional

diagnostic tools.

1 INTRODUCTION

Sometimes, we find a genital ulcer case in our daily

practice. This condition can be differentiate by the

etiologies, infectious or non-infectious. The most

common cause for the infectious etiology are from

sexually transmitted infections (STI), such as herpes

simplex virus (HSV), syphilis (Treponema pallidum),

chancroid (Haemophilus ducreyi), lympho

granuloma venereum (Chlamydia trachomatis),

fungal infection (e.g., Candida species) and others.

In America, the most common cause of genital ulcer

are HSV type 1 and 2, followed by syphilis and

chancroid. (Roet MA et al., 2013; Ballard RC, 2008)

Usually, ulcer is accompanied with pain or

uncomfortable sensation. That’s why finding the

right etiology in the most efficient time, is so

important.

We report one case of genital ulcer that was

caused by a fungal etiology. At first, we thought

about an atipical genital herpes symptom but later on

the manifestations was changed. Balanoposthitis due

to candida infection only occurs 20% of all

balanoposthitis cases. (Edwards EK et al.,

2013).That’s why it is quite important for us, as

clinicians, to be more careful and examine patient

more thoroughly in the future. Thus, we can

consider a KOH examination for an additional

simple diagnostic tools to make a decision.

2 CASE

A 34-year-old man, Japenese origin, presented with

a multiple genital ulcer since 2 days before (Figure

1). He felt moderate pain upon pressure and also

uncomfortable sensation while urinating. No history

of discharge from urethra. He said that his last

sexual intercourse is only with his wife. He also did

an oral sex. He hasn’t give any topical medicine or

taking an oral medication for his conditions. No

fever or other prodromal symptoms. On the physical

examinations, the penis was uncircumcised and there

were multiple ulcers, around 10 – 15 ulcers,

Indriatmi, W. and Komala, G.

Multiple Genital Ulcer on a Male Patient Due to Fungal Balanoposthitis Suspect of Candida Albicans Infection Mimicking Genital Herpes: A Case Report.

DOI: 10.5220/0009987903250328

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 325-328

ISBN: 978-989-758-469-5

325

approximately 1 mm – 5 mm diameters, mostly on

the preputium and a few on a coronary sulcus. The

ulcer itself was shallow, clean, moist, no induration,

confluence, tender, no active discharge, and edema

surrounding the ulcer. No lymph nodes enlargement

on the inguinal area.

Figure 1.Clinical image of multiple ulcers on preputium

and a few on coronary sulcus.

We did some laboratory examinations for this

patient, consist of HSV-1 IgM, HSV-2 IgM, VDRL,

TPHA, Anti-HIV, resistance and microorganism

culture examination from the base of the ulcer, and

complete urinalysis. The complete urinalysis just

showed a slightly increase in white blood cells count

(5-7/Hpf). So, our working diagnosis was initial

lesion of genital herpes. We gave him valacyclovir

500 mg, twice daily, for 7 days.

One week later, the patient came for a second

visit. The rest of the laboratory result was finished,

all were within normal limit except for the resistance

and microorganism culture examination, showed an

unspecified fungal colonies. He also complains that

the ulcer was getting worse, itchy instead of pain

and there’s an active discharge from his ulcer. He

also stated that his wife also complain of itchy in her

genital. From the physical examination, the numbers

of the ulcers was increased, become a deep red

colour, some confluenced with each other, and a

thick curdy white-yellowish exudate (Figure 2 and

3). So, we changed our working diagnosis from

HSV infection to fungal balanoposthitis, with

suspicion of Candida albicansinfection. We treated

him with a single dose of fluconazole 150 mg orally,

topical bifonazole 1% cream, twice daily and topical

hydrocortisone 1% cream, twice daily. The

hydrocortisone was applied right after the bifonazole

cream.

Figure 2.A thick curdy white-yellowish exudates covering

most of the glans penis.

Figure 3. After being cleaned with normal saline, the ulcer

was showed more deep red color and there was a few new

small ulcers, on the glans of the penis and coronary sulcus.

Five days later, the patient came in again for a

follow up. The pain was minimal, no itchy, no

discharge and the number of ulcers were less than

before. Physical examination showed no ulcer,

erythema and discharge (Figure 4). So we

considered the treatment was completed.

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Figure 5. Healed of multiple ulcer after anti fungal

treatment.

3 DISCUSSION

A multiple genital ulcer usually caused by sexual

transmitted infection (STI), such as HSV, syphilis

and chancroid. Risk factors for genital ulcers are

lack of male circumcision, multiple sex partners (life

time or current), nonrecognition of ulcers in

prodormal stage, serodiscordant sex partners,

unprotected sexual contact and uprotected skin to

skin contact with ulcers. In genital ulcer case, we

should ask for more complaints in addition to the

symptoms of STI. Moreover, the past medical and

sexual history is important to assess the risk

behavior of the patient with STI. .(Roet MA et al.,

2013; Ballard,2008)

Balanoposthitis is defined as inflamation of the

glans or the prepuce.(Edwards EK et al., 2013;

Griffiths et al., 2016). A lot of condition can affect

the glans condition, from infectious to non-

infectious. Infectious etiologies such as Candida

species, Streptococci, anaerobes, Staphylococci,

Trichomonasvaginalis, herpes simplex virus etc. For

non-infectious such as, lichen sclerosus, lichen

planus, psoriasis, zoon balanitis, eczema to

premalignant condition, such as bowen’s disease,

bowenoid papulosis. (Ballard RC, 2008) But, all

cases of balanoposthitis was associated with poor

hygine and uncircumcised.(Edwards EK et al., 2013;

Habif TP, 2016; Griffiths et al., 2016). In this case,

the patient had a history of unprotected sex, he

confessed he only have sexual intercourse with his

wife. Patient’s history matches the risk factors for a

genital ulcer and also balanoposthitis.

Genital ulcer has several characteritics according

to the causative agent.(Roet MA et al., 2013; Ballard

RC,2008; Kundu RV, 2012; Habif TP, 2016; Farida

Z 2015). Genital HSV infection usually begins as

multiple vesicular lesions, located inside the foreskin,

labia, vagina, or rectum. Vesicles may rupture

spontaneously, becoming painful, shallow ulcers.

Sometimes there’s a prodormal symptoms, around

20% of the case. Primary syphilis usually begins

with a single, painless, well-demarcated ulcer

(chancre) with a clean base and indurated border.

Chancroid ulcers are usually deep, nonindurated,

bleeds easily, painful and usually cover with

yellowish grey exudate. The ulcers occur on the

prepuce and frenulum of the penis in men or on the

vulva or cervix in women.(Kundu RV et al., 2013;

Habif TP, 2016; Griffiths et al., 2016)

Candida balanoposthitis less than 20% of cases

of balanoposthitis3, and the most common pathogen

is Candida albicans.

It can give a manifestation as

maculopapular lesions with diffuse erythema, edema,

ulcerations, and fissuring of prepuce, also itchy

sensation.(Edwards EK et al.,2013; Habif TP, 2016

In our patient, with a multiple shallow genital ulcer,

painful in the beginning, it’s really similar with the

herpes simplex ulcer. That’s why we diagnosed this

patient as genital HSV infection, at first. But later,

when the symptoms become itchy and especially the

culture showed a fungal growth, it become more

convincing to suspect of Candida albicansinfection.

It’s important to determine a causative etiology

for genital ulcer. Laboratory evaluation of an initial

genital ulcer should include culture or polymerase

chain reaction, testing for HSV infection, HSV type-

specific serology, serologic testing for syphilis, and

culture for H. Ducreyiin settings with a high

prevalence of chancroid. For candidalbalanoposthitis,

the work ups are sub-preputial culture and KOH

examinations.

1-3

This patient was done a serology test

for syphilis, HSV, HIV, culture examination, gram

examinations and complete urinalysis. We didn’t do

a KOH examination, because of the manifestations,

we haven’t thought about fungal infection in the first

place. But it can be a learning experience for

clincians when facing this kind of cases in the future.

The treatment for genital ulcers is depend on the

causative agent but for candida balanoposthitis, the

recommended topical regimens are clotrimazole

cream 1% and miconazole 2% cream. For the

alternative regimen, are fluconazole 150 mg

3,10

orally (if the symptom is severe) or nystatin 100.000

units/gram

(if resistance or allergy to imidazoles).

Although there’s one case report in China, 2016,

about a Candida albicansresistance towards

Multiple Genital Ulcer on a Male Patient Due to Fungal Balanoposthitis Suspect of Candida Albicans Infection Mimicking Genital Herpes:

A Case Report

327

fluconazole, so they’re implied to treat C.albicans

infection according to the drug sensitivity test.(Hu Y

et al., 2017).Topical imizadole can also be applywith

hydrocortisone 1% if there’s a sign of marked

inflammation.(Edwards EK et al., 2013).For this

patient we gave himfluconazole 150 mg, single dose,

orally, because we thought the discharge from the

candida is alot and there’s also a marked inflamation

around the ulcer. We also gave bifonazole 1% for

thetopical antifungal and hydrocrotisone 1% for the

inflamation. Balanoposthitis is often reccurenton a

poor hygene person, so the main definitive therapy

for this is circumcision.( Habif TP, 2016)

4 CONCLUSION

Genital ulcer is just a clinical manifestation which

sometimes can be difficult to diagnose properly.

Balanoposthitis is an inflamation in glans or prepuce,

but turns out, it can also manifest as a genital ulcer.

So, when it’s confusing to make a diagnosis for

genital ulcer, KOH examinations can be considered

as additional work up to find the causative etiology

of balanoposthitis in the future, especially when the

patient is uncircumcised.

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