Pattern Recognition

I recently saw a 36-yr-old female who had a 5-day history of vaginal irritation with a "burning" sensation.  She was seen a few days earlier and given diflucan for a presumed yeast infection, but her condition had not improved.  She told me, "It just really burns" and "When I try to pee, nothing comes out".  Her UA and GC/CT were negative.  On physical exam, her labia was erythematous and markedly swollen.  I suddenly remembered the last time I saw a patient with a similarly swollen labia and the same complaint of dysuria and urinary retention: it was a 14-yr-old girl who had come to the pediatric ED where I was doing a residency rotation. We initially suspected cellulitis.  She was in so much pain that conscious sedation was required for her pelvic exam.  After a meticulous search, we finally found a vesicular lesion: it turned out this young girl had the worst case of genital herpes in the history of the universe.

I did manage to find one shallow ulcerated lesion on my 36-yr-old patient's perineum which I promptly swabbed for HSV culture.  She was very skeptical about the provisional diagnosis of herpes, but she was willing to try taking acyclovir.  A few days later, the culture came back positive for HSV-2.