Q & A: New Case - Vaginal Adhesions

Q.

I have a 30 year old patient who was diagnosed with recurrent herpes about 9 months ago. I documented the lesions with cultures and treated her with three different antivirals. Despite all of them, she continued to have painful vaginal erethematous spots in the vagina and on the vulva. She cultured negative, but the symptoms never went away. We then tried a series of creams and douches, in the way of wound care and eliminating bacterial superinfections, which didn't help. I tried three weeks of nothing, thinking we had developed an inflammatory response to all of the medications, which did not improve the picture. I biopsied some lesions and got only inflammatory response. I then referred her to an infectious disease colleague, who treated her with prophylactic antivirals for three months. In the meantime, we did a series of blood tests and ruled out HIV, and auto immune groups. I just saw her back and she had narrowing of the vagina (she has been abstaining from sex during the last 6 months), and on digital exam, I found I was breaking up rather dense adhesions throughout the vagina and at the top of the vagina around the cervix. In 20 years, I have never seen the vagina form adhesions like this. Any ideas you have would be greatly appreciated. Both my infectious disease colleague and I are stumped. I plan an exam under anesthesia and multiple biopsies,

A.

Joe P: Well, there is the old maxim which is applicable to ALL of medicine: Never let a patient die without steroids.

Since the lesions are apparently NOT infectious and they ARE inflammatory, then I think you can't help but think about a course of SYSTEMIC steroids, and observe...

Bob Woolley: I'm puzzled why you seem to be focussing on this being infectious. Seems to me you proved adequately long ago that these spots are not herpetic. So why do you persist in treating them as though they were? Yes, she has herpes, but she has something else causing these spots. Scratch viral agents off the list of possibilities.

I assume you all know the three laws of dermatology:

1) If they're on steroids, take them off; if they're not on steroids, put them on.

2) If it's dry, wet it; if it's wet, dry it.

3) If you know what it is, you don't need to touch it; if you don't know what it is, you don't want to touch it.

Jay Naliboff, MD: The only similar case I have seen turned out to be licen planus of the vagina and vulva. Does she have any oral lesions? 

Note: This is an extract from the Medical Professional Forum. Click here to view the original thread.