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Acute genital ulcer in a 14-month-old girl

Question:
Sónia Almeida, Mónica León, Inês Sobreira, Maria Manuel Flores, Sílvia Almeida,
Department of Pediatrics, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal.

Address for Correspondence: Alameda Silva Rocha, nº 103, apart 4.4, Aveiro, Portugal, 3800-385. Email: Sonimalmeida@gmail.com

A previously healthy 14-month-old girl, presented to the emergency room with six days of fever. One day before, parents noticed a genital ulcer. Parents also mentioned some days of diarrhoea and one day of vomiting in the previous week. There was no history of trauma, suspected sexual abuse or medications. Physical examination showed a 7mm necrotic, violaceous-edged and painful ulcer with local induration and a black crust with a grey exudate on her left major labia with a symmetrical 2mm ulcer on the right major labia (“kissing ulcers”) (fig 1). There was local edema, hyperemia and a fetid smell on the left labia. Blood test revealed white cell count of 6000/cumm and C-reactive protein 6.3mg/dL. ANA was negative. Serology for herpesvirus, syphilis, hepatitis B and C, HIV, Epstein Barr virus (EBV), cytomegalovirus, mycoplasma pneumoniae and toxoplasmosis were all negative. Swabs were taken with negative results for sexually transmitted infections. Stool culture, fecal rotavirus and adenovirus antigens were also negative. She was discharged with analgesia and amoxicillin/clavulanic acid. After one day she had no fever, one week later the smaller ulcer was resolved and four weeks later the left major labia ulcer was also resolved with no scarring.

What is the diagnosis?