Lipschütz Ulcer in an Adolescent Girl: A Rare Manifestation Associated with SARS-CoV-2 Infection


Lipschütz ulcer, a rare and self-limited condition, is characterized by the sudden onset of painful vulvar ulceration, with a higher prevalence in adolescent girls. Unlike other sexually transmitted infections (STIs), Lipschütz ulcer is not associated with sexual activity. In this case study, we explore the unique presentation of Lipschütz ulcer in an 11-year-old girl, linking it to a recent SARS-CoV-2 infection.

Case Presentation: The patient, a previously healthy and sexually inactive 11-year-old girl, presented with a two-day history of dysuria leading to urinary retention. Five days prior, she had been diagnosed with active SARS-CoV-2 infection, experiencing fever in the initial three days without respiratory symptoms. Notably, the patient had no history of recurrent oral/genital ulcers, and there was no family history of Behçet’s or Crohn’s disease.

Clinical Examination: Upon physical examination, the patient displayed a distended bladder, along with three painful vulvar ulcers and vaginal exudate. Remarkably, her hymen was intact. The clinical findings aligned with Lipschütz ulcer, a condition previously linked to viral infections.

Investigations: In-depth testing ruled out other viral infections, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), adenoviruses, and influenza A and B. Moreover, traditional STIs, such as herpes simplex virus type 1/2, Chlamydia trachomatis, Haemophilus ducreyi, human immunodeficiency virus, and syphilis, were also excluded. The diagnosis of Lipschütz ulcer was suspected when SARS-CoV-2 was detected through reverse transcription polymerase chain reaction (RT-PCR) in a nasopharyngeal swab sample.

Treatment: The patient received topical fusidic acid and lidocaine 2% as part of the treatment plan. After 10 days, she exhibited significant clinical improvement, with the ulcers showing signs of healing. A residual scar was noted, emphasizing the self-limited nature of Lipschütz ulcer.

Discussion: Lipschütz ulcer, although rare, should be considered in the differential diagnosis of painful vulvar ulceration, especially in adolescent girls. This case adds to the growing body of literature linking Lipschütz ulcer to viral infections, with SARS-CoV-2 being a notable example. The absence of a history of recurrent ulcers and the intact hymen further underscore the unique nature of this case.

Conclusion: Complete resolution of Lipschütz ulcer is expected, emphasizing the importance of early diagnosis and treatment to prevent complications such as urinary retention. This case highlights the need for healthcare providers to be aware of the diverse manifestations of SARS-CoV-2 infection, including rare conditions like Lipschütz ulcer, especially in pediatric populations. Further research is warranted to explore the underlying mechanisms linking viral infections, such as SARS-CoV-2, to the development of Lipschütz ulcer.

Exploring SARS-CoV-2 Omicron Variant Transmission Dynamics: Insights from Pharyngeal, Vaginal, and Anal Swab Analyses in Non-Pregnant Women

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, is an RNA virus characterized by high mutation potential. The virus adapts to new hosts through the process of “mutation-selection-adaptation,” resulting in a strain with robust replication ability that often lacks severe pathogenicity for most hosts. Recent studies have suggested that the virus evolves towards increased spreading ability and decreased pathogenicity (Cameroni et al., 2022; Cao, 2020; Liu et al., 2021).

Viral Presence in Various Body Fluids:

Since the onset of the COVID-19 pandemic, SARS-CoV-2 has been detected in various body fluids, including nasopharyngeal secretions, feces, urine, semen, and tears (Wang et al., 2020). Notably, the virus’s presence in the gastrointestinal (GI) tract has been a subject of interest, with studies indicating viral RNA detection in feces nearly as frequently as in respiratory secretions. Moreover, the positive rate of nucleic acid detection in anal swabs has been linked to the severity of the disease (Xu et al., 2020; Zhang et al., 2020).

Recent research by Natarajan et al. (2022) focused on mild to moderate COVID-19 cases and revealed that viral RNA in feces persisted for several months, correlating with GI symptoms. This finding is valuable for estimating population-level prevalence through wastewater studies. The virus’s presence in the female reproductive tract has shown varied results, with some studies detecting SARS-CoV-2 in vaginal secretions, especially in mild cases (Schwartz et al., 2021; Barber et al., 2021).

The Omicron Variant:

The emergence of the Omicron variant, characterized by substantial mutations, has raised concerns regarding its transmission dynamics and immune escape capabilities. Notably, the variant exhibits enhanced binding affinity to the human ACE2 receptor, leading to increased infectivity compared to earlier strains (Cameroni et al., 2022; Tian et al., 2022).

Moreover, the Omicron variant demonstrates reduced neutralizing antibody titers in individuals with three vaccinations, highlighting the potential for immune evasion. While the variant’s gene mutations enhance transmission, they also pose challenges in antibody-mediated immunity (Wang et al., 2022).

Investigating Transmission Routes:

To assess the potential routes of transmission for the Omicron variant, a study conducted simultaneous nucleic acid detection in pharyngeal, vaginal, and anal swabs in non-pregnant infected women. The findings indicated a limited ability of the Omicron variant to invade the digestive tract, with low detection rates in anal swabs. No SARS-CoV-2 was detected in vaginal fluid, aligning with previous studies (Cui et al., 2020; Qiu et al., 2020; Uslu Yuvacı et al., 2021).

Possible Explanations for Vaginal Fluid Findings:

While some studies reported positive cases in vaginal fluid, potential explanations include the low expression of ACE2 receptors in vaginal tissue, the timing of sampling, low viremia incidence, host immune status, and sample size variations (Morelli et al., 2021).

Clinical Characteristics and Vaccination Status:

The clinical analysis of 63 patients infected with the Omicron variant revealed a higher proportion of mild infections than asymptomatic cases. Age, menopausal status, underlying diseases, and hospitalization duration did not significantly impact symptom severity. Vaccination, even with more than two doses, did not prevent mild disease, suggesting a potential weakening of vaccine effectiveness against the Omicron variant.

Clinical Manifestations and GI Symptoms:

Common clinical manifestations in mild cases included upper respiratory tract symptoms, possibly related to the Omicron variant’s replication in bronchial epithelial cells. The correlation between GI symptoms and viral RNA in the GI tract remains uncertain, with diarrhea in some cases not consistently linked to positive anal swabs.

As of June 7, 2020, the Centers for Disease Control and Prevention (CDC) reported a total of 8,207 cases of COVID-19 in pregnant women, accounting for approximately 9% of cases among women of reproductive age with available pregnancy status data. This chapter delves into the specific findings of this report, providing a nuanced analysis of the impact of COVID-19 on pregnant women.

Pregnancy Status and Demographics: The report notes that the percentage of COVID-19 cases among pregnant women is higher than expected, possibly due to an increased risk for illness or the high proportion of missing data on pregnancy status. The findings also suggest that pregnant women who are Hispanic and black might be disproportionately affected by SARS-CoV-2 infection during pregnancy, with 46% being Hispanic, 22% black, and 23% white.

Symptoms and Comorbidities: Analysis of symptom data reveals that similar percentages of pregnant and nonpregnant women were symptomatic, but one-third of pregnant women had missing symptom status, raising the possibility of a higher proportion of asymptomatic cases among pregnant women. Notably, pregnant women reported lower percentages of fever, muscle aches, chills, headache, and diarrhea compared to nonpregnant women. The report highlights an increased prevalence of diabetes mellitus, chronic lung disease, and cardiovascular disease among pregnant women, emphasizing the need for further investigation into the impact of these comorbidities on COVID-19 outcomes.

Hospitalization and Severity of Illness: While hospitalization occurred more frequently among pregnant women, distinguishing COVID-19-related hospitalizations from those related to pregnancy was challenging. However, after adjusting for relevant factors, pregnant women exhibited significantly higher risks for ICU admission and receipt of mechanical ventilation compared to nonpregnant women. These findings align with international studies, such as the one conducted in Sweden, indicating elevated risks for severe outcomes in pregnant women with COVID-19.


This study provides crucial insights into the transmission dynamics of the Omicron variant in non-pregnant women. The limited dissemination capacity through the GI tract and the low possibility of transmission through the lower genital tract suggest specific patterns for this variant. Further comprehensive research is warranted to confirm these findings and guide public health measures in the face of evolving SARS-CoV-2 variants.

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