14-year-old girl with insulin-dependent diabetes mellitus presented to
us with a 3-day history of burning vaginal pain. She had no fever,
vomiting, or diarrhea. She had no previous hospital admissions for
diabetes, and had no history of any sexually transmitted diseases.
Examination showed an erythematous and edematous perineal area dotted
with numerous painful vesicles extending over the entire external
genital organs, including clitoris, labia majora and the anal region (Fig.
1); along with inguinal lymphadenopathy. There was no vaginal
discharge. Blood gas analysis revealed metabolic acidosis, and urine
examination confirmed presence of glycosuria and ketonuria. We diagnosed
her as having diabetic ketoacidosis induced by genital herpes infection.
Herpetic serology was initially negative, but seroconversion for herpes
simplex virus 2 (IgM) was documented after one month. She was treated
with intravenous aciclovir (10 mg/kg/dose 8 hourly) for 10 days along
with insulin therapy. Genital lesions began to improve after two days of
treatment.
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Fig. 1 Multiple vesicles over genital
region in an adolescent girl.
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Genital lesions caused by herpes simplex virus are
rare in children and adolescents, who are not sexually active. The main
differential diagnosis is vulvo-vaginal candidiasis, which is
characterized by the pruritus and raspberry aspect of the inguinal folds
surmounted by whitish coating. In the presence of a clump of painful
vesicles associated with inguinal adenopathy, the diagnosis of genital
herpes is very likely.