Genital Ulcer as a Complication of COVID-19 Infection: A Case Report

Abstract

Coronavirus disease 2019 (COVID-19), as a pandemic disease and a global concern, is a respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Besides its common symptoms, some other less common symptoms, including genital ulcers, have been reported. Other complications such as autoimmune disease can present with genital ulcers. Differential diagnosis includes Reiter syndrome, Behcet’s disease, and psoriasis. We report a 32-year-old married man with genital ulcers due to COVID-19 infection and as a complication of his disease.

Introduction

COVID-19, as a pandemic disease and a global concern, is a respiratory tract infection caused by SARS-CoV-2. Its common clinical manifestations include fever, cough, fatigue, sputum production, shortness of breath, sore throat, and headache. Besides its common symptoms and considering its effect on various body organs, some other less common symptoms have been reported. The disease’s manifestations vary among different patients. It can cause various skin manifestations in various kinds in some parts of the skin including the genital area. Such reports have been published in different countries and regions with varying prevalence (Singh et al., 2021).

Case Presentation

A 32-year-old healthy married single-partner non-smoking man presented with a chief complaint of penile ulcers. He was a known case of COVID-19, confirmed by positive polymerase chain reaction (PCR) test 14 days ago. Symptoms first appeared as bullae on the second day of his episodes of non-documented high-grade fever because of COVID infection. After bullae were ruptured, erosive lesions appeared. Lesions were hemorrhagic and had sputum discharge. As can be seen from Figure 1, the areas of genitalia that were involved included glans of penis, corona glandis, external orifice, and dorsal and ventral surface of penis body. He did not point to any lower unitary tract symptoms (LUTS), and there was no evidence of pain or tenderness of lesions. The patient denied any recent sexual risk behavior. He did not declare any history of autoimmune disease in himself or his family. He did not declare any history of specific drug consumption. Review of system was negative except for the above-mentioned. Besides the COVID infection’s drugs, clobetasol propionate ointment and mupirocin 2% ointment were prescribed twice a day for topical consumption for the ulcers. He was also recommended to wash the wounds with normal saline (0.9%) every 12 hr. The ulcers’ response to the chosen treatment was satisfying and symptoms subsided immediately after the drugs’ consumption started. After 2-week follow-up, the lesions were completely healed, and there was no evidence of recurrent ulcer or any prolonged symptoms of LUTS in the patient.

Figure 1.

Erosive Lesions Involving Glans of Penis, Corona Glandis, External Orifice, and Dorsal and Ventral Surface of Penis Body

Discussion

Genital ulcers as a clinical manifestation has multiple differential diagnosis including viral infections (Herpes zoster virus [HZV] type 1 and 2, Epstein–Barr virus [EBV], cytomegalovirus [CMV], etc.), autoimmune disease (Behcet’s disease, Reiter’s syndrome, and psoriasis), and sexually transmitted diseases (STDs). As reported by Krapf et al. (2021), Lipschütz ulcers could be associated with COVID infection as reactive non-sexually related genital ulcers in adolescent women.

Another study reported that genital ulcers as a manifestation of COVID infection were very rare and uncommon. Multiple viral infections such as HZV, HIV, CMV, and EBV can trigger Lipschütz ulcers. After reports of these ulcers’ association with COVID infection, it seems that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be added to the list above and should be considered (Jacyntho et al., 2022).

Autoimmune disease can be a cause for genital lesions as we noted earlier. Daunt and colleagues reported genital manifestation of a woman with Reiter’s syndrome. Skin manifestations of this disease could be restricted to the genital area and could be associated with other lesions. Diagnosis is established when other probable causes are ruled out by multiple laboratory tests (Daunt et al., 1982).

One of the most important autoimmune diseases that is reported to be associated with genital ulcers is Behcet’s disease. Behcet’s disease is a chronic, recurrent, multisystemic vasculitis that can be presented by multiple clinical manifestations, and as Guedes-Barbosa reported in his study, one of those manifestations can be genital ulcers. In the case reported by him, the patient was complaining of recurrent oral and genital ulcers associated with a history of erythema nodosum (Guedes-Barbosa, 2019).

Most of the patients reported in similar studies were adolescent women, and there was less report and evidence of genital manifestation of COVID infection in men. Our findings were not in contrast with other studies, and similar to other studies, we emphasize on the importance of genial manifestations of the novel coronavirus infection as a newly seen complication of the disease. However, it is important to point out that we can establish the diagnosis only if we rule out other probable causes with proper laboratory tests.

Conclusion

COVID-19 has a wide spectrum of clinical manifestation and symptoms. One of those symptoms could be genital ulcers. Most studies reporting genital ulcer as a complication of COVID-19 infection were on female patients, but as we reported, these lesions can be seen in male genitalia as well. SARS-CoV-2 infection should be taken into account as a differential diagnosis of genital ulcers. Its diagnosis can be confirmed only if we rule out other possible diagnoses.