P3C027: Lipschütz Ulcers in a Pre-adolescent Female Following covid-19 Vaccine

Introduction: Persistent vulvar ulcerations in children are uncommon, and an array of etiologies can be considered including infection, autoinflammatory and autoimmune conditions, and non-accidental trauma. In cases that lack a clear etiology, differentiating among the various possible causes warrants a detailed medical and sexual history along with laboratory workup.

Case Description: We describe the case of an 11-year-old girl with acute onset of painful vulvar ulcerations alongside fever and sore throat shortly after receiving the Pfizer Covid-19 vaccine. After an unremarkable workup for infectious and inflammatory etiologies and nonspecific histology from punch biopsies of the lesion, she was diagnosed with Lipschutz ulcer. Her symptoms resolved with 3 weeks of topical steroids and supportive care.

Discussion: Lipschütz ulcers, also known as reactive nonsexually related acute genital ulcerations, are painful genital lesions that most commonly occur in adolescent, sexually inactive women.

Given that genital ulceration in pre-adolescent females can have broad array of etiologies, Lipschütz ulcers are considered a diagnosis of exclusion. Infectious etiologies to consider on the differential diagnosis include viral infections such as HSV, CMV, and EBV, as well as mycoplasma, bullous impetigo, and syphilis. Inflammatory and autoimmune conditions including Crohn’s disease, Bechet syndrome, pyoderma gangrenosum, and autoimmune blistering conditions should be ruled out. A thorough history, including sexual history taken in confidence without the caregiver present, is crucial to assess for sexual abuse and accidental or non-accidental mechanical, thermal, or chemical trauma.

In this case, low clinical suspicion for sexual abuse, negative infectious studies, and unremarkable review of systems and laboratory workup for underlying inflammatory conditions pointed toward a diagnosis of Lipschütz ulcers. She tested negative for influenza and EBV, which are known viral associations with Lipschütz ulcers. Her findings were likely associated with the Covid-19 vaccine given temporality of receiving the vaccine prior to ulcer onset and associated transient fever and sore throat.
There have been numerous cases of vulval aphthous ulcers associated with Covid-19 infection and/or immunization reported in the literature since the onset of the Covid-19 pandemic. This novel association is important to be aware of to facilitate more prompt diagnosis and avoidance of extraneous testing.
Lipschütz ulcers generally self-resolve within weeks, and treatment is primarily supportive with sitz baths as well as pain relief with oral analgesics and topical anesthetics.

Conclusion: Vulvar ulcerations in children have a broad differential diagnosis, and it is important to uphold suspicion for Lipschütz ulcers in young sexually inactive girls. Knowledge of this entity may facilitate avoidance of extraneous tests and invasive procedures. Covid-19 infection and vaccination is a newer reported entity associated with the development of Lipschütz ulcers.