What is the likely diagnosis for a 54-year-old female with vaginal irritation, bleeding, and lesions after sexual intercourse, treated with Monistat (clotrimazole) and an over-the-counter 1-day pill, and presenting with dysuria upon contact with lesions?

Differential Diagnosis

• Single most likely diagnosis
  • Herpes Simplex Virus (HSV) infection: The patient's symptoms of vaginal lesions, irritation, and bleeding, along with a lesion on her finger, are consistent with a primary HSV infection. The timing of symptoms after sexual intercourse and the description of the lesions also support this diagnosis.
• Other Likely diagnoses
  • Syphilis: The patient's history of sexual intercourse with a new partner and the presence of vaginal lesions could suggest syphilis, particularly if the lesions are painless. However, the presence of pain and irritation makes this less likely.
  • Genital warts (Human Papillomavirus, HPV): The patient's symptoms of vaginal lesions could be consistent with genital warts, although the acute onset and associated symptoms of irritation and bleeding are less typical.
  • Bacterial vaginosis (BV) or yeast infection: The patient's initial symptoms of irritation and her history of BV could suggest a recurrence of BV or a yeast infection, although the development of lesions and the lack of response to over-the-counter treatment make this less likely.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • HIV infection: Although the patient denies any history of STDs, her high-risk behavior (frequent travel to Mexico to see her boyfriend) and symptoms of vaginal lesions could suggest an HIV infection, particularly if she is in the acute retroviral syndrome phase.
  • Lymphogranuloma venereum (LGV): This is a rare but serious STD that can cause genital lesions, and the patient's symptoms and travel history could suggest this diagnosis.
• Rare diagnoses
  • Granuloma inguinale (Donovanosis): This is a rare STD that can cause genital lesions, although it is typically associated with more chronic symptoms and is less likely given the patient's acute presentation.
  • Molluscum contagiosum: This is a viral infection that can cause skin lesions, although it is typically associated with more benign symptoms and is less likely given the patient's genital symptoms.