Verrucous condyloma lata mimicking condyloma acuminata: An unusual presentation.

A 15-year-old boy from a child center presented with a three-month history of a growth in the perianal region. There was a history of repeated peno-anal sexual exposures. On examination there was a fleshy, hyperpigmented, verrucous plaque around the anal verge. The Venereal Disease Research Laboratory Test was reactive in a titer of 1 : 64. Lesional biopsy showed marked epidermal hyperplasia without koilocytes, with a dermal infiltrate composed of lymphocytes, plasma cells and histiocytes. Patient was treated with parenteral penicillin with complete healing of the plaque. This is a rare presentation of secondary syphilis showing condyloma lata resembling condyloma acuminata.

INTRODUCTION

Syphilis is a sexually transmitted disease known to have varied presentations and hence it is known as the ‘Great Imitator’.[1] The lesions of secondary syphilis that appear in the mucocutaneous areas are called as condyloma lata. Generally, they are reddish-brown or purple, flat-topped and moist and are seen in the anogenital region.

Here we report an unusual presentation of verrucous condyloma lata masquerading as condyloma acuminata. This is the first report of such a morphological variant in literature.

CASE REPORT

A 15-year-old boy from a child center presented with a three-month history of a growth in the perianal region. There was a history of repeated sexual assaults peno-anal type with the patient being the receptive partner. There was no history of any raw lesions on the genitals, urethral discharge and burning micturition, rash on the body or any constitutional symptoms. On examination, there was a fleshy, hyperpigmented, verrucous plaque about 4 cm in diameter circumferentially around the anal verge [Figure 1]. In addition, there was a single, firm, moist, non-tender, flat-topped and pink to reddish papule of 0.5 cm in size over the shaft of the penis. There was no rash on the body and palms and soles were spared. He had multiple, discrete, non-tender, shotty lymph nodes about 1 to 3 cm in diameter of the vertical and horizontal groups of superficial inguinal lymph nodes. The cervical, submental, suboccipital, submandibular lymph nodes of about 1 to 3 cm were also enlarged. The epitrochlear lymph nodes were not enlarged. There was typical moth eaten alopecia on the scalp [Figure 2]. A provisional diagnosis of verrucous condyloma lata and condyloma acuminata was considered.

Figure 1

Condyloma lata at presentation

Figure 2

Moth eaten alopecia at presentation

The hematological and biochemical investigations were normal. The Venereal Disease Research Laboratory Test was reactive in a titer of 1 : 64. Serological testing for HIV was negative. A biopsy from the verrucous plaque and scalp was taken [Figure 3a and b].

Figure 3a

Verrucous plaque- Epidermal hyperplasia, spongiosis, dermal infiltrate on 10x

Figure 3b

Verrucous plaque-Dermal infiltrate composed of lymphocytes and plasma cells on 40x

The biopsy from verrucous plaque showed epidermal hyperplasia with a diffuse infiltrate composing of lymphocytes, plasma cells, histiocytes in the dermis devoid of koilocytes.

The biopsy from the scalp showed telogenization (increase in the telogen count) of the hair follicles with lymphocytic infiltrate and plasma cells around the hair follicles. Gomori-methamine-silver staining of tissue and scalp biopsy did not show any spirochetes.

Based on the history, examination findings and serological results, a final diagnosis of condyloma lata (verrucous type) was made.

He was treated with a single dose of benzathine penicillin 2.4 mu (1.2 mu given in each buttock) after sensitivity testing. There was a 90% reduction in the size of the perianal growth and disappearance of the lesion on the glans penis after three weeks of giving benzathine penicillin [Figure 4]. There was hair growth seen after one month [Figure 5].

Figure 4

Condyloma lata after three weeks of Benzathine penicillin

Figure 5

Hair growth after one month of Benzathine penicillin

DISCUSSION

Secondary syphilis is known to have varied cutaneous manifestations from rash to mucous membrane involvement and hair / nail changes. The common manifestations of secondary syphilis are rash (75–100%), lymphadenopathy (50–80%) and mucocutaneous lesions like mucous patches and condyloma lata (40–50%).[1] Other symptoms common at this stage include fever, sore throat, malaise, weight loss, headache, meningismus and enlarged lymph nodes. Rare manifestations that occur in about 2% of patients include acute meningitis, hepatitis, renal disease, hypertrophic gastritis, patchy proctitis, ulcerative colitis, rectosigmoid mass, arthritis, periostitis, optic neuritis, interstitial keratitis, iritis and uveitis.

Condyloma lata are flesh colored or hypopigmented, macerated papules or plaques. They have been reported in 9 to 44% of syphilis cases. Their surface may be smooth, papillated or covered with cauliflower-like vegetations. The common sites are the genital and anal areas where the condylomas are usually smooth and moist.[1] Hypertrophic condyloma lata have been reported in the axillae, umbilicus, nape of neck and inner thighs.[23] Condyloma lata resemble condyloma acuminate in being raised lesions but there are differences:

condyloma acuminata are cauliflower-like, while condyloma lata are smooth

condyloma acuminata are dry, while condyloma lata are moist

condyloma acuminata are bulky while, condyloma lata are flat

Hair loss may be the only presenting sign of secondary syphilis[4] in 3 to 7% of patients. It may be patchy, diffuse or both. The more characteristic moth-eaten type consists of non-scarring alopecia throughout the scalp but predominantly on the occipital and parietal regions. It can also involve the eyebrows and the beard areas. Histopathology and clinically syphilitic alopecia resembles alopecia areata. Both show perivascular and perifollicular lymphocytic infiltrate and telogenization of hair follicles. Syphilitic alopecia will show follicular plugging, lymphocytic and plasma cell infiltrate around hair follicles and follicle-oriented melanin clumping while alopecia areata will show eosinophilic and lymphocytic infiltrate predominantly.[5] Clinically, alopecia areata patches are larger, round and smooth and only a few in number. Characteristic exclamation mark hairs can be easily demonstrated.

In our patient, a very high index of suspicion helped us to consider condyloma lata as the diagnosis.

The first-choice treatment for all manifestations of syphilis remains penicillin. For people known to have allergic manifestations to penicillin, alternatives like doxycycline or tetracyclines have been used. On treatment the rash resolves first; it may take a few months for condyloma lata and about a year for moth-eaten alopecia to resolve completely.

A verrucous presentation of condyloma lata is very rare and a perianal verrucous variant of condyloma lata is first to be reported in literature.