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Revista da Sociedade Portuguesa de Dermatologia e Venereologia

versão impressa ISSN 2182-2395versão On-line ISSN 2182-2409

Rev Soc Port Dermatol Venereol vol.79 no.3 Lisboa set. 2021  Epub 30-Set-2021

https://doi.org/10.29021/spdv.79.3.1346 

Case Report

Extensive Condylomata Lata as the Only Manifestation of Secondary Syphilis

Condiloma Lata Exuberante como a Única Manifestação de Sífilis Secundária

Rita Bouceiro-Mendes1 
http://orcid.org/0000-0002-5034-3613

Leandro Silva2 
http://orcid.org/0000-0001-7804-3092

Pablo Espinosa-Lara1 
http://orcid.org/0000-0003-0692-7301

Luís Soares-de-Almeida1  3 
http://orcid.org/0000-0003-4026-6105

J. Borges-da-Costa1  3  4 
http://orcid.org/0000-0001-8903-209X

1Dermatology Department, Hospital de Santa Maria, Centro Hospitalar e Universitário Lisboa Norte, Lisboa, Portugal;

2Dermatology Department, Hospital Egas Moniz, Lisboa, Portugal

3Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal

4Instituto de Higiene e Medicina Tropical, Lisboa, Portugal


ABSTRACT

Syphilis is a sexually transmitted infection with a multiplicity of clinical presentations that has been known for centuries. Recently, a new wave of syphilis has been reported in developed countries and men who have sex with men, especially those coinfected with human immu-nodeficiency virus (HIV), have the highest rates of syphilis infection. In these patients, cutaneous manifestation can be even more diverse. We report a case of secondary syphilis in a young male patient coinfected with HIV whose presentation consisted of extensive condylomata lata lesions.

KEYWORDS: Condylomata Acuminata/etiology; Syphilis/complications; Syphilis, Cutaneous/complications.

RESUMO

A sífilis é uma doença de transmissão sexual com um vasto leque de manifestações clínicas, conhecida desde há séculos. Nos últimos anos, esta infeção tem ressurgido nos países desenvolvidos, especialmente no grupo de homens que têm sexo com homens (HSH). Dentro deste grupo populacional, a incidência de sífilis atinge o pico, naqueles com infeção concomitante pelo vírus da imunodeficiência humana (VIH). Nestes doentes, as manifestações de sífilis são ainda mais diversificadas e atípicas. Descrevemos um caso de sífilis secundária num doente HSH com coinfecção pelo VIH, cuja manifestação consistiu unicamente em lesões extensas de condiloma lata.

PALAVRAS-CHAVE: Condiloma Acuminado/etiologia; Sífilis/complicações; Sífilis Cutânea/complicações

INTRODUCTION

Syphilis is an infectious disease caused by the bacteria Treponema pallidum that is transmitted through direct contact with infected mucosal lesions. It is most commonly transmitted by sexual contact, but it can also be spread congenitally.1-4Thirty percent of sexual partners of recently infected patients develop syphilis.3,5In infected individuals, T. pallidum disseminates within days after infection resulting in early invasion of distant tissues.6 Clinical manifestations are the result of inflammatory responses elicited by the replicating bacteria within the tissues1,4and are highly variable often mimicking those of other diseases.1,4,5If left untreated the disease can progress over years through four stages (primary, secondary, latent, and tertiary) and lead to serious cardiovascular or neurological complications.2-4The primary stage of the infection is classically defined by an asymptomatic, indurated genital ulcer at the inoculation site.3,7Secondary stage usually occurs 6 to 8 weeks after the onset of the primary phase8 and it is the most florid and clinical diverse stage of the disease.5,9It classically features a symmetric, copper-coloured, maculopapular skin rash of any morphology, presenting typically on the palmar and plantar surfaces.3 Verrucous lesions, appearing as moist exophytic plaques, especially on mucus surfaces, referred as condylomata lata, have also been described.7 Syphilis remains a worldwide problem and incidence rates have increased substantially around the world especially in men who have sex with men (MSM) and in human immunodeficiency virus (HIV) infected individuals.3,6,8

CASE REPORT

A 24-year-old Caucasian male patient was observed in our Dermatology Department for a one-month history of mildly pruritic and painful growing perianal skin lesions. The patient was HIV-seropositive, and he was on antiretroviral therapy with regular appointments (CD4 cell count was normal and viral load was undetectable). He referred one sexual male partner in the last 6-months and reported no history of genital ulcer nor other previous skin lesions.

Physical examination revealed multi-lobulated masses in the perianal area forming rubbery, skin-coloured, plaques and masses with a smooth and moist surface (Fig. 1A). Broad-based papillomatous whitish plaques were also observed in the oral mucosa (Fig. 1B). There were no abnormal cutaneous findings on his palms, soles, trunk or extremities, or any sign of concomitant systemic disease.

A 4-mm punch skin biopsy of the perianal lesions and serological tests were performed. T. pallidum antibodies in the patient’s serum were reactive, T. pallidum hemagglutination (TPHA) assay was positive. In addition, rapid plasma reagin (RPR) titer was positive and the Veneral Disease Research Laboratory (VDRL) test was reactive (128 dil). Hepatitis C virus, and hepatitis B virus serology results were negative. Histopathology of the skin biopsy showed irregular acanthosis and papillomatosis, along with endothelial cell swelling and a prominent dermal infiltrate, rich in lymphocytes and plasma cells (Fig. 2A & B). Immunohistochemical stains using antibodies to treponemal antigens allowed the direct detection of the spirochetes (Fig. 2C). A diagnosis of secondary syphilis, presenting as perianal and oral mucous condylomata lata, was made. The patient was treated with a single dose of 2.4 million units IM of penicillin G benzathine and advised to inform the partner for testing and treatment. Lesions resolved completed in 3 months.

Figure 1 Condylomata lata, clinical picture: (A) Multi-lobulated masses in the perianal area forming rubbery, skin-colored, plaques and masses with a smooth and moist surface; (B) Broad-based papillomatous whitish plaques in the oral mucosa. 

Figure 2 Condylomata lata, histopathological picture: (A) irregular acanthosis and papillomatosis, along with endothelial cell swelling and prominent dermal infiltrate rich in lymphocytes and plasma cells (H&E, x25); (B) Plasma cells are clearly observed within the dermal infiltrate (H&E, x400); (C) Section of the skin biopsy tissue stained with antibodies against treponemal antigens, showing the direct detection of the spirochetes (x40). 

DISCUSSION

We reported a case of secondary syphilis presenting solely as extensive condylomata lata lesions in a young male patient with HIV coinfection. Concomitant HIV and syphilis infection is becoming increasingly common since the presence of one infection facilitates the acquisition of the other and both conditions have the same route of infection.5 Besides, preexposure HIV prophylaxis is also contributing to syphilis dissemination among this community, due to decreased condom use.6 This is important because many atypical and, well-characterized but less frequent syphilis presentations have been described in patients with HIV coinfection. This diversity of clinical signs is more common during the secondary stage of syphilis.5,7,9Since syphilis is more common in MSM, a population with also high rates of HIV infection, awareness of these less common presentations that may lead to delayed diagnosis and treatment is important. In our case, the clinical presentation and the sexual history could be suggestive of condylomata lata, although extensive lesions with no other accompanying symptoms are not commonly described.10Condylomata lata, are highly infectious, intertriginous moist papules, typically associated with secondary syphilis, but less frequently observed, reported in 9%-44% of cases.11 They occur mainly on the perianal area and the vulva although atypical locations (palms, face, ankle, umbilicus and toe webs) have been described.12 Differential diagnosis includes verruca vulgaris, condylomata acuminatum, Hailey-Hailey10 and Buschke-Löwenstein tumor.13 Condylomata lata histopathology is variable but a skin biopsy revealing a dense plasma cell infiltrate and spirochetes visualized by silver or immunohistochemical stains confirms the diagnosis.14,15Direct detection of T. pallidum may be used in patients presenting with chancre, condylomata lata or lesions of congenital syphilis however, secondary syphilis diagnosis does not necessarily require histopatholo-gical examination of a skin biopsy.4,15,16In fact, the diagnosis is usually based on the patient’s history, physical examination, and serologic testing that involve treponemal and nontreponemal tests.4,6,15

Treatment recommendations do not depend on HIV status or non-treponemal test titer.15 Patients should be monitored at 6 and 12 months after treatment.

Syphilis remains an important public health and clinical problem with increasing rates among MSM. Besides, frequent co-infection of HIV and syphilis in this population is frequent. Clinicians should keep in mind that in HIV infected patients severe, persistent, and atypical manifestation are more common. The present case shows extensive condylomata lata lesions as the only manifestation of secondary syphilis in an HIV infected patient. A high index of suspicion is essential not to miss the diagnosis.

Acknowledgements

We thank Dr. Isabel Viana for performing the immunohistochemical study..

REFERENCES

1. Çakmak SK, Tamer E, Karadag AS, Waugh M. Syphilis: A great imitator. Clin Dermatol. 2019;37:182-91. doi: 10.1016/j.clindermatol.2019.01.007. [ Links ]

2. Hook EW, 3rd. Syphilis. Lancet. 2017;15;389:1550-7. doi: 10.1016/S0140-6736(16)32411-4. [ Links ]

3. O'Byrne P, MacPherson P. Syphilis. BMJ. 2019;365:l4159. doi: 10.1136/bmj.l4159. [ Links ]

4. Peeling RW, Mabey D, Kamb ML, Chen XS, Radolf JD, Benzaken AS. Syphilis. Nat Rev Dis Pri-mers. 2017;3:17073. doi: 10.1038/nrdp.2017.73. [ Links ]

5. Ivars Lleó M, Clavo Escribano P, Menéndez Prieto B. Atypical cutaneous manifestations in syphilis. Actas Dermosifiliogr. 2016;107:275-83. doi: 10.1016/j.ad.2015.11.002. [ Links ]

6. Ghanem KG, Ram S, Rice PA. The modern epidemic of syphilis. N Engl J Med. 2020;382(9):845-54. doi: 10.1056/NEJMra1901593. [ Links ]

7. Yancheva N, Petrova E, Tchervenyakova T. Atypical secondary syphilis presentation in a patient with human immunodeficiency virus infection: a case report. J Med Case Reports. 2019;13:360. [ Links ]

8. Puccio JA, Cannon A, Derasari K, Friend R. Resurgence of syphilis. Adv Pediatr. 2019;66:231-44. doi: 10.1016/j.yapd.2019.03.006. [ Links ]

9. De Carvalho Fagundes FN, Simoes JP, Pereira Magnago AG, De Sousa Brito Xavier MH. Annular and arcuate syphilis: an uncommon presentation of disseminated secondary syphilis. Dermatol Online J.2018;24:13030/qt2nb2k1xd. [ Links ]

10. Hua H, Zhu X, Yang L, Li M, Jiang P. Multiple condylomata lata: a case report. Int J Dermatol. 2008;47:56-8. [ Links ]

11. Aggarwal P, Aggarwal K, Jain VK. Extensive condylomata lata in an adolescent: An uncommon and unusual presentation. Indian J Sex Transm Dis AIDS. 2019;40:165-7. doi: 10.4103/ijstd. IJSTD_63_16. [ Links ]

12. Ikeda E, Goto A, Suzaki R, Sawada M, Dekio I, Ishizaki S, et al. Condylomata lata on the ankle: an unusual location. Dermatol Pract Concept. 2016;6:49-51. doi: 10.5826/dpc.0602a09. [ Links ]

13. Pinto-Gouveia M, Pinho A, Reis JP. Condylomata Lata Mimicking Buschke-Löwenstein Tumor. Acta Med Port. 2016;29:231. [ Links ]

14. Tayal S, Shaban F, Dasgupta K, Tabaqchali MA. A case of syphilitic anal condylomata lata mi-micking malignancy. Int J Surg Case Rep. 2015;17:69-71. [ Links ]

15. Forrestel AK, Kovarik CL, Katz KA. Sexually acquired syphilis: Laboratory diagnosis, ma-nagement, and prevention. J Am Acad Dermatol. 2020;82:17-28. doi: 10.1016/j. jaad.2019.02.074. [ Links ]

16. Katz AR, Johnson DW, Komeya AY, Tomas JE, Namiki TS, Kobayashi K. Dermatologically challen-ging syphilis presentation. Int J STD AIDS. 2019;30:707-9. doi: 10.1177/0956462418817636 [ Links ]

1Conflicts of Interest: The authors have no conflicts of interest to declare. Financing Support: This work has not received any contribution, grant or scholarship. Confidentiality of Data: The authors declare that they have followed the proto-ols of their work center on the publication of data from patients. Patient Consent: Consent for publication was obtained. Provenance and Peer Review: Not commissioned; externally peer reviewed. Conflitos de Interesse: Os autores declaram a inexistência de conflitos de interesse na realização do presente trabalho. Fontes de Financiamento: Não existiram fontes externas de financiamento para a realização deste artigo Confidencialidade dos Dados: Os autores declaram ter seguido os protocolos da sua instituição acerca da publicação dos dados de doentes. Consentimento: Consentimento do doente para publicação obtido. Proveniência e Revisão por Pares: Não comissionado; revisão externa por pares.

2© Author(s) (or their employer(s)) 2021 SPDV Journal. Re-use permitted under CC BY-NC. No commercial re-use. © Autor (es) (ou seu (s) empregador (es)) 2021 Revista SPDV. Reutilização permitida de acordo com CC BY-NC. Nenhuma reutilização comercial

Received: February 01, 2021; Accepted: March 15, 2021

Corresponding Author: Rita Bouceiro Mendes Address: Hospital de Santa Maria - Serviço de Dermatologia, Piso 5 Av. Prof. Egas Moniz, 1649-035 Lisboa E-mail: rita.bouceiro.mendes@gmail.com

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