Clinical Review & Education
JAMA Dermatology Clinicopathological Challenge
Eroded and Pedunculated Buttock Nodule Karen Itumeleng Mosojane, MSV; Lara Wine Lee, MD, PhD; Carrie L. Kovarik, MD
A
B
C
Figure. A, Photograph of a 2-cm macerated pedunculated growth on the left buttock. B, Histopathologic image of an exophytic growth on the buttock with marked epidermal hyperplasia (hematoxylin-eosin, original magnification ×40). C, Histopathologic image of immunohistochemical staining for spirochetes (original magnification ×400).
A man in his 60s presented with a slowly enlarging, painful mass on his buttock. He recalled that a small lesion had appeared approximately 8 months prior, and over the past several months he had noted significant growth and pain. A nonpruritic rash had also become apparent on his forearms and thighs. Physical examination showed a 2-cm macerated pedunculated growth on the left buttock within the intergluteal cleft (Figure, A). An erythematous rash was noted on the forearms and thighs with fine scale present at the wrists. A shave biopsy specimen of the exophytic growth on the buttock revealed marked epidermal hyperplasia (Figure, B) with a dense dermal infiltrate containing lymphocytes and plasma cells.
WHAT IS THE DIAGNOSIS?
A. Condyloma acuminata B. Condyloma lata C. Verrucous herpes simplex virus D. Granuloma inguinale
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Clinical Review & Education JAMA Dermatology Clinicopathological Challenge
Diagnosis B. Condyloma lata
Microscopic Findings Immunohistochemical staining for spirochetes identified sheets of organisms throughout the lesion (Figure, C). A rapid plasma reagin test was strongly positive for antibodies and Treponema pallidum– specific testing confirmed the diagnosis. The patient was diagnosed as having secondary syphilis with condyloma lata and was treated with benzathine penicillin, 2.4 million U intramuscular injection in a single dose, and his lesions resolved completely over the following weeks.
Discussion Syphilis is a sexually transmitted disease caused by T pallidum, a microaerophilic spirochete.1 The Centers for Disease Control and Prevention estimates that, annually, 55 400 people in the United States are newly infected with syphilis.2 The infection is transmitted through direct contact with syphilitic lesions, which can be on the external genitalia, vagina, anus, rectum, lips, and in the mouth.1,3 Transmission can occur during vaginal, anal, or oral sexual contact, and the incubation period ranges from 10 to 90 days.1,4 It is divided into primary, secondary, latent (early and late), and tertiary stages.5 In the primary stage, there is often appearance of a chancre at the point of inoculation.5 The chancre is often described as painless, most of the time unnoticed, lasting 3 to 6 weeks, regardless of treatment.1,4 However, without treatment, primary disease may progress to the secondary stage, which has many clinical manifestations. Lesions of sec-
ondary syphilis can appear during the healing phase of the chancre or several weeks after its healing.1 The rash can be papular, nodular, erythematous, scaly, psoriasiform, or plaquelike and usually well demarcated, nonpruritic, and affect the trunk, face, and extremities.4,5 Along with the more characteristic widespread lesions, secondary syphilis more uncommonly manifests with lesions of condyloma lata, which are of particular interest because they may be confused with condyloma acuminata, keratoacanthoma, squamous cell carcinomas, and atypical pyogenic granulomas.6 Condyloma lata are smooth, flat, moist, flesh-colored, or hypopigmented, macerated papules, plaques, or nodules.7,8 The common sites involved are the genital and anal areas, making them even more difficult to distinguish from condyloma acuminata. In nonmucosal sites, such as the axillae, umbilicus, nape of the neck, and thighs, condyloma lata may be hypertrophic.8 Other symptoms of secondary syphilis can include fever, lymphadenopathy, pharyngitis, patchy alopecia, headaches, weight loss, myalgia, and fatigue.5 Rarely, it may cause other issues, including acute meningitis, hepatitis, renal disease, arthritis, periostitis, optic neuritis, iritis, and uveitis.8 Serological diagnosis is through nontreponemal tests (venereal disease research laboratory and rapid plasma reagin) and treponemal tests (treponemal pallidum particle agglutination and fluorescent treponemal antibody absorption test).4,5 Direct visualization may be achieved through dark field microscopy, silver stains (Warthin-Starry), and immunohistochemical staining of lesions tissue.4,5 The results of tissue staining should be corroborated by serology to confirm the diagnosis of syphilis.
ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliations: University of Botswana, Gaborone, Botswana (Mosojane); Children’s Hospital of Philadelphia and Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (Lee); Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (Kovarik).
Additional Information: Ms Mosojane will receive her MBBS degree as part of the first graduating class of the University of Botswana, School of Medicine.
Corresponding Author: Carrie L. Kovarik, MD, Department of Dermatology, University of Pennsylvania, 3600 Spruce St, 2 Maloney Building, Philadelphia, PA 19104 (carrie.kovarik @uphs.upenn.edu). Section Editor: Molly A. Hinshaw, MD; Assistant Section Editors: Soon Bahrami, MD; Nicole Fett, MD, MSCE; Anna K. Haemel, MD; Arni K. Kristjansson, MD; Lori D. Prok, MD.
REFERENCES 1. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw Hill Medical; 2008. 2. Syphilis-CDC Fact Sheet. Centers for Disease Control and Prevention. http://www.cdc.gov/sTD /syphilis/STDFact-Syphilis.htm. Accessed February 2, 2014. 3. Wolff K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw-Hill; 2009.
4. Treponema. National Center for Biotechnology Information. http://www.ncbi.nlm.nih.gov/books /NBK7716/. Accessed February 22, 2012. 5. Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a reemerging infection. Am Fam Physician. 2012;86(5):433-440. 6. Tham SN, Lee CT. Condyloma latum mimicking keratoacanthoma in patient with secondary syphilis. Genitourin Med. 1987;63(5):339-340. 7. Kim JS, Kang MS, Sagong C, Ko JY, Yu HJ. An unusual extensive secondary syphilis: condyloma lata on the umbilicus and perineum and mucous patches on the lips. Clin Exp Dermatol. 2009;34(7): e299-e301. 8. Deshpande DJ, Nayak CS, Mishra SN, Dhurat RS. Verrucous condyloma lata mimicking condyloma acuminata: an unusual presentation. Indian J Sex Transm Dis. 2009;30(2):100-102.
Published Online: December 17, 2014. doi:10.1001/jamadermatol.2014.3238.
336
JAMA Dermatology March 2015 Volume 151, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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jamadermatology.com
JAMA Dermatology Clinicopathological Challenge
Eroded and Pedunculated Buttock Nodule Karen Itumeleng Mosojane, MSV; Lara Wine Lee, MD, PhD; Carrie L. Kovarik, MD
A
B
C
Figure. A, Photograph of a 2-cm macerated pedunculated growth on the left buttock. B, Histopathologic image of an exophytic growth on the buttock with marked epidermal hyperplasia (hematoxylin-eosin, original magnification ×40). C, Histopathologic image of immunohistochemical staining for spirochetes (original magnification ×400).
A man in his 60s presented with a slowly enlarging, painful mass on his buttock. He recalled that a small lesion had appeared approximately 8 months prior, and over the past several months he had noted significant growth and pain. A nonpruritic rash had also become apparent on his forearms and thighs. Physical examination showed a 2-cm macerated pedunculated growth on the left buttock within the intergluteal cleft (Figure, A). An erythematous rash was noted on the forearms and thighs with fine scale present at the wrists. A shave biopsy specimen of the exophytic growth on the buttock revealed marked epidermal hyperplasia (Figure, B) with a dense dermal infiltrate containing lymphocytes and plasma cells.
WHAT IS THE DIAGNOSIS?
A. Condyloma acuminata B. Condyloma lata C. Verrucous herpes simplex virus D. Granuloma inguinale
jamadermatology.com
(Reprinted) JAMA Dermatology March 2015 Volume 151, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Florida Atlantic University User on 05/22/2015
335
Clinical Review & Education JAMA Dermatology Clinicopathological Challenge
Diagnosis B. Condyloma lata
Microscopic Findings Immunohistochemical staining for spirochetes identified sheets of organisms throughout the lesion (Figure, C). A rapid plasma reagin test was strongly positive for antibodies and Treponema pallidum– specific testing confirmed the diagnosis. The patient was diagnosed as having secondary syphilis with condyloma lata and was treated with benzathine penicillin, 2.4 million U intramuscular injection in a single dose, and his lesions resolved completely over the following weeks.
Discussion Syphilis is a sexually transmitted disease caused by T pallidum, a microaerophilic spirochete.1 The Centers for Disease Control and Prevention estimates that, annually, 55 400 people in the United States are newly infected with syphilis.2 The infection is transmitted through direct contact with syphilitic lesions, which can be on the external genitalia, vagina, anus, rectum, lips, and in the mouth.1,3 Transmission can occur during vaginal, anal, or oral sexual contact, and the incubation period ranges from 10 to 90 days.1,4 It is divided into primary, secondary, latent (early and late), and tertiary stages.5 In the primary stage, there is often appearance of a chancre at the point of inoculation.5 The chancre is often described as painless, most of the time unnoticed, lasting 3 to 6 weeks, regardless of treatment.1,4 However, without treatment, primary disease may progress to the secondary stage, which has many clinical manifestations. Lesions of sec-
ondary syphilis can appear during the healing phase of the chancre or several weeks after its healing.1 The rash can be papular, nodular, erythematous, scaly, psoriasiform, or plaquelike and usually well demarcated, nonpruritic, and affect the trunk, face, and extremities.4,5 Along with the more characteristic widespread lesions, secondary syphilis more uncommonly manifests with lesions of condyloma lata, which are of particular interest because they may be confused with condyloma acuminata, keratoacanthoma, squamous cell carcinomas, and atypical pyogenic granulomas.6 Condyloma lata are smooth, flat, moist, flesh-colored, or hypopigmented, macerated papules, plaques, or nodules.7,8 The common sites involved are the genital and anal areas, making them even more difficult to distinguish from condyloma acuminata. In nonmucosal sites, such as the axillae, umbilicus, nape of the neck, and thighs, condyloma lata may be hypertrophic.8 Other symptoms of secondary syphilis can include fever, lymphadenopathy, pharyngitis, patchy alopecia, headaches, weight loss, myalgia, and fatigue.5 Rarely, it may cause other issues, including acute meningitis, hepatitis, renal disease, arthritis, periostitis, optic neuritis, iritis, and uveitis.8 Serological diagnosis is through nontreponemal tests (venereal disease research laboratory and rapid plasma reagin) and treponemal tests (treponemal pallidum particle agglutination and fluorescent treponemal antibody absorption test).4,5 Direct visualization may be achieved through dark field microscopy, silver stains (Warthin-Starry), and immunohistochemical staining of lesions tissue.4,5 The results of tissue staining should be corroborated by serology to confirm the diagnosis of syphilis.
ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliations: University of Botswana, Gaborone, Botswana (Mosojane); Children’s Hospital of Philadelphia and Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (Lee); Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (Kovarik).
Additional Information: Ms Mosojane will receive her MBBS degree as part of the first graduating class of the University of Botswana, School of Medicine.
Corresponding Author: Carrie L. Kovarik, MD, Department of Dermatology, University of Pennsylvania, 3600 Spruce St, 2 Maloney Building, Philadelphia, PA 19104 (carrie.kovarik @uphs.upenn.edu). Section Editor: Molly A. Hinshaw, MD; Assistant Section Editors: Soon Bahrami, MD; Nicole Fett, MD, MSCE; Anna K. Haemel, MD; Arni K. Kristjansson, MD; Lori D. Prok, MD.
REFERENCES 1. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw Hill Medical; 2008. 2. Syphilis-CDC Fact Sheet. Centers for Disease Control and Prevention. http://www.cdc.gov/sTD /syphilis/STDFact-Syphilis.htm. Accessed February 2, 2014. 3. Wolff K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 6th ed. New York, NY: McGraw-Hill; 2009.
4. Treponema. National Center for Biotechnology Information. http://www.ncbi.nlm.nih.gov/books /NBK7716/. Accessed February 22, 2012. 5. Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a reemerging infection. Am Fam Physician. 2012;86(5):433-440. 6. Tham SN, Lee CT. Condyloma latum mimicking keratoacanthoma in patient with secondary syphilis. Genitourin Med. 1987;63(5):339-340. 7. Kim JS, Kang MS, Sagong C, Ko JY, Yu HJ. An unusual extensive secondary syphilis: condyloma lata on the umbilicus and perineum and mucous patches on the lips. Clin Exp Dermatol. 2009;34(7): e299-e301. 8. Deshpande DJ, Nayak CS, Mishra SN, Dhurat RS. Verrucous condyloma lata mimicking condyloma acuminata: an unusual presentation. Indian J Sex Transm Dis. 2009;30(2):100-102.
Published Online: December 17, 2014. doi:10.1001/jamadermatol.2014.3238.
336
JAMA Dermatology March 2015 Volume 151, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Florida Atlantic University User on 05/22/2015
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