HISTORY:
A 40+ year-old male presented with a 1-month history of itchy, painful, irregular lesions around the rectum. He denied prior treatments and any history of radiation or prior non-healing wounds. The patient also denied any malodor, drainage, or change in bowel habits. A shave biopsy was taken from the right medial buttock.
Based on the clinical images and features present, which diagnosis is most likely?
- Bowen’s Disease
- Extramammary Paget’s Disease
- Condyloma acuminata
- Condyloma lata
- Cutaneous Crohn’s
Psoriasiform epidermal hyperplasia with hyperkeratosis and parakeratosis (4x)
10x highlighting intracorneal lymphocytes and neutrophils as well as a superficial and deep perivascular and periadnexal lymphohistiocytic and plasmacytic infiltrate.
20x highest power highlighting the admixed plasmacytic infiltrate within the dermis.
10x numerous spirochetes within the epidermis and dermis (red stain)
20x closer view of the spirochetes (treponema pallidum organisms)
40x highest power showing slender rod like organisms, many of which having the corkscrew-like shape.
Click to view enlarged photo.
ANSWER: Condyloma lata
PATHOLOGY:
Histologic features present in this case include psoriasiform epidermal hyperplasia, intracorneal neutrophilic microabscesses with a lichenoid superficial and deep periadnexal lymphocytic, histiocytic and plasmacytic infiltrate. Immunohistochemical staining with a Spirochetal stain highlights numerous treponemal organisms within the dermis and epidermis, having characteristic slender rod-like structures. Many of these demonstrate their characteristic corkscrew-like shape, which is thought to facilitate their motility within biologic tissues. These findings are consistent with secondary syphilis (condyloma lata).
SUMMARY:
The diagnosis is consistent with secondary syphilis. The pathophysiology of secondary syphilis is that spirochetes from the primary chancre spread hematogenously. Prodromal symptoms can occur usually 2-10 weeks after the chancre and can include flu-like symptoms with generalized lymphadenopathy. Mucosal lesions can include patches and ulcers in the mouth. Condyloma lata, when present, can be seen in mucosa, anogenitally as in this case, or sometimes in the inguinal or genital folds. Patients should be screened for ocular involvement as symptoms may include pain, redness, and photophobia. When untreated, 25% of secondary syphilis patients relapse within 24 months and may have progression to tertiary or latent syphilis. Of note, the clinical lesions of secondary syphilis are contagious by direct touch and reiterate the importance of contact precautions. Patients diagnosed with one sexually-transmitted infection (STI) should also be tested for additional STIs.
FOLLOW-UP:
Referral was made to the Department of Health where the patient underwent treatment with a single dose of Penicillin G 2.4 million units and subsequently was lost to follow-up. Additional testing was ordered including HIV, gonorrhea, and chlamydia, which the patient chose to perform at an outside facility.
By: Dr. Gaurav Singh, MD; Dr. John Pujals, MD; Dr. Ashley Dietrich, MD; and Dr. Betsy Wernli, MD