Practice Easily Missed

Syphilitic condylomata lata mimicking anogenital warts

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1259 (Published 17 March 2015) Cite this as: BMJ 2015;350:h1259
  1. F G Bruins, dermatologist-venereologist1,
  2. F J A van Deudekom, resident in internal medicine2,
  3. H J C de Vries, dermatologist-venereologist345
  1. 1Clinic for Dermatology, DermaPark, Uden, Netherlands
  2. 2Department of Internal Medicine, Kennemergasthuis, Haarlem, Netherlands
  3. 3Department of Dermatology, Academic Medical Centre, University of Amsterdam, 1100 DD Amsterdam, Netherlands
  4. 4STI Outpatient Clinic, Public Health Service Amsterdam, Amsterdam, Netherlands
  5. 5Centre for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
  1. Correspondence to: H J C de Vries h.j.devries{at}amc.nl

The bottom line

  • Condylomata lata are a cutaneous manifestation of secondary syphilis and can be misdiagnosed as genital warts

  • Prompt diagnosis and treatment with intramuscular benzathine benzylpenicillin are needed to prevent serious neurological complications (such as syphilitic meningitis and cerebrovascular disease), cardiac complications (such as aortic valve destruction), and ongoing transmission

  • Initial diagnostic tests includes an anti-treponemal serological assay and an anticardiolipin test

  • Once condylomata lata are suspected, refer promptly to a specialist centre such as a sexual health clinic or to a (dermato-)venereologist for further investigations (including sexually transmitted infection screen), treatment, contact tracing, and follow-up

A 41 year old man who has sex with men visited our dermatology outpatient clinic with a three month history of non-painful anal papules. He reported protected anal contact with multiple (anonymous) male partners.

Physical examination showed perianal flesh coloured papules with a verrucous surface (fig 1). One papule showed partial ulceration. Our differential diagnosis was between human papillomavirus (HPV) associated genital warts and condylomata lata, a cutaneous manifestation seen in secondary syphilis. On histopathological examination of a lesional biopsy, immunostaining for Treponema pallidum showed a dense plasma-cellular infiltrate and numerous spirochetes. An HPV specific nucleic acid amplification test did not detect viral DNA in the biopsy. The diagnosis was confirmed by serological testing with a T pallidum specific enzyme immunoassay and the Venereal Disease Research Laboratory (VDRL) test; HIV-1 and HIV-2 serology were both negative. He was given intramuscular injections of 2.4×106 IU benzathine benzylpenicillin, and the lesions had disappeared completely at a follow-up visit.

Figure1

Fig 1 Condylomata lata in a man with secondary stage syphilis characterised by verrucous hyperkeratotic perianal papules. The condylomata latum on top shows partial ulceration

What are condylomata lata?

These are one of the cutaneous signs of secondary syphilis. They reside in skin folds, such as those seen in the inguinal, perianal, and perivaginal regions and appear as flat papules with a moist, cauliflower-like or velvety surface. Moreover, they contain numerous spirochetes and are highly infectious (fig 2A).1 They can mimic anogenital warts (condylomata acuminata), which are associated with HPV infection, and are characterised by verrucous or papilliform, pink or skin coloured papules (fig 2B).2

Figure2

Fig 2 (A) Perianal condylomata lata with a typical verrucous aspect. (B) Perianal and intra-anal genital warts characterised by verrucous papules

How common are they?

Between 2012 and 2013 the overall incidence of infectious syphilis in England increased by 9%—3249 cases were reported.3 In genitourinary medicine clinics, syphilis is mainly seen in men who have sex with men, with 81% (2393/2970) of cases in men being in this group.

Why are they missed?

Because of the painless nature of condylomata lata patients can easily miss these lesions, especially if they are located at an internal site such as the anus, vagina, or mouth. Moreover, they can easily be mistaken by doctors for another dermatological condition such as anogenital warts (fig 2B), bowenoid papulosis, HPV induced anal intraepithelial neoplasia, or skin tags.4

Why does this matter?

Misdiagnosis delays adequate treatment and results in ongoing transmission to sex partners. Syphilis is treated completely differently from genital warts. If untreated, syphilis can have irreversible consequences, including neurosyphilis (such as syphilitic meningitis and cerebrovascular disease) and cardiovascular disease (such as aortic valve destruction).

How are they diagnosed?

Clinical

Condylomata lata are characteristic of secondary syphilis. By contrast, the primary stage of syphilis is characterised by a small painless, indurated ulcer, typically with rolled edges, which is accompanied by regional lymphadenopathy. Secondary syphilis can present with a variety of symptoms, most often a maculopapular rash, but also alopecia, leucoplakic or erythematous lesions on oral mucous membranes, and perianal or perivaginal condylomata lata.

Investigations

A clinical suspicion of syphilis is initially confirmed by serology, using an anti-treponemal serological assay (for example, the T pallidum enzyme immunoassay, which is usually reported as positive or negative or as a semi quantitative index; or the T pallidum haemagglutination assay (TPHA)) and an anticardiolipin test (such as the VDRL test, reported as titre). In primary syphilis, serological tests can be falsely negative in the window phase, so serology may need to be re-evaluated after several weeks; the TPHA and VDRL tests have 70.4% and 74.9% sensitivity, respectively. In secondary syphilis serological testing is highly sensitive—98.6% and 97.4% for TPHA and VDRL tests, respectively5; VDRL also usually shows a high titre (>1:16).

In specialist clinics, dark field microscopy may be used to diagnose ulcerative primary stage lesions and condylomata lata, by visualising T pallidum in lesional exudate. This is a cheap and quick diagnostic method but requires a specialised microscope and expertise.

To differentiate syphilitic condylomata from HPV induced manifestations, such as genital warts or bowenoid papulosis, a biopsy is needed for histopathological examination. A dense plasma cell infiltrate and numerous spirochetes visualised by immunostaining confirm condylomata lata. Numerous nucleic acid amplification tests to detect T pallidum have been developed in house but are not available routinely. These tests are highly specific and sensitive in the diagnosis of primary syphilis, irrespective of the serological window phase.6

How are they managed?

It is advisable to refer patients suspected of having syphilis to a specialised setting, such as a sexual health or infectious diseases clinic, or to a (dermato-)venereologist, where additional investigations and treatment are readily available and contact tracing and follow-up can be offered.

The primary, secondary, and early latent stages of syphilis can easily be treated with a single intramuscular 2.4×106 IU dose of benzathine benzylpenicillin. Patients diagnosed as having syphilis should always undergo tests for other sexually transmitted diseases, including HIV and hepatitis B serology, and nucleic acid amplification testing of urine, vaginal, anorectal or pharyngeal swabs (depending on the patient’s sexual practices) for chlamydia and gonorrhoea. Furthermore, partner notification is needed to prevent transmission, although this may be a problem when sexual contacts are anonymous.7 Men who have sex with men who often have new or casual partners are advised to be screened for sexually transmitted infections and HIV every three months.3

Notes

Cite this as: BMJ 2015;350:h1259

Footnotes

  • This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, professor of primary care, Department of Primary Care Health Sciences, University of Oxford, and Richard Lehman, general practitioner, Banbury. To suggest a topic for this series, please email us at practice{at}bmj.com.

  • Contributors: FGB, FJvD, and HJdV all contributed to the acquisition, analysis, conception, design, drafting, and revision of the work and its intellectual content; gave their final approval of the version to be published; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HJdV is guarantor.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent not required (patient anonymised, dead, or hypothetical).

References

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