Robert A. Norman - Clinical Cases in Infections and Infestations of the Skin

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William Eng

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A 46 year old black male presented with a complaint of multiple growths on his penis. He was previously diagnosed with condylomata acuminata, HIV infection and diabetes. He admitted to having numerous sexual partners and rarely used barrier contraception.

The patient had three cauliflower-like lesions on his penis, one was located on the glans of the penis while the other two were found on the penis shaft. The lesion on the glans penis measured 0.80.40.1 cm. The larger lesion on the penis shaft measured 1.40.90.6 cm while the smaller lesion on the penis shaft measured 0.60.30.3 cm. All lesions had a soft consistency and was not friable. The lesion on the glans penis was pink in color while the other two lesions on the penis shaft were darker pigmented than the surrounding skin (Fig. ).

(Multiple red-brown, pigmented papules or plaque on genital skin)

Microscopically, there were two distinct areas (Fig. ).

BOWENOID PAPULOSIS ARISING ADJACENT TO A CONDYLOMA. Bowenoid papulosis is caused by a high risk HPV group which includes types 16, 18 most commonly and less commonly types 31, 33, 35, 39, and 53. There is a 12 % risk for progression to squamous cell carcinoma so this is clinically an aggressive disease. This is considered a sexually transmitted disease, so a workup for other STDs should also be included.

While a junctional nevus can present with a clinical appearance similar to bowenoid papulosis, the microscopic examination would show nests of nevus cells. A seborrheic keratosis can both appear similar to a condyloma both on clinical examination and microscopically, however, the characteristic koilocytic changes would not be seen in a seborrheic keratosis. In cases where the distinction is critical (i.e. questionable sexual abuse), then HPV typing can be done on the fixed tissue. However, the HPV typing is performed using a cocktail, so a specific HPV is not identified, but rather a group of either low risk or high risk. Psoriasis in the genital area can be deceptive clinically since the typical silvery scales are not seen, but instead an inverse pattern is found where only a sharply demarcated erythematous base is present which can mimic bowenoid papulosis. A biopsy easily resolves this issue. Whereas psoriasis presents with comb-like acanthosis and focal collections of neutrophils, these features are not found in either bowenoid papulosis or condyloma. Syphilis (Condyloma lata) has been known throughout history for its protean nature. A biopsy may show an irregular psoriasiform hyperplasia only. Establishing this diagnosis requires a high degree of clinical suspicion, a Steiner (silver) stain is helpful in revealing the spiral/corkscrew bacilli. Recently, an immunostain is also commercially available to aid in the identification of syphilis.

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William Eng

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A 95 year old white female nursing home patient presented with three lesions on her face, one of which was rapidly growing. She had a history of skin cancers, primarily squamous cell carcinomas and pre-cancers (actinic keratosis). In her youth, she spent considerable time outdoors and had multiple episodes of sun burns.

On her right cheek, a hyperkeratotic growth was identified measuring 1.51.5 cm. On the left temple, a 1.51.0 cm flat, flakey erythematous area was identified. At the left forehead, a 1.01.0 cm raised erythematous lesion with indistinct borders was found (Fig. ).

(Raised erythematous lesion on sun exposed skin)

The lesion on the right cheek showed atypical nests of keratinocytes (Squamous cell carcinoma) while the left temple showed basal nests of various sizes (Basal cell carcinoma). The left forehead showed two distinct diseases. One was full thickness squamous atypia with overlying parakeratosis. The second showed irregular shaped sheets of small, round cells with scant amounts of cytoplasm (Fig. ).