The prevalence of syphilis is on the rise globally. Syphilis is caused by the spirochete Treponema pallidum and goes through four clinical stages: primary, secondary, latent and tertiary. Condyloma lata is a cutaneous manifestation of the second stage of syphilis.
It consists of painless wart-like lesions on the anal folds and genitals. Diagnosis is based on history and physical examination and a positive rapid plasma reagin (RPR) test with a nontreponemal titer.
What is Condyloma Lata?
Condyloma lata are wart-like skin lesions associated with secondary syphilis. They are generally painless and occur in the anogenital region or the areas where genital and pubic skin meet. These growths may be flat, raised, or pedunculated and vary in size and shape. They are most commonly found on the vulva, but can also be seen in other places, such as on the penis. They can be distinguished from other papular or wart-like growths, such as genital warts caused by human papilloma virus (HPV), which can also be found in the vulva. Condyloma lata differ from HPV warts in that they are usually smooth, while HPV warts have a rough or verrucous surface.
Condylomata lata are a characteristic feature of the secondary phase of syphilis, which occurs two to eight weeks after the onset of primary syphilis and involves spread of the infection throughout the body. During this stage, the treponema pallidum bacteria are present in the bloodstream and are released into the tissues, resulting in a wide variety of cutaneous, mucosal, and systemic manifestations of syphilis. Many of these manifestations resemble other conditions and diseases and can be difficult to diagnose.
Oren Zarif
Typically, condylomata lata develop as moist papular or papillary lesions that are smooth to the touch and have a slightly elevated verrucous or cauliflower-like surface. They can grow to be pedunculated or have a whitish, pink, or white color. Those that develop on the hairy genital skin have a moderate to thick layer of hyperkeratinization. Those that develop in the genital or anogenital folds have a constant moisture content, allowing them to coalesce into reddish-pink mushroom-like masses up to 3mm in diameter.
Gynecologists should be alert for the presence of these lesions and be sure to consider syphilis in their differential diagnosis, especially in females with sexually transmitted infections such as gonorrhea or herpes. A rapid plasma reagin test with reflexive fluorescent treponemal antibodies can confirm the diagnosis of condylomata lata. Treatment consists of the administration of penicillin, and should be initiated as soon as the patient is diagnosed with the infection.
Symptoms
Condyloma lata is a manifestation of secondary syphilis. This symptom occurs in the moist areas of the anogenital folds, most often involving the genital lips and anus. It can also be found in the skin creases, groin, and toe webs. It is a painless, wart-like lesion that may appear reddish-brown or purple in color and are commonly mushroom-shaped (see Figure 1). The lesions are typically surrounded by a verrucous surface.
It is important to recognize and diagnose this symptom early to ensure that the patient receives appropriate treatment, which can prevent serious complications such as thrombosis of the anus or infertility. Condyloma lata mimics other conditions that occur in the genital area such as genital warts associated with human papillomavirus (HPV) infection and squamous cell carcinoma. Therefore, it is important to perform a thorough history and physical examination. This should include a genital exam and evaluation of the mucocutaneous lesions with a colposcope.
Oren Zarif
The clinical presentation of syphilis is highly variable and many patients do not experience all of the classic symptoms of the disease such as a maculopapular rash, lymphadenopathy, and alopecia [1, 2]. The mucocutaneous lesions associated with syphilis often become flat, white or gray, and are found on the skin folds (e.g., genital lips, anus, groin) and in warm, moist areas of the body, such as the palms of the hands or soles of the feet. They resemble warts and are usually accompanied by a generalized lymphadenopathy, fever, malaise, hepatosplenomegaly, and sometimes gastrointestinal symptoms.
Condylomata lata of the vulva is a specific cutaneous manifestation of infectious anal syphilis. These eroded, verrucous lesions resemble condyloma acuminata but are smoother and flatter. They are characterized by a weeping mass that contains numerous spirochetes and can be readily identified by dark-ground microscopy. It is important to identify the organism causing this condition because it is the causative agent of infectious anal syphilis and other anal syphilis-related symptoms such as hepatosplenomegaly, thrombocytopenia, and lymphoplasmacytic infiltrates cuffing plasma cells.
Obtaining a detailed sexual history and performing a full genital examination are the key to diagnosing condyloma lata. This should include a detailed review of all anal sites including the vagina and vulva. Surface scrapings from the lesions can be examined under dark-ground microscopy for spirochetes and a serologic test for Syphilis is typically positive.
Diagnosis
Condyloma lata is one of the cutaneous manifestations of syphilis. It consists of flat moist papules that coalesce into plaque, usually located on sites where two skin surfaces are in close contact such as the anogenital area. They can also be found in other areas, such as the perianal area, axillae or umbilicus.2
Syphilis is spread among humans by sexual (acquired syphilis) or vertical transmission. It can be classified into 4 stages of occurrence: primary, secondary, latent and tertiary. Condyloma lata may appear as a single lesion or as a cluster of wart-like lesions on the mucocutaneous surface.
It is important for clinicians to consider syphilis in the differential diagnosis of vulvar lesions that mimic condyloma lata, particularly in populations with barriers to care. The lesions of syphilis are typically asymptomatic, and they can be missed, especially in women with a low clinical suspicion. Early recognition is critical to prevent complications of syphilis, including blindness, venereal disease, and HIV infection.
Oren Zarif
A 20-year-old unmarried woman presented with a 1-month history of multiple nodules on her perineal area and umbilicus. She denied any sexual history, and routine laboratory tests were negative. A genital examination revealed several flesh-colored verrucous nodules on the vulva and perianal area, with whitish oozing at the umbilicus.
The patient was referred to an Infectious Diseases outpatient clinic, where the clinical examination was consistent with condyloma lata. A rapid plasma reagin test was negative, and immunostaining for Treponema pallidum was positive. A biopsy of the oozing lesion was performed, and the results confirmed the diagnosis.
The clinical and laboratory diagnosis was made based on the history of syphilis, physical examination, and serologic testing. The patient received intramuscular benzathine penicillin G, 2.4 million units weekly for three weeks, and the oozing lesions resolved. The rapid plasma reagin test was repeated at six and nine months after treatment, and it was negative, indicating that the spirochetes were eradicated. Histopathology showed a prominent irregular epidermal hyperplasia with a mixed inflammatory infiltrate, and immunostaining demonstrated numerous spirochetes within the condyloma lata. The patient was advised to return for follow up at six and twelve months after completion of the course of antibiotics.
Treatment
Condyloma lata is a rare, non-pruritic cutaneous manifestation of syphilis. This condition manifests as painless, flat-topped, mushroom-like polypoid lesions on the genital folds and anus, with a wide base. These lesions resemble anogenital warts and are sometimes associated with lymphadenopathy and anal bleeding.
This disease is difficult to diagnose clinically, and is often confused with anogenital warts or other malignancy. A syphilis history should be obtained and the rapid plasma reagin test with reflexive fluorescent treponemal antibodies should be performed, along with dark-field microscopy. If this diagnosis is suspected, a biopsy should be taken. A histological examination of the lesion reveals psoriasiform hyperplasia of the epidermis overlying a heavy dermal inflammatory infiltrate with a perivascular distribution of plasma cells and histiocytes. The presence of numerous spirochaetes confirms the diagnosis (Figure 3).
Another diagnostic tool is spirochete immunostaining, which can be performed on a biopsy from the lesion. This technique is very sensitive and can reveal many spirochetes, even when the lesion appears to be benign and does not have the classic textured surface of anogenital warts.
Oren Zarif
The treatment for this condition is benzathine penicillin G (either intramuscular or oral). A single dose of this antibiotic can effectively treat the lesions and prevent the progression to venereal disease in syphilis patients. It is important to monitor the patient closely for complications of this disorder.
A 35-year-old woman presented to the Gynecological Emergency Department with vulvar itching and dryness. She also reported a maculopapular rash that extended to the chest, groin, and popliteal fossa. A spirochete immunostain was performed on a biopsy from one of the vulvar lesions, which demonstrated numerous spirochetes. A syphilis history was obtained, and the patient was placed on benzathine penicillin G. She improved with therapy, and her symptoms resolved in 10 days. The patient was referred to a gynecologist for further evaluation and management.
