Perianal Giant Condyloma Acuminata in Men Who Have

Sex with Men with HIV

Eunice Gunawan

, Syafria Zidni

, Retno Indar Widayati

, Puguh Riyanto

, Ika Pawitra Miranti

1,2,3,4

Departement of Dermatovenereology, Medical Faculty of Diponegoro University/ Dr. Kariadi Hospital, Semarang

Departement of Pathological Anatomy, Medical Faculty of Diponegoro University/ Dr. Kariadi Hospital, Semarang

Corresponding auhtor

Keywords: Giant Condyloma Acuminata, HIV, HPV, MSM

Abstract: Giant condyloma acuminata (GCA) is a large condylomacaused by the proliferation of squamous epithelial

cells in the presence of Human Papillomavirus (HPV) infection, mostly type 6 and 11. It is most commonly

seen in the genital, anal, and perianal regions. Sexual behavior of MSM further increases the risk of HIV

infection and other viral infections such as GCA. An unmarried Javanese 38-year-old man complained of a

wart on his perianal area since one year ago. Initially, the lesion was small and progressively enlarged tothe

size of a chicken’s egg. The patient was an MSM with multiple sexual partners. The patient was HIV-

positive and received antiretroviral therapy (ARV). The clinical finding showed a large cauliflower-like

growth tumor on the perianal area, 7x5 x 2centimeters in size, with a positive ace-to-whitening test.

Histopathological examination showedpapillomatosis, hyperkeratosis, parakeratosis, and koilocytosis, in

accordance with GCA diagnosis. The VCT result showed a CD4 of 51cell/ml. Therapy for this patient was

electrodesiccation and curettage. The diagnosis of GCA was established on the history, clinical findings,

and histopathological examination.Electrodesiccation and curettage and ARV therapy in perianal GCA

patient showed a satisfactory result. Regular examination after therapy is required to identify and prevent

recurrence or metastasize potential.

1 INTRODUCTION

Giant condyloma acuminata (GCA) is a large

condyloma caused by the proliferation of squamous

epithelial cells in the presence of Human

Papillomavirus (HPV) infection, mostly type 6 and

11. It is most commonly seen in the genital, anal,

and perianal regions.GCA-also is known as

Buschke-Lowenstein Tumor (BLT)-is classified as a

sexually transmitted infection due to the factthat

more than 90% of cases are transmitted through

sexual contact.GCA is a semi-malignant

verrucoustumor characterized by aggressive growth

into the underlying dermal structure. It is recurrent

in 30-70% of cases and can progress slowly into

exophytic, ulcerative, and cauliflower-like tumors

that can form abscesses and fistulas (Suarez et al,

2016; Rahmayunita et al, 2017).

Due to a variety of sexual behavior nowadays,

i.e., men who have sex with men (MSM) can further

increase the risk of HIV infection and other viral

infections such as GCA. The prevalence of HPV on

MSM with HIV increased sixty-fold compared to

men in the general population (Indriatmi et al,

2016).

The treatment for GCA is based on size, location,

and a number of lesions. The therapeutic options

include topical ointments, cryotherapy, laser

vaporization, electrosurgery, and surgical excision

(Suarez et al, 2016; Murtiastutik et al, 2008;

Mistrangelo et al, 2018).

The aim of this case report is to report a case of

perianal giant condyloma acuminata, which is one of

the sexually transmitted infections, on an HIV

patient with MSM sexual behavior treated with

electrodesiccation and curettage.

2 CASE

Anunmarried Javanese 38-year-old man came to

thedermatology and venereology clinic of Dr.

Kariadi Hospital Semarang. He complained of a

wart on the perianal area since one year ago at first

362

Gunawan, E., Zidni, S., Widayati, R., Riyanto, P. and Miranti, I.

Perianal Giant Condyloma Acuminata in Men Who Have Sex with Men with HIV.

DOI: 10.5220/0009989003620365

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 362-365

ISBN: 978-989-758-469-5

small and then grew to the size of a chicken’s egg.

Sometimes itchy but not painful and not quickly

bled. HIV screening result from two years ago was

positive. The patient takes ARV regularly,

consistingof Efavirenz 600mg, Lamivudine 300 mg,

and Tenofovir disoproxil 300 mg. The patient

hadnever complained of any wart before. He had a

history of sex with multiple men. The patient has

never used a condom during intercourse. The history

of injury on the genital was denied, the patient has

never received a blood transfusion, nor has he had a

history of injection drug use. None of his family

experienced the same complaint. The patientwas a

store employee. Health costwas covered by BPJS.

The social, economic status was below average.

From the physical examination, we found the

patient to be compos mentis, with a body height of

165 centimeters, and the bodyweight of 58

kilograms. The blood pressure was 110/70 mmHg,

pulse rate 88 times/minute, respiratory rate 20

times/minute, and the axillary temperature was 36.8 ̊

C. Dermatologic status founda large cauliflower-like

growth tumor covering all perianal area, 7x5 x 2

centimeters in size, with positiveacetowhitening test.

Laboratory examination found reactive VCT

examination with CD4 of 51 cells/ml, a serologic

examination of TPHA and VDRL werenegative, and

other blood tests were within average values. The

rectal examination and the colonoscopy showed the

anal canal mucosa was healthy and free of

tumor.The histopathological examination

showedhyperplastic stratified keratinized squamous

epithelium with papillomatosis, parakeratosis, and

koilocytosis. Dermis consisted of hyperemic fibrous

connective tissue along with scattered lymphocytes,

histiocytes, PMN leucocytes; there was no sign of

malignancy. And all of these histopathological

findings were in accordance with GCA diagnosis.

The diagnosis we established was giant perianal

condylomaacuminataon HIV patient.

Electrodesiccation and curettage therapy in the

lithotomy position and general anesthesia was

performed to the patient. Post-operative therapy was

Clindamycin 300 mg twice a day for seven days,

Mefenamic acid 500 mg three times a day, wound

care, and Fusidic acid cream 2% twice daily on post

electrodesiccation and curettage wound.The patient

also took anti-retroviral (ARV) medicine.

On the first week post-surgery, the wound healed

well. And on the fourth-month post-surgery, there

was no sign of recurrence.

3 DISCUSSION

The diagnosis of Giant condylomaacuminata(GCA)

was established fromanamnesis, physical

examination, and histopathological examination. An

unmarried Javanese 38-year-old man came to the

dermatology and venereology clinic of Dr.

KariadiHospital Semarang. He complained of a wart

on the perianal area since one year ago at first small

and then grew to the size of chicken’s

egg.Sometimes itchy but not painful and not quickly

bled.He had a history of sex with multiple men. The

literature mention that GCA is a verrucoustumor

characterized by aggressive growth and mostly seen

in the genital, anal, and perianal regions. GCA

caused by HPV infection, in which the risk factors

for HPV infection are related to sexual behavior, like

homosexuality, multiple sexual partners, poor

genital hygiene, and chronic genital infection.The

incidenceof HPV infection is common in active

sexual individuals. The prevalence of HPV infection

rises over the age of 25 years to 40 years and over.

(Suarez et al, 2016; Rahmayunita et al, 2017).

The patient’s HIV screening resultwas positive

from two years ago.The patient takes ARV regularly

consisting of Efavirenz 600mg, Lamivudine 300 mg,

and Tenofovirdisoproxil 300 mg. The literature

mention that HIV is one of immunocompromised

condition that also included in sexually transmitted

infection. In HIV patients, condylomaacuminatacan

be an opportunistic infection that often occurs in

stage 2,3, and 4 of HIV. The frequency of

condylomaacuminata in men and women is the

same, in which the sexual behavior of male who has

sex with male (MSM) increases the risk of HIV

infection and other viral infections such as HPV

infection. Infection is transmitted by sexual contact

with the initial lesion at the trauma site during

intercourse. Generally, CA does not cause any

complaints, but the CA on the perianal region

sometimes can cause irritation, pain, or bleeding.

(Indriatmi et al, 2016;Murtiastutik et al,2008)

From the physical examination, we founda

sizeable cauliflower-like growth tumor covering all

perianal area, 7x5 x 2 centimeters in size, with

positive acetowhitening test. According to the

literature, the clinical manifestations of GCA can

resemble cauliflower-like tumor, consisting of

papules or dermal and epidermal nodules on the

perineum, genitals, and anus.The literature mention

that GCA is not like a simple condyloma, GCA is a

large condyloma, although it is still controversial in

the determination of the size. Acetic acid is helpful

in visualizing lesions on the cervix and anus. This

Perianal Giant Condyloma Acuminata in Men Who Have Sex with Men with HIV

363



examination is necessary for unusual lesions or

subclinical lesions. (Indriatmi et al, 2016

; Atkinson

et al,2014;Murtiastutik et al,2008)

The histopathological examination showed

hyperplastic stratified keratinized squamous

epithelium with papillomatosis, parakeratosis, and

koilocytosis. Dermis consisted of hyperemic fibrous

connective tissue along with scattered lymphocytes,

histiocytes, PMN leucocytes; there was no sign of

malignancy. This finding is consistent with the

literature, where histopathological findings for

condylomaacuminata are characterized by

acanthosis and papillomatosis on Malpighi layer,

thickening, and elongation of rete ridges, with

parakeratosis on the cornified layer. On stratum

corneum, can be found mitotic cells, nucleus

koilocytosis, and mononuclear inflammatory cells

that infiltrated into the dermis, and no sign of

malignancy. The histopathology appearance of GCA

is similar to the simple condyloma and difficult to

differentiate, but it has to be distinguished from

squamous cell carcinoma. (Suarez et al, 2016;

Murtiastutik et al, 2008; Murtiastutik et al, 2008)

Management of this patientwas

electrodesiccation and curettage. Post-operative

therapy was Clindamycin 300 mg twice a day for

seven days, Mefenamic acid 500 mg three times a

day, wound care, and Fusidic acid cream 2% twice

daily on post electrodesiccation and curettage

wound. Based on the literature, there are several

options that are available to treat human

papillomavirus (HPV) related anogenital disease,

with the treatment of CA being the most widely

studied. Treatment of CA is generally not directed at

the treatment of HPV infection but rather at the

physical removal of lesions or stimulation of the

host immune response. Available therapeutic

modalities fall into two categories; The first one is

patient-applied, such as imiquimod, podofilox gel,

the newer polyphenon E ointment, and topical

cidofovir; The second is provider-administered,

including cryotherapy, surgical removal

(electrosurgery, curettage, excision, cryotherapy),

intralesional interferon (IFN), trichloroacetic acid

(TCA), and intralesionalcidofovir. While there are

many available treatment options for HPV-related

anogenital disease, comparative trials to evaluate the

efficacy of various treatment modalities are lacking,

and there is often a lack of consensus regarding best

practices among clinicians treating these diseases.

The treatment of GCA is determined by the size of

the lesion, the location, amount of the lesion, patient

preference, maintenance cost, comforts, side effects

and provider experience

(Rahmayunita et al, 2017;

Indriatmi et al, 2016;Gormley et al,2012).

The prognosis of this patient was quo ad vitam

and quo ad sanam dubia ad malam. Due to the

inability of the immune system against the entry of

pathogenic effectof HIV infection.Furthermore, any

STI that the patient suffers from can get worse,

recurrent or resistant, and the possibility of

developing another life-threatening infection is

higher.(Mudrikova et al,2008) Quo ad cosmeticam

wasdubiaadbonam. Due tothe complete removal of

all lesions and a low risk of scarring.

Figure 1. A.Pre-operative status of the disease. B.The

postoperative result after electrodesiccation and curettage

(four months post-treatment)

Figure 2. Histopathological Findings. A. Acanthosis,

Papillomatosis, Koilocytosis (100x).

B. Koilocytosis (400x) (H&E)

4 CONCLUSION

A case of perianal giant condyloma acuminata in an

MSM man with HIV.The management of this

patient was performed with electrodesiccation and

curettage. The prognosis of this patient was quo ad

vitam and quo ad sanam dubiaadmalam, and quo ad

cosmeticam dubia ad bonam.

A B

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

364

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