Dermatology: Practical and Conceptual Letter | Dermatol Pract Concept 2019;9(1):18 73 Dermatology Practical & Conceptual Introduction We describe an uncommon case of papillomatous erythema- tous plaques of the scrotum. Case Presentation A 28-year-old man presented with a 2-month history of pain- ful growing scrotal lesions and relapsing fever. The patient was otherwise in good health. He was heterosexual and did not report any recent high-risk sexual behavior. Physical examination revealed 2 broad-based, elevated papillomatous erythematous plaques 10 and 6 mm in diameter, respectively, located on the front of the scrotum (Figure 1A). No other cutaneous or mucosal abnormalities were found. Dermoscopy revealed whitish papillomatous structures on a milky-red background; vessels showed a homogeneous punctiform pattern (Figure 1B). A skin biopsy and serological tests were performed. Histopathology of a 4-mm punch biopsy showed a prominent dermal infiltrate, rich in plasma cells, together with endothelial proliferation and swelling (Figure 2). Sero- logical tests for syphilis were requested, and the Treponema pallidum enzyme immunoassay titer was positive, T pal- lidum hemagglutination was reactive, and the rapid plasma reagin titer was 1:64. Human immunodeficiency virus (HIV), hepatitis C virus, and hepatitis B virus serology results were negative. A diagnosis of secondary syphilis was made, and scrotal lesions were diagnosed as condylomata lata. Lesions and symptoms completely resolved with a single dose of 2.4 million units IM of penicillin G benzathine. Conclusions Due to their friable consistency, condylomata lata represent an infectious form of secondary syphilis, a systemic venereal disease caused by T pallidum that can involve most organs and tissues of the human body and have several clinical stages (primary, secondary, early latent, late latent, and tertiary). After a decline in the late 20th century, a new wave of syphilis has been reported over the last 2 decades, especially among men who have sex with men and patients with HIV. Primary syphilis is often overlooked because of its quick course and poor symptomatology; therefore, many patients come to clini- cal consultation when they show mucocutaneous involvement in the secondary stage of the disease, 6-8 weeks after inocula- tion of T pallidum [1,2]. Papillomatous Erythematous Plaques of the Scrotum Ambra Di Altobrando1, Carlotta Gurioli1, Antonietta D’Antuono1, Valeria Gaspari1 1 Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy Key words: syphilis, condylomata lata, plaques, Treponema pallidum Citation: Di Altobrando A, Gurioli C, D’Antuono A. Gaspari V. Papillomatous erythematous plaques of the scrotum. Dermatol Pract Concept. 2019;9(1):73-74. DOI: https://doi.org/10.5826/dpc.0901a18 Published: January 31, 2019 Copyright: ©2019 Di Altobrando et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Ambra Di Altobrando, MD, Dermatology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 1, 40138 Bologna, Italy. Email: ambra.dialtobrando@gmail.com 74 Letter | Dermatol Pract Concept 2019;9(1):18 References 1. Afra TP, Handa S, Razmi TM, Vinay K. Secondary syphilis: lest we forget it. Post- grad Med J. 2018;94(1113):415. 2. Rysgaard C, Alexander E, Swick BL. Nod- ular secondary syphilis with associated granulomatous inflammation: case re- port and literature review. J Cutan Pathol. 2014;41(4):370-379. tigations, including serological tests for syphilis. However, the absence of dermoscopic pathognomonic features and increasing unusual clinical mani- festations justify the frequent missed and delayed diagnosis of condylomata lata and of secondary syphilis. In conclusion, a high level of suspi- cion is necessary to achieve early diag- nosis and therapy and prevent further progression. Skin lesions of secondary syphilis can take many mucocutaneous forms, including condylomata lata, but also macular, papular, follicular, lichenoid, psoriasiform, pustular, Sweet syn- drome-like, and annular aspects, thus justifying the label “the great imitator.” Besides skin lesions, systemic symp- toms such as fever, headache, malaise, and lymphadenopathy are common in secondary syphilis [2]. However, the absence of pathognomonic features and the increasing unusual manifestations often determine a delay in diagnosis and treatment. In our case, the clinical presenta- tion could be suggestive of condylo- mata lata, even if the patient’s history was quite misleading. Aside from the protean clinical manifestations, the his- topathological features of condylomata lata are also polymorphic and aspecific, representing a diagnostic challenge for the dermatopathologist. The most fre- quent histological patterns show hyper- keratotic, psoriasiform, or ulcerated aspects. The dermis generally shows a perivascular and periadnexal infiltrate, rich in plasma cells [1,2]. Dermoscopy may turn out to be very useful in order to exclude differ- ential diagnoses, especially neoplastic ones. Differential diagnoses include squamous cell carcinoma, basocellular carcinoma, genital warts, eruptive xan- thomas, papular granuloma annulare, lymphoma, leukemia, leprosy, sarcoid- osis, psoriasis, and cutaneous tubercu- losis [2]. Moreover, the observation of papillomatous structures and homog- enous dotted vessels on dermoscopy can suggest to the clinician an infec- tious origin and support further inves- Figure 2. A promi- nent dermal infiltrate rich in plasma cells to- gether with endothe- lial proliferation and swelling. [Copyright: ©2019 Di Altobrando et al.] Figure 1. (A) Broad-base infiltrated papillomatous, erythematous plaques measuring 10 and 6 mm in diameter, respectively, on the front of the scrotum. (B) Whitish papillomatous struc- tures on a milky-red background; dotted vessels represent the main vascular pattern. [Copy- right: ©2019 Di Altobrando et al.] A B