Dermatology: Practical and Conceptual Observation | Dermatol Pract Concept 2016;6(2):9 49 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Introduction Syphilis is an infectious disease caused by Treponema palli- dum. Secondary syphilis presents with generalized lesions on the skin and mucous membranes, primarily macules and then progressing to papules. When the papules become hypertro- phic and coalesced on macerated skin or mucous membranes, they are called condyloma lata, which more commonly occur around the anus and vulva. We report a case of condylomata lata occurring on the ankle, an unusual site. Condylomata lata on the ankle: an unusual location Eri Ikeda1, Akane Goto1, Reiko Suzaki1, Mizuki Sawada1, Itaru Dekio1, Sumiko Ishizaki1, Mariko Fujibayashi2, Hayato Takahashi3, Masaru Tanaka1 1 Department of Dermatology, Tokyo Woman’s Medical University Medical Center East, Tokyo, Japan 2 Department of Pathology, Tokyo Woman’s Medical University Medical Center East, Tokyo, Japan 3 Department of Dermatology, Keio University School of Medicine, Tokyo, Japan Key words: condyloma lata, syphilis, dermoscopy, unusual location, ankle Citation: Ikeda E, Goto A, Suzaki R, Sawada M, Dekio I, Ishizaki S, Fujibayashi M, Takahashi H, Tanaka M. Condyloma lata on the ankle: an unusual location. Dermatol Pract Concept 2016;6(2):9. doi: 10.5826/dpc.0602a09 Received: November 10, 2015; Accepted: March 19, 2016; Published: April 30, 2016 Copyright: ©2016 Ikeda 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. All authors have contributed significantly to this publication. Corresponding Author: Eri Ikeda, MD, Department of Dermatology, Tokyo Women’s Medical University Medical Center East, 2-1-10 Nishi-Ogu, Arakawa-ku, Tokyo 116-8567, Japan. Tel. +81 3 3810 1111; Fax. +81 3 3894 1441. Email. eriikeda-tjo@umin.net A 43-year-old Japanese man presented with reddish nodules on the ankle. The nodules had a yellowish crust and eroded surface. Dermoscopy revealed red to milky-red globules at the periphery and some glomerular vessels in the center and a whitish-pink network, which corresponded to capillary dilata- tion in the papillary dermis and prominent acanthosis, respectively. These structures were surrounded by a yellowish peripheral structureless area and multiple white, small, round structures in the center, corresponding to the macerated horny layer and keratin plugs. Blood samples were positive for rapid plasma reagin (1:64), Treponema pallidum hemagglutination assay (1:20480), and fluorescent trepo- nemal antibody-absorption (1:1280). A lesional skin biopsy specimen showed irregular acanthosis and papillomatosis. The Warthin-Starry and anti-Treponema pallidum antibody stains on the biopsy specimen revealed many spirochetes in the lower epidermis and the papillary dermis. A diagnosis of secondary syphilis with condylomata lata was made. After one week of treatment with oral benzylpen- icillin benzathine hydrate (Bicillin® G granules 400,000 units; Banyu Pharmaceutical Co., Ltd, Tokyo, Japan), 1.6 million units (U) daily, the ankle lesions had resolved with a small ulcer and pigmentation. Although syphilis is a relatively common disease, this case study reports an unusual presentation as well as dermoscopy findings. ABSTRACT 50 Observation | Dermatol Pract Concept 2016;6(2):9 with the following titers: blood rapid plasma reagin (sero- logical test for syphilis) at 1:64 (normal, 1:<1), T. pallidum hemagglutination assay at 1:20480 (normal, 1:<80) and fluorescent treponemal antibody-absorption test at 1:1280 (normal, 1:<20). The anti-HIV antibody test was negative. A biopsy sample was obtained from the larger nodule. The histopathological findings included irregular acanthosis and papillomatosis, a parakeratotic horny layer, and dense lymphocytic and plasma cell infiltration in the papillary and upper dermis (Figure 3A). Warthin-Starry (Figure 3B) and Case presentation A 43-year-old Japanese man presented at a dermatology clinic with multiple erythema on the legs, which had been noticed for three months. Because treatment with a topical gluco- corticosteroid, betamethasone butyrate propionate ointment (Antebate, Torii Pharmaceutical, Tokyo), was not effective and several nodules were also present on the left ankle the patient was referred to our University Hospital. The family history and patient’s past medical history were not remarkable. When asked, the patient denied contracting syphilis by a non-sexual route. His work history indicated he was a field superinten- dent and wore protective shoes throughout the workday. Physical examination showed an indurated reddish nod- ule measuring 30 x 25 mm with an “8”-shaped raised border and partly covered by yellowish crust (Figure 1A). There was another yellowish, crusted nodule measuring 15 x 5 mm near the heel. Multiple scaly reddish macules measuring up to 5 mm were noted on the palms and soles (Figure 1B). Dermoscopy of the largest nodule demonstrated red to milky red globules and some glomerular vessels and a whitish pink network on the raised border (Figure 2). A yellowish struc- tureless area was noted at the periphery and multiple white, small, round structures were noted in the center. Laboratory data showed a white blood cell count of 10400/ml (normal, 3900 to 9800). The assays were positive Figure 1. Clinical photographs. (A) An indurated reddish nodule of 30 x 25 mm with an “8”-shaped raised border partly covered by yellowish crust. (B, C) Multiple scaly erythematous plaques up to 5 mm on the palms and soles. [Copyright: ©2016 Ikeda et al.] Figure 2. Dermos- copy of condyloma lata. Red to milky- red globules, glo- merular vessels and a whitish-pink network on the raised border. There is a yellowish structureless area at the periphery and multiple white, small, round structures in the center. [Copy- right: ©2016 Ikeda et al.] A B C Observation | Dermatol Pract Concept 2016;6(2):9 51 was not seen during the treatment. The patient discontinued hospital visits after four weeks of oral treatment. Conclusions Condylomata lata consist of flat-topped eroded weeping papules occurring mainly on the perianal area and the vulva [1]. Unusual sites of occurrence include the axilla, palms, face, umbilicus, and toe webs [2-7]. The reason for the unusual or widespread lesions could be attributed to mechanical fric- tion and local hyperhidrosis [2, 3]. The present case showed an extremely rare site for the occurrence of condylomata lata. This rare occurrence of condylomata lata on the ankle could be explained by the patient’s work history of wearing protective shoes that cause a hyperhidrotic environment coupled with the physical friction associated with walking. We hypothesize that the cause for condyloma lata in this case might be due to the patient’s work history of wearing protec- tive shoes that provide an ideal environment for the prolifera- tion of the treponemal spirochetes. The route of transmission of infection is unknown because the patient denied any route. Dermoscopy of condyloma lata has not been previously reported in the literature. The pathological features of promi- nent acanthosis seemed to correspond to the whitish-pink network on dermoscopy. The capillary dilatation in the papil- lary dermis appeared to be corresponding to red to milky-red globules. The yellowish structureless area at the periphery and multiple whitish clods in the center could be explained by the macerated horny layer and keratin plugs. This study was presented at the 113th Annual Meeting of the Japanese Dermatological Association. References 1. Kinghorn GR. Syphilis and bacterial sexually transmitted infec- tions. In: DA Burns, SM Breathnach, NH Cox et al, ed. Rook’s Textbook of Dermatology. 8th ed. Southern Gate: Blackwell, 2010: 34.1-14. 2. Fiumara NJ. Unusual location of condyloma lata. A case report. Br J Vener Dis 1977;53:391-3. PMID: 606337 3. El-Saad El-Rifaie M. Condylomata lata of the palms: an unusual site. Br J Vener Dis 1980;56:267-8. PMID: 7427699 4. Sundararaj AS, Williams J, Gopinathan R, Deivam S. Unusual manifestations of early syphilis in a married male. Florid manifesta- tions of condylomata lata on the face. Int J STD AIDS 1995;6:52-3. PMID: 7727585 5. Hayashi M, Ito K, Ishiji T, et al. Secondary-stage syphilis with unusual clinical features. Pract Dermatol 2012;34:1189-92. 6. Tham SN, Lee CT. Condyloma latum mimicking keratoacanthoma in patient with secondary syphilis. Genitourin Med 1987;63:339- 40. PMID: 3679220 7. Rosen T, Hwong H. Pedal interdigital condylomata lata: a rare sign of secondary syphilis. Sex Transm Dis 2001;28:184-6. PMID: 11289202 anti-T. pallidum antibody (Figure 3C) stains revealed many spirochetes in the lower epidermis and the papillary dermis. Based on the above clinical, serological, and histopathological findings, the diagnosis of secondary syphilis (condylomata lata on the ankle and syphilitic psoriasis on the palms and soles) was made. One week after treatment with oral benzylpenicillin ben- zathine hydrate (Bicillin® G granules 400,000 units; Banyu Pharmaceutical Co., Ltd, Tokyo, Japan) 1.6 million U daily, the ankle lesions had almost resolved with a small ulcer and pigmentation remaining. The Jarisch-Herxheimer reaction Figure 3. Histopathology from condyloma lata. Hematoxylin-eosin staining (A) showing irregular acanthosis and papillomatosis, a parakeratotic horny layer, and dense lymphocytic and plasma cell infiltration in the papillary and upper dermis. Warthin-Starry (B) and anti-Treponema pallidum antibody (C) stains revealing many spirochetes in the lower epidermis and the papillary dermis. [Copy- right: ©2016 Ikeda et al.] A B C