A 23 y.o. transgender female comes to the ED with itching near the anus

What are you concerned about?

she has a pinkish papular lesion near the anus

Our patient had condyloma lata from secondary syphilis and her RPR was positive at 1:256.

In assessing an anal lesion, consider the spectrum of disease from benign anal warts, to infectious lesions like condyloma lata to squamous cell carcinoma.

ANOGENITAL WARTS

Anogenital warts (condyloma accuminata) are usually benign with 90% caused by nononcogenic HPV types 6 or 11. They are also associated with conjunctival, nasal, oral and laryngeal warts. Intra-anal warts are observed predominantly in persons who have had receptive anal intercourse. HPV is the most common sexually transmitted infection worldwide with 13% of the global population.

Liquid nitrogen or podophyllotoxin are the standard treatments for these lesions.

CONDYLOMA LATA

Syphilis is known as “the great imitator” because it can present in many ways. The low rate of syphilis in the 2000s was followed by an epidemic of infections with a 71% increase between 2014 and 2018.  In 2018 most cases were reported in men who had sex with men but  syphilis in women has increased by 30% between 2017 and 2018.

While primary syphilis has a painless chancre,  condyloma lata are often painful.  These lesions are highly contagious

condyloma lata of the vulva

ANAL MALIGNANCY

Verrucous carcinoma of the mucosa is an uncommon type of well-differentiated squamous cell carcinoma.  When it presents in the anal region the term used is Buschke-Lowenstein tumor.  It is a slow growing but locally invasive tumor which produces bulky fungating masses sometimes with a cauliflower morphology.

buschke-lowenstein low grade squamous malignancy

Penncook K, McCready T. condyloma acuminata. StatPearls  Aug 9,2021

Pourang A, Fung M, Tartar D, Brassard A. Condyloma lata in secondary syphilis JAAD Case Rep 2021 Apr;10:18-21.

Liu Z, Wang L, Zhang G, Long H. Warty mucosal lesions: oral condyloma lata of secondary syphilis. Indian J Dermatol Venereol Leprol. 2017;83:277.

Martin J, Molin I, Monteagudo C, et al. Buschke-Lowenstein tumor. Journal of Dermatological Case Reports. 2008 Dec 27;2(4):60-62.

Khodaee M, Radi R.  A painful anal lesion. J Family Med Prim Care. 2018 Sep-Oct 7(5):1139-40.