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Acta Obstétrica e Ginecológica Portuguesa

versão impressa ISSN 1646-5830

Acta Obstet Ginecol Port vol.12 no.4 Coimbra dez. 2018

 

ISSUE IMAGE/IMAGEM DO TRIMESTRE

Genital Warts - not always the human papillomavirus's harmless consequence

Verrugas genitais - nem sempre a consequência inofensiva do vírus do papiloma humano

Margarida da Silva Cunha*, Jorge Simões**, Rita Luz***

Departamento de Ginecologia e Obstetrícia - Centro Hospitalar de Setúbal, EPE; Setúbal, Portugal

*Interna de Formação Específica de Ginecologia e Obstetrícia

**Assistente Hospitalar Graduado

***Departamento de Ginecologia e Obstetrícia do Hospital Garcia de Orta, Assistente Hospitalar

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

ABSTRACT

Human papillomavirus (HPV)-related genital warts are the commonest viral sexually transmitted disease. We present a case of exuberant vulvar lesions in a human immunodeficiency virus (HIV)-positive and immunosuppressed woman, in which risk factors and clinical features required a differential diagnosis with more serious conditions. The lesions were surgically excised successfully and histopathological outcome was condylomata acuminata.

With this clinical report we highlight that benign and apparently harmless situations, such as genital condylomata, can be very morbilliform and even mutilating. Appropriate recognition, proper treatment and follow-up measures as early as possible are cornerstone.

Keywords: Buschke-Lowenstein Tumor; Cervical Intraepithelial Neoplasia; Condylomata Acuminata; HIV Infection; Human Papilloma Virus


 

Genital warts are the most common manifestation of genital human papillomavirus (HPV) infection, with serotypes 6 and 11 accounting for 90% of the cases1. However, these lesions only appear in 10% of the patients who come in contact with HPV. Human immunodeficiency virus (HIV) is the most significant predisposing risk factor2.

We report a case of a nulliparous 56-years-old woman, with a past history of multiple sexual partners, alcoholism, hepatitis C and stage 3-HIV infection on antiretroviral therapy, who presented with one-year perineal growth (Figure 1). Vulvoscopy revealed multiple vulvo-perineal tumors, the biggest of roughly 13/5 cm in right labium majus. Colposcopy was impossible to perform due to non colaboration and cytology revealed low grade intraepithelial lesion. HPV-11 and 18 (low and high risk, respectively) were detected in endocervix. We proceeded with local surgical excision with direct closure and large loop excision of the transformation zone due to the inability to keep colposcopic surveillance. Histopathological exam revealed condylomata acuminata and no features of cervical intraepithelial neoplasia on the cervix. Postoperative evolution was favorable and the patient was doing well at the 5-week follow up consultation (Figure 2).

 

 

 

HPV-related condylomata acuminata is the commonest viral sexually transmitted disease3. Despite its benignity, the impact on psychosocial wellbeing is substantial, possibly even greater than other diseases such as VIN2/3, which are considered clinically more serious4. Condylomata accuminata often cause discomfort, sexual dysfunction and self-image issues; a minority resolve without treatment but healthcare costs are significant1,4. The delay in seeking medical care, due to negligence, shame or fear, may lead to an increase in number and size of lesions, limiting treatment options and often requiring surgical excision.

The competence of the immune system plays an important role in HPV infection as in HIV-positive patients condylomata accuminata recurs significantly more often and within a shorter period of time after treatment3. Also in HIV-positive patients its clinical differential diagnosis from intraepithelial neoplasia or Buschke-Löwenstein tumor (giant condyloma) may be challenging5.

This case is outstandsing by the exuberance of genital warts, which in presence of several risk factors for malignant transformation required the exclusion of concomitant more severe lesions. Thus, surgical management was the best option, allowing complete histological evaluation of all surgical specimen with an excellent aesthetic result. This is a patient with a high risk of recurrence, who will need periodic surveillance.

With this clinical report we highlight that benign and apparently harmless situations, such as genital condylomata, can be very morbilliform and even mutilating. Appropriate recognition, proper treatment and follow-up measures as early as possible are cornerstone.

 

REFERENCES

1. Lacey CJN, Lowndes CM, Shah KV. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine 2006; 24 (Suppl 3):35-41.         [ Links ]

2. Stanley M. Immune responses to human papillomavirus. Vaccine 2006; 24 (Suppl 1):16-22.         [ Links ]

3. Mudrikova T, Jaspers C, Ellerbroek P, Hoepelman A. HPV-related anogenital disease and HIV infection: not always ‘ordinary ’condylomata acuminata. Neth J Med. 2008;66(3):98-102.         [ Links ]

4. Dominiak-Felden G, Cohet C, Atrux-Tallau S, Gilet H, Tristram A, Fiander A. Impact of human papillomavirus-related genital diseases on quality of life and psychosocial wellbeing: results of an observational, health-related quality of life study in the UK. BMC Public Health. 2013; 13:1065.         [ Links ]

5. Werner RN, Westfechtel L, Dressler C, Nast A. Anogenital warts and other HPV-associated anogenital lesions in the HIV-positive patient: a systematic review and meta-analysis of the efficacy and safety of interventions assessed in controlled clinical trials. Sex Transm Infect. 2017;0: 1-8.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

Margarida da Silva Cunha

E-mail: anamcunha3@gmail.com

 

Recebido em: 09/12/2017

Aceite para publicação: 04/05/2018

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