11 September 2008 – Case of the Week #129

 

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Solid variant of adenoid cystic carcinoma

 

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Case of the Week #129

 

Clinical History

 

A 52 year old man had a clinical history of Condyloma acuminata peri-rectal wart lesions present for 2 months.  They were excised.

 

Micro images: #1#2#3  

 

What is your diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis:

 

Anal syphilis

 

Discussion:

 

At high power, numerous plasma cells were evident (image4).  The Steiner stain demonstrated the spirochetes (#1#2).

 

Syphilis is a genital ulcerative disease caused by the spirochete Treponema pallidum, that causes significant complications if untreated.  It also facilitates the transmission of HIV.  Although the rate of primary and secondary syphilis in the United States declined 90% between 1990 and 2000, it increased 25% between 2001 and 2006 (Centers for Disease Control and Prevention - STD Surveillance 2006).  Most of the increase appears due to MSM (men having sex with men), with the estimated proportion of primary syphilis cases from this group increasing from 4% in 2000 to 62% in 2004 (Am J Public Health 2007;97:1076).

 

Microscopy shows capillary proliferation, obliterative endarteritis and heavy plasma cell infiltration.  Lymphocytes and macrophages may also be present.

 

In this case, the diagnosis of syphilis was missed initially, but was caught at a secondary review.  Thus, this case reminds us that multiple diagnoses may be present, particularly for sexually transmitted diseases, and that explanations for histologic findings extraneous to a diagnosis (such as plasma cells with condyloma) should be sought.

 

Additional references: eMedicine

 

 

Nat Pernick, M.D., President
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