Perianal pathology includes a variety of manifestations of multiple diseases, sometimes very similar and difficult to distinguish from each other [1]. Generally having a profound negative impact in the patients’ quality of life, their prognosis and therapeutic options are diverse. Ranging from infectious diseases to malignancy, the medical specialties to which they present can vary and, depending on who the patient is referred to, some causes are not always remembered when the differential diagnosis is discussed.

Syphilis is a sexually transmitted disease caused by Treponema pallidum and presents in four stages that can overlap, being them primary, secondary, tertiary, and latent syphilis [2]. Condylomata lata are an infrequent manifestation of secondary syphilis [3],[4].

We present a Condylomata lata case report in which, after a non-linear diagnostic pathway, initially focusing mainly on excluding malignancy, the instituted therapeutics, after achieving the correct diagnosis, devolved the patients’ quality of life quite quickly.

The purpose of this case report is to discuss the differential diagnosis of perianal pathology, recalling the non-surgical etiologies that are less frequently managed in General Surgery departments and, therefore, can pose a challenge to the surgeon [4]. In hospitals that have no Infectious Diseases department, like ours, this can have a significant impact in patient management and outcomes.

We present the case of a 70-year-old male patient who came to the emergency department (ED) of our hospital complaining of perianal discomfort and pain with several weeks of duration, that aggravated during straining and defecation. The case was forwarded to the surgical team. The patient denied any relevant previous history or current diseases as well as any medication. When asked, he denied unprotected sexual intercourse. He was underweight and poor hygiene was noticed. On physical examination it was assumed that an anal fissure was causing the symptoms and the patient was medicated accordingly, with a topical cream (containing zinc oxide, titanium dioxide, and tetracaine hydrochloride), a stool softener (lactulose), and oral analgesia (paracetamol). The patient returned to the ED a month later with the same complaints. On the physical examination an exuberant papillomatous lesion associated with perianal moisture was observed and an incisional biopsy was performed, thinking of a neoplasm of the anal canal or rectum. A follow-up appointment in the outpatient clinic was scheduled.

The biopsy revealed an inflammatory infiltrate, was negative for human papillomavirus infection, and suggested no diagnosis. In the outpatient clinic appointment, blood tests for human immunodeficiency virus (HIV), B hepatitis virus (HBV), and C hepatitis virus (HCV), and a contrast-enhanced computed tomography (CT) of the abdomen and pelvis were ordered. The serologies were negative for HIV, HCV, and HBV, and the CT showed only an external mass with no internal or intrarectal growth.

The patient again returned to the ED after a month, maintaining the same complaints, and on physical examination a growth of the lesion was observed (Figure 1), as well as new lesions in the penis and bilateral inguinal adenopathy. The patient was observed by Dermatology and the diagnosis of an infectious disease was suggested and a new biopsy was performed. As there is no Infectious Disease Department in our hospital, the case was discussed with an infectious disease specialist from another hospital and a photograph of the lesions was sent. The hypothesis of condylomata lata was posed as the most likely diagnosis and Rapid Plasma Reagin (RPR) and T. pallidum hemagglutination assay (TPHA) blood tests were ordered. Because of the high clinical suspicion, immediate empiric therapeutic with intramuscular penicillin G benzathine, 2.4 million units, was administered. The patient was advised to warn any sexual partners to be tested. Serologies confirmed infection with T. pallidum, with a RPR of 128 Kahn Units and a TPHA with a titer of 1/10240. The response to the instituted therapy was very satisfactory and the patient presented in the outpatient clinic after three weeks, showing a significative reduction in the size of the perianal lesions (Figure 2), disappearance of the penile lesions and mentioning a marked improvement in his quality of life. By this time the second biopsy result was verified and was again not conclusive but posed the hypothesis of a spindle cell carcinoma, diagnosis that was discarded because of the regression of the lesions after administration of penicillin G benzathine.

Perianal pathology is vast and englobes a large variation of signs and symptoms that have multiple etiologies and very different prognosis [1]. Most of the patients referred to the General Surgery outpatient clinic for perianal complaints present with hemorrhoidal disease, perianal fistulizing disease, and anorectal or perianal skin neoplasms. Despite these being the most common diagnosis, the differential diagnosis should also consider infectious diseases like condylomata lata in the context of secondary syphilis (T. pallidum), condylomata acuminata (HPV), tuberculosis (Mycobacterium tuberculosis), lymphogranuloma venereum (Chlamydia trachomatis), and chancroid (Haemophilus ducreyi) [3]. It is important to note that the differential diagnose of perianal warty lesions is commonly difficult to make based solely on the macroscopy. Many of the perianal presentations of infectious diseases are similar and share overlapping features.

Each medical specialty is used to a different specter of diseases and a less frequent clinical diagnosis can be missed [3]. As the surgeon is mainly familiarized with the previously mentioned diagnosis, the diagnostic pathway is not always conducted in a hastily fashion concerning the other pathologies. In this case, the initial investigation concerning non-surgical diseases was limited to HIV, HBV, HCV, and HPV exclusion, with the articulation with an infectious disease specialist being crucial to arrive to a clinical diagnosis and conduct an adequate laboratorial investigation as well as to initiate proper treatment.

The authors emphasize the need for a more complete investigation on infectious diseases, including HIV, HBV, HCV, and HPV, as performed, but also infection by T. pallidum, M. tuberculosis, C. trachomatis, and H. ducreyi.

The incidence of syphilis has been rising in the last years and it is more frequent in males who have sexual intercourse with other males [1],[3],[4]. Secondary syphilis manifestations can range from macules to eruptions and condylomata lata, the late being an infrequent but highly infectious manifestation of secondary syphilis [1],[2],[3],[5].

Other than the exclusion of an infectious cause, it is never to forget the relevance of ruling out malignancy, not only with an incisional biopsy and CT scan, as performed, but also with and endoscopic examination. This is mandatory if the resolution of the lesions is not complete with the instituted therapy, as these kinds of lesions can present a cancerous degeneration and also to exclude a florid presentation of anal or rectal malignancy.

A faulty diagnostic investigation can lead to a delay in the diagnosis as well as to subjecting the patient to inappropriate and unnecessary imaging and endoscopic examinations, biopsies, and therapeutics. Besides allowing for lesion growth with worsening of the patients’ symptoms, this generates an unnecessary use of resources such as inappropriate exams and inadequate treatments that can have deleterious effects to the patient and are time and money consuming both for the patient and the health institution.

The clinical suspicion allows an adequately directed diagnostic pathway and an effective treatment as the diagnosis is made, as well as the correct orientation of the patient with the exclusion of other sexually transmitted diseases, sexual partner diagnosis, health education, and counseling toward this topic [4].

Perianal pathology diagnosis can be difficult as it can be originated by a variety of diseases, often with similar manifestations. Being infrequent, exuberant manifestations of secondary syphilis diagnosis can be missed. Articulation between different specialties can facilitate clinical diagnosis and allow for a correct investigation and timely treatment.