Photo Rounds

Genital growths

A 22-year-old woman presented to a family physician (FP) with many growths around her vagina and anus that she’d had for more than one year. She admitted to having many sexual partners and receiving payment for sex with either money or drugs. She was in recovery at a residential chemical dependency program for intravenous heroin use.

What's your diagnosis?


The FP diagnosed this patient with probable condyloma acuminata but was also concerned about the possibility of other sexually transmitted infections (STIs). He ordered a rapid plasma reagin (RPR) and a human immunodeficiency virus (HIV) test.

A Pap smear was also performed using liquid-based technology to include screening for gonorrhea and chlamydia. While condyloma lata (secondary syphilis) was considered in the differential diagnosis, the verrucous appearance of the lesions pointed to condyloma acuminata from human papillomavirus (HPV).

The RPR came back positive for syphilis with a titer of 1:32. The confirmatory serologic test for syphilis was also positive. The remaining STI screening tests were negative, including the HIV test. The patient remembered having a nonhealing sore on her labia about 2 months ago that healed on its own, making this most likely a case of early latent syphilis.

For the syphilis, the FP treated the patient with a single intramuscular injection in the buttocks of 2.4 million units of benzathine penicillin G. The patient was told to follow up in 6 months for a repeat RPR.

The physician offered treatment for the condyloma acuminata on the first visit. The patient chose to have cryotherapy, which was performed with liquid nitrogen and a cryo-gun. Only one freeze thaw cycle was performed, as the patient found it too painful to have a second cycle. An appointment was made to repeat the cryotherapy in 4 weeks. While the patient was interested in using topical imiquimod, she did not have health insurance and could not afford it.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Genital warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

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