Dermoscopy of Circinate Balanitis in Sexually Acquired Reactive Arthritis

Introduction

Reactive arthritis is an inflammatory arthritis which occurs as an aberrant autoimmune response to gastrointestinal (shigella, Salmonella, campylobacter) or genitourinary (chlamydia trachomatis) infections. The classic triad of symptoms includes urethritis, uveitis, and joint pain, which may not coexist at the same time. The cutaneous manifestations consist of keratoderma blenorrhagicum, circinate balanitis, aphthous ulcers, and nail changes. Circinate balanitis occurs as annular erythematous plaques/pustules with raised borders over glans, shaft of the penis or rarely scrotum. Dermoscopic features of circinate balanitis have rarely been reported in the literature. Here, we report dermoscopy features of circinate balanitis in reactive arthritis post chlamydia urethritis.^[1-3]

Case Presentation

A 29-year-old male patient with high-risk sexual behavior presented with asymmetrical peripheral oligoarthritis of shoulder right, knee joint right, and ankle joints, associated with morning stiffness for the past 3 months. Arthritis was heralded by redness and pain of both eyes which was followed 2 weeks later by the appearance of multiple asymptomatic reddish lesions on his penis. The patient also complained of mild dysuria which resolved spontaneously over 2 weeks.

Dermatological examination revealed single well-defined erythematous annular plaque over glans and shaft of the penis [Figure 1].

Figure 1: Well demarcated erythematous annular plaque with raised borders (black arrow) and well defined round erythematous papule (green arrow) over glans of penis

Dermoscopy (DermLite DL4 attached to Vivo android phone), done on the 2^nd day of appearance of circinate balinitis, revealed homogeneous dotted vessels over faint red background with radiating furrows and peripheral diffuse scaling [Figure 2].

Figure 2: Dermoscopy (DermLite DL4 attached to vivo android phone) of papule over glans shows dotted vessels (black arrow) over faint erythematous background (green arrow), radiating furrows (yellow arrow), and peripheral fine scaling (blue arrow)

On investigation, venereal disease research laboratory test, treponema pallidum hemagglutination assay, and human leukocyte antigen B27 were found to be positive. Levels of C-reactive protein and Chlamydia trachomatis IgM antibody (1933 mg/dl) were raised. Radiography of bilateral foot revealed calcaneal spurs. However, enzyme-linked immunosorbent assay for human immunodeficiency virus, rheumatoid factor, and anti-cyclic citrullinated peptide antibodies were negative.

The patient was diagnosed with a case of reactive arthritis with syphilis and treated accordingly.

Conclusion

Dermoscopy is an important noninvasive tool that can aid in the diagnosis of cutaneous manifestations of reactive arthritis.

Dermoscopy of circinate balanitis in our case revealed dotted vessels over a faint red background corresponding to elongation of rete ridges and changes in dermis including enlargement with increased number of capillaries. The periphery of the lesion showed diffuse fine scaling which corresponds to parakeratosis. These findings are in consonance with the observation of Panigrahi et al.,^[2] however we noticed radiating furrows in the surrounding of the lesion as an additional finding which has not been reported hitherto. This additional finding can further help delineate circinate balanitis from close mimics such as annular lichen planus (reticular whitish structures that correspond to Wickham striae) and pustular psoriasis (regularly distributed dotted vessels with milky globules on a reddish background). Further dermoscopy studies of circinate balanitis with a larger number of patients will help in increasing the diagnostic accuracy and obviate the requirement of biopsy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.