Giant condyloma acuminatum (GCA), alternatively known as the Buschke-Lowenstein tumor, is a slow-growing cauliflower-like neoplasm notable for its size and presentation in the anogenital region. Scrotal Buschke-Lowenstein tumors are rare, and more so in human immunodeficiency virus (HIV) patients. A patient with untreated HIV presenting with a scrotal GCA and the considerations taken in his care are reviewed.
A 34-year-old incarcerated Hispanic male patient presented to the Emergency Department with a 1-year history of a rapidly growing mass that had overtaken the scrotal area that initially presented as a small wart at the base of his penis. Eight months before this visit, the patient was diagnosed with HIV but declined therapy. In the 7 days before presentation, the verrucous nodule grew rapidly and encompassed the scrotum, causing extreme pain and nausea. On examination, the mass had a 12- × 10-cm cauliflower-like morphology, was exquisitely tender, and drained malodorous pus. Additional small verrucous lesions were found on the base and shaft of the penis. At the time of presentation, the patient reported no abdominal pain, dysuria, penile pain, or penile discharge and was admitted for further work up by the Urology service. Scrotal ultrasound was negative for torsion or other intrascrotal abnormality, and the CD4 count was 88. Complete resection of the large condyloma and smaller peripheral condylomata were completed 13 days after presentation (Fig. 1).
Human papillomavirus (HPV) has been discovered to be the causative agent of Buschke-Lowenstein tumors, most commonly those caused by the subtypes 6 and 11. Immunosuppression increases the oncogenicity of these HPV subtypes.1 The HPV subtypes causing GCA are largely sexually transmitted, accounting for the common distribution in the anogenital and oral regions.2 This may explain the rarity of scrotal involvement, as the penis has a much higher chance of inoculation than the scrotum. In addition, scrotal presentations of this tumor may pose less interference to coitus and other sexual function, contributing to the delay in patient presentation for treatment. Vaccination against these HPV subtypes may precipitate a decrease in the prevalence of GCA, as the Gardasil vaccine protects against subtypes 6, 11, 16, and 18—including 2 of the most common subtypes of HPV found in GCA.3 Cervarix protects against subtypes 16 and 18 and therefore would be less likely to protect against GCA.
Aspects of this patient's case were typical for GCA, such as immunosuppression and uncircumcised status, though lack of circumcision as a risk factor likely only applies to penile GCA.4 GCA in HIV patients is still very rare and even rarer in this case, given its large size (13.5 × 13.5 × 8.5 cm). Only one previous report exists in the English literature on GCA of the scrotum in an HIV-positive patient.5 A higher number of reports would be expected as HPV infection has a high prevalence in HIV-infected individuals.6 It is unlikely that highly active anti-retroviral therapy (HAART) eradicates this type of tumor, as evidence suggests that HAART therapy has little to no effect in suppressing HPV lesions.1,7,8 Patients with HPV lesions who are treated with HAART therapy may even experience an increased growth of lesions during the initial treatment period.6 Radical surgical excision remains the primary method of treatment for Buschke-Lowenstein tumors.2,4,5,9–11
Reports of scrotal Buschke-Lowenstein tumors in HIV patients are scarce in current literature.5 Why scrotal skin appears to be preserved in most cases of GCA even with extensive anogenital involvement remains unclear. The possibility of underreporting in the current literature is high, considering the strong relationship between HPV and HIV. This case further supports the use of HPV vaccination in both high-risk groups and the male population to potentially prevent manifestations of this virus as occurred in this patient.
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