Alright, I think it's time
we moved on to case number 2.
A 23-year-old man now presents to your office,
concerned about some bumps on his penis.
He noticed them several
weeks ago in the shower.
He tried rubbing alcohol, God knows why,
and then a topical antifungal, to no avail.
These lesions are not itchy or painful, he denies any
fevers or chills, no dysuria, no penile discharge.
His social and family history
is essentially non-contributory,
except that he has been sexually active with
5 female partners in the past 12 months.
Review of systems is negative, his vital
signs are over the normal limits.
And then on exam of his genitourinary system, he has
numerous, nontender, skin colored, fleshy papules,
scattered on the shaft and base of his penis.
No mucosal involvement and
no inguinal lymphadenopathy.
So, highlighting a few key features here,
the time course appears to be subacute.
He noticed them several weeks ago.
In terms of the pattern of skin involvement, it is
asymmetric involvement exclusively of his genitalia.
Skin inflammation, they're nontender,
there don't appear to be pustules
so doesn't sound there's much skin inflammation.
And lastly, systemic involvement -
we're not seeing any.
So, that's basically what we've got at this point.
Alright, let's take a look at
our differential diagnosis.
Condyloma acuminata, acrochordon, genital
herpes, verruca vulgaris and chancres.
Well that's a mess of Greek and Latin.
Let's see if we can make our way through it all.
First off, condylomata acuminata,
that's a fancy term for genital warts.
The etymology actually means pointed, round
tumor which distinguishes a genital wart
from the more flat appearance of plantar and
common warts which are also caused by HPV.
In any event, these asymptomatic
lesions are incredibly common.
In fact, they're the most common sexually
transmitted disease above all else
and they manifest on the shaft of the penis.
They're more common in sexually active men and
women so this one clearly is gonna stay on our list.
Next stop, acrochordon.
What's with the fancy words?
Okay, an acrochordon is the official term for a
skin tag which is depicted here in our image.
It's a fleshy papilloma that most
often occurs in flexural creases,
like the nape of the neck, the axilla, the groin.
We should probably keep this one on our list for now.
Genital herpes, finally some english.
Genital herpes is typically
caused by herpes simplex virus 2,
though it can also be caused by HSV 1.
It's relatively common viral infection
with myriad skin manifestations
but the lesions of HSV 2 are more of
the painful vesicular or ulcerative type
rather than our patient's painless, fleshy papules.
So I think we can safely take HSV-2
and genital herpes off the list.
And here we're back to the latin.
This is a fancy word for common wart.
Common warts is one subtype of cutaneous warts.
The others of which include plantar warts and flat warts,
we've already mentioned another type of wart above.
Cutaneous wart is an umbrella term for warts caused by
HPV that are not occuring in the anogenital region
which is we've already discussed
are called condylomata acuminata.
Hence, since our patient's lesions are
in fact in the anogenital area,
if they were gonna have any kind of wart,
it would be condylomata acuminata.
So we can safely take verruca
vulgaris off of our list.
A bit of taxonomy goes a long way.
A chancre is the classic
lesion of primary syphilis.
Now it starts as a painless papule, similar
to our patient at the site of inoculation.
though it eventually progresses to a painless ulcer.
It'd be unusual to have multiple lesions
like we have on our patient and also,
you'd more likely have some
Now, while the chancre represents
the primary syphilis lesion,
the spirochete bacterium of
syphilis, Treponema palliidum,
soon goes systemic even as the
ulcer heals over several weeks.
So, patients develop some systemic manifestations.
And later, secondary syphilis can occur with a diffuse, classic,
maculopapular rash eruption on the trunk and extremities,
including the palms and soles.
It's really not sounding at all like what our
patient has had for the past several weeks,
so I think we can safely take
off chancre and syphilis.