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5. A 31-years old renal transplant recipient developed this lesion in his anal region 4 years after successful treatment of acute AMR. He is currently on Tacrolimus (trough 8 ng/ml), MMF 750 mg bd and prednisolone 5 mg od. The lesion is itchy.
- What is your differential diagnosis?
- What do you confirm the diagnosis?
- What is the treatment?
- Does this condition affect other parts of the body?
- What are the clinical presentations of this disease?
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Anogenital Wart caused by HPV
DD :SCC ,BCC ,Kaposi sarcoma
Diff areas affected :perioral and hands
Diagnosis by biopsy
treatment: decreasing immunosuppressive dose and switching CNI to mtor
Local excision
1.D/D : Genital warts, SSC, BCC.
2.confirm by biopsy & H/P.
3.Local excision, reduce TAC, switch MMF to mTORi.
4.genital areas, perioral area.
5.itching, burning sensation, mild bleeding.
What is your differential diagnosis?
What do you confirm the diagnosis?
Biopsy of the lesion
What is the treatment?
Reduction of immunosuppression, switching MMF to mTORi, liquid nitrogen, excision
Does this condition affect other parts of the body?
Genitalia area
What are the clinical presentations of this disease?
Itchiness, bleeding and pain
Differential diagnosis of the lesions are Genital warts due to HPV, Kaposis’s sarcoma, Malignant melanoma, squamous cell carcinoma and basal cell carcinoma…the typical location and lobulated flower like lesion of the genital region is suggestive of Ano genital warts due to human papilloma virus after transplant…
it is also common in HIV and other immunosuppuresed states
The treatment of the same is excision of the lesion under local anesthesia….
The other treatment in reduction of immunosuppression namely CNI and substitution with mTOR inhibitores as it has anti proliferative effects…
The same lesions make occur over the hands and the perioral regions…the ano genital warts are due to HPV..Hence the recommendations for the vaccine for reproductive age group irrespective of the gender is indicated…There are quadrivalent and bivalent vaccine available….
What is your differential diagnosis
Condyloma acuminatum (genital warts )
Risk factors for the development of giant condyloma acuminatum include an immunodeficient state, such as human immunodeficiency virus infection, post-organ transplantation,
The tumor was successfully treated with a combination of topical podophyllin and cryotherapy and transanal surgical excision, followed by bleomycin irrigation.
https://pubmed.ncbi.nlm.nih.gov/25597932/#:~:text=Risk%20factors%20for%20the%20development%20of%20giant%20condyloma,marrow%20transplantation%20are%20extremely%20rare%20%280.3%20to%201.3%25%29.
Possible differential diagnosis of this case is papillomaviruses infection with genital warts ” condyloma accuminata ” due to over immunosuppression after treatment of previous rejection episode.
Other diagnoses include Kaposi sarcoma, anorectal carcinoma, squamous cell carcinoma, syphilitic condyloma, malignant melanoma, neurofibromatosis or molluscum contagiosum.
Confirmation of diagnosis is achieved by biopsy from the lesion. Viral serology could be of help to detect viral load.
Treatment options are based on reduction of immunosuppression, better switching CNI to mTORi. Medical local measures vary among 5 fluorouracil or cryotherapy, liquid nitrogen, salicylic acid, and imiquimod. Surgical excision also can be of value.
Other parts affected could be the genital areas (groin, penis, scrotum, vagina, vulva and cervix).
Different clinical presentations could be mild bleeding, burning sensation, discomfort, genital itching or irritation. Warts spread along genitalia as well.
Differential diagnosis of Anal lesions include:
-Condyloma Accuminata by HPV infections
-Basal cell carcinoma
-Squamous cell carcinoma
Diagnosed essentially through excisional biopsy
-Treatment of the cause either through antivirals and imiqimoid , radiotherapy or cryotherapy accordingly .
● What is your differential diagnosis?
Anal itchy lesion with cauliflower type in intensive Immunocompromised patient consists with:
☆ Papillomaviruses infection with genital warts ” condyloma accuminata ”
☆ Kaposi sarcoma
☆ Anorectal carcinoma
☆ SCC
☆ Syphilis with condyloma
☆ Melanoma
☆ Neurofibromatosis
☆ Molluscum contagiosum
● What do you confirm the diagnosis?
☆ MDT team include : Dermatologist, oncologist, cytopathlogist, radiologist, and surgeon.
☆ Excisional biopsy
☆ papillomaviruses PCR
● What is the treatment?
☆ Reduction of immunosuppression drugs with shifting metabolite to m-TORi
☆ Tropical treatment with 5 fluorouracil or cryotherapy , liquid nitrogen , salicylic acid , and imiquimod
☆ lazer and cauteryzation
● Does this condition affect other parts of the body?
Yes. Genital areas, palmers of the hands, neck, feet, and head
● What are the clinical presentations of this disease?
Asymptomatic , Itch, bleeding, Pain, and Irritation or burning sensation
Q1:
1- Genital wart (condylomata acuminata)
Caused by HPV-6,11,42,43,44
2-squamos cell carcinoma caused by HPV16,18,31,33,35,39,45
3-Bowenoid papulosis
4-adenocarcinoma.
Q2: Confirmation of diagnosis is by carful visual inspection and confirmatory biopsy or HPV-DNA test
Q3: treatment needs: multi-disciplinary team, immunosuppression reduction, local therapy with cauterization, excisional surgery or laser cryotherapy metastatic evaluation for SCC by CT scan and complete laboratory test is recommended.
In addition, chemotherapy or radiation may be needed in SCC.
Podopyllotoxin, imiquimod, TCA are used locally.
Q4: other sites of infection include: mons pubis, vulva, vagina, cervix, in females and perineum, urethra, perianal area, anal canal, inner thighs in both sex. Men may involve glans, coronary sulcus, scrotum.
Anal carcinoma affects colon rectum, too.
Q5: They are warty, flat, dome-shaped, popillomatous, filiform, keratotic growth of normal skin color, rarely are in flamed or hyper-pigmented.
They are painless, but may be itchy.
Reference:
Yuan, J., Ni, G., Wang, T., Mounsey, K., Cavezza, S., Pan, X., & Liu, X. (2018). Genital warts treatment: Beyond imiquimod. In Human Vaccines and Immunotherapeutics (Vol. 14, Issue 7). https://doi.org/10.1080/21645515.2018.1445947
Golušin, Z. (2013). Genital warts: New approaches to the treatment / Genitalne bradavice – novi pristupi u lečenju. Serbian Journal of Dermatology and Venerology, 1(3). https://doi.org/10.2478/v10249-011-0010-3
This is Anogenital warts which typically present with a characteristic “cauliflower” appearance (condyloma acuminata). Kidney transplant patients have a similar appearance as in immunocompetent individuals. However, they may be more common, recur more often, appear larger and more numerous.
Differential diagnosis–There are many verrucous-looking lesions of the genitals:
What do you confirm the diagnosis?
Usually it can be diagnosed by its cauliflower apperance. But we may need biospy if it has atypical apperence or not responding to treatment.Also to rule out any AIN and internal wars we may require anal pap with High resolution Anoscopy.
What is the treatment?
In order to maximize cure, first pare down presoaked skin using a pumice stone, nail file, emery board or scalpel. Therapy may be either patient applied (salicylic acid, imiquimod), or provider applied (cryotherapy) Cryotherapy can be repeated every three weeks. Imiquimod is typically applied once daily before bedtime, three times a week. This can be repeated for up to 16 weeks. kidney transplant and other immunocompromised hosts may require additional cycles of therapy, or may have incomplete response. Given the high incidence of nonmelanoma and other cancers, biopsy if any lesions look atypical or do not respond to therapy .
Does this condition affect other parts of the body?
Groin area.,
Penis.
scrotum.,
vagina,
vulva,
cervix,
What are the clinical presentations of this disease?
Most probably this patient has condyloma acuminata due to human papilloma virus infection with DD of Anogenital warts, cancers melanoma, scc, Basal cell carcinoma.
For confirmation needs Biopsy with histopathologic examination
Treatment
Application of salicylic acid solution or podophyllin resin, or imiquimod
Cryoablation may be tried
If resistant to treatment
Then surgery may be indicated
In addition to reducing immunosuppression especially MMF
Any external anogenital wart may indicate presence of internal HPV related lesions
Clinical symptoms may include pain, itching, irritation of the anogenital verge or even asymptomatic
· What is your differential diagnosis?
Condyloma acuminta, anogenital warts, Mollascum contgiosum,anogenital tumors, seborrheic keratosis.
· What do you confirm the diagnosis?
biopsy
· What is the treatment?
Topical therapies, cryotherapy, and surgical excision are available treatment options. Surgical options include electrosurgery, curettage, scissors excision, and laser therapy.
· Does this condition affect other parts of the body?
Anogenital areas, penis, vulva, vagina, cervix, perineum
· What are the clinical presentations of this disease?
Aaymptomatic, bleeding, itching, pain
What is your differential diagnosis?
What do you confirm the diagnosis?
What is the treatment?
Presentation
Sites of affection
References
Monk BJ, Tewari KS. The spectrum and clinical sequelae of human papillomavirus infection. Gynecol Oncol 2007; 107(2 Suppl 1): S6– S13. 2. Euvrard S, Kanitakis J, Chardonnet Y et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Arch Dermatol 1997; 133: 175–178. 3. Euvrard S, Kanitakis J, Cochat P, Cambazard F, Claudy A. Skin diseases in children with organ transplants. J Am Acad Dermatol 2001; 44: 932–939. 4. Penn I. Cancers of the anogenital region in renal transplant recipients. Analysis of 65 cases. Cancer 1986; 58: 611–616. 5. Paternoster DM, Cester M, Resente C et al. Human papilloma virus infection and cervical intraepithelial neoplasia in transplanted patients. Transplant Proc 2008; 40: 1877–1880. 6. Dyall-Smith D, Trowell H, Dyall-Smith ML. Benign human papillomavirus infection in renal transplant recipients. Int J Dermatol 1991; 30: 785–789. 7. Boyle J, MacKie RM, Briggs JD, Junor BJR, Aitchison TC. Cancer, warts, and sunshine in renal transplant patients. Lancet 1984; 1: 702–705. 8. Bonnez W, Reichman R. Papillomaviruses. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases, 6th Ed. Philadelphia, Churchill Livingstone, 2006: 1841–1856. 9. Euvrard S, Kanitakis J, Chardonnet Y et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Arch Dermatol 1997; 133: 175–178. 10. von Knebel Doebertiz M. Biomarkers in screening of cervical cancer. In: Monsonego J, ed. Emerging Issues on HPV Infections: From Science to Practice. Basel, Karger, 2006: 1–19. 11. Alloub MI, Barr BB, McLaren KM, Smith IW, Bunney MH, Smart GE. Human papillomavirus infection and cervical intraepithelial neoplasia in women with renal allografts. BMJ 1989; 298: 15
DIFF DIAGNOSIS
ANAL WART
THROMBOSED PILES
SKIN CANCER , LIKE SCC
MELANOMA – NOT USUAL SITE
MULTIDISCIPLINARY TEAM INVOLVINNG SKIN SPECIALIST , SURGICAL ONCOLOGY
BIOPSY OF LESION IS ADVISED
LESION DUE TO HERPES VIRAL infection like warts are likely to seen in other parts of body like oral cavity , mucocutaneous junctions , genitals
mostly herpes simplex infection is asymptomatic
reduction of IS is mainstay of treatment
local therapy – chemical cauterisation , podophylline are useful
– Anogenital wart ( condylomata acuminata)
– Anal cancer
– Haemorrhoid
– Seborrhoeic keratosis
– Polyp/ skin tag
–History :
– Present in other part of genital region
– Any itching or pain
– H/O sexual exposure
– Duration
– Anorectal bleeding
– Bowel habit
– Constitutional symptom
Physical examination
– Similar lesion in other part of genital region
– Anoscopy
Investigation
-CBC, CRP
– Biopsy of the lesion
– Exclude GIT malignancy by USS, CT/MRI of abdomen, proctoscopy, colonoscopy
Treatment
According to cause (most probably anogenital wart)
a) Cyto destructive therapy
– Podophylotoxin and podophyllium
– Trichloroacetic acid and bichloracetic acid
– Fluorouracil
b) Immunne- mediated therapy
– Imiquimod
– Sinecatechins
– Interferon
C) Surgical intervention
– Laser ablation
– Electrocautery
– Excision
Yes, can affect in penis, vulva, groin, perineum
Usually asymtomatic without such kind of lesion
– Cauliflower lesion:
Confirmation:
MDT approach, dermatology, surgery.
HPV PCR
Biopsy of lesion
Treatment:
Reduction of immunosuppression, 50% reduction of MMF, CNI levels
CNI to mTOR switch
Monitoring for rejection
Specific treatment:
Podofilox.
Imiquimod.
cryotherapy.
lazer
surgical excision.
Other sites:
oral cavity, vulva, vagina , cervix, penis and scrotum.
Clinical presentation:
Itching bleeding
Differential diagnosis:
1-Anal warts
2-Condylomata accumulata
3-Anorectal cancer
4-Anal polyp
5-Heamorrhoids
What do you confirm the diagnosis:
Detailed history and examination. This includes immunosuppression history, viral infection and sexually transmitted diseases. Also, any other lesions in the body. Any systemic symptoms.
Then we need to take tissue biopsy to confirm the diagnosis.
Check for associated viral infection.
Check for other lesions colonoscopy and endoscopy.
What is the treatment:
Treatment options for HPV-associated disease in kidney transplant recipients depend on the size, location and grade of the lesion.
Main treatment strategy is surgical removal then reduction of immunosuppression after confirmation of diagnosis.
Involvement of oncologist, pathologist and colorectal surgeon.
If confirmed as warts:
Therapy may be either patient applied (salicylic acid, imiquimod), or
Provider applied (cryotherapy).
Cryotherapy can be repeated every three weeks. Imiquimod is typically applied once daily before bedtime, three times a week.. Given the high incidence of nonmelanoma and other cancers, we recommend biopsy if any lesions look atypical or do not respond to therapy.
Does this condition affect other parts of the body:
Yes, it can affect the colon, other parts of GIT, other skin parts.
What are the clinical presentations of this disease:
Presentation usually, asymptomatic, rarely with pain and itching,
References :
1-Semin Nephrol. 2016 September ; 36(5): 397–404. doi:10.1016/j.semnephrol.2016.05.0161
What is your differential diagnosis?
1) Wart /papilloma – HPV associated
2) Condyloma acuminate – HPV associated
3) Drug induced warts
4) Skin cancer: SCC
5) Kaposi sarcoma.
6) Anal cancer.
What do you confirm the diagnosis?
1) Detail examination – skin lesions (dermatologist consult)
2) Excision biopsy
3) Proctoscopy, DRE and Sigmoidoscopy / colonoscopy
4) CECT or PET-CT scan – look for other sites of involvement, pelvic and inguinal lymph nodes.
What is the treatment?
· Excision biopsy – curative for solitary superficial lesion; histopathology shall reveal details
· Topical keratolytic and caustic agent – (if patient denies surgery)
o Topical 5FU / imiquimod cream application – post excision to prevent recurrence
o Topical podophyllin, physical ablation
· Reduction of Immunosuppression
o To stop MMF / AZT
o Reduction of CNI or switch to mTOR-inhibitor
Does this condition affect other parts of the body?
HPV lesions affects
Male genitalia, penile skin,
external meatus and distal penile urethra
Females: Cervix and vagina
What are the clinical presentations of this disease?
· Skin – Cutaneous warts, SCC – asymptomatic lesion / itchiness, bleed
· Anogenital – Anogenital warts, anal cancer,
– CIN, cervical cancer and vulvar SCC / Melanoma
– penile carcinoma
References:
1) Chin‐Hong P.V., Reid G.E. Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical transplantation 2019; 33(9), 13590.
2) Hand book of kidney transplantation 6th edition
What is your differential diagnosis?
Genital warts related to HPV
Condylomata acumolata
Condylomata lata
Polyps
Skin tags
Anal neoplasia
Moluscum contageosum
Non-melanoma skin cancer
What do you confirm the diagnosis?
Biopsy for histopathological examination
HPV screening test
What is the treatment?
Local applying drugs:
Imiquimod 3.75% or 5% cream
Podofilox 0.5% solution or gel
Sinecatechins 15% ointment
OR
Laser or cautary
Surgical removal
Chemotherapy or radiotherapy or both
Does this condition affect other parts of the body?
Yes it can affect the Cervix, vagina, urethra, perineum, anus, or scrotum.
What are the clinical presentations of this disease?
Either Asymptomatic
Or present with Pain or pruritis
Growth (flat, papular, or pedunculated)
Reference:
H. K. Larsen et al. Risk of Anogenital Warts in Renal Transplant Recipients Compared with Immunocompetent Controls: A Cross-sectional Clinical Study, Acta Derm Venereol 2021; 101: 10.2340/00015555-3858.
1) HPV associated Condyloma acuminate ( Most likely )
2) Drug induced warts
3) Anal cancer.
4) Skin cancer: Non-melanoma skin cancer.
5) Kaposi sarcoma.
1) this lesion should be removed and send to histopathology
2) HPV PCR
3) PAP smear for females
4) Pan CT or PET scan looking for other sites of involvement
Human papillomavirus causes cutaneous and anogenital warts and is associated with cervical intraepithelial neoplasia, squamous cell carcinoma, and anogenital carcinoma. Premalignant skin and cervical lesions are more common and progress more rapidly to cancer among organ transplant recipients. Cutaneous warts, keratotic skin lesions, and anogenital warts should be monitored and referred for early dermatologic or colorectal evaluation, biopsy, and treatment. Treatments include topical keratolytic and caustic agents, topical and oral retinoids, imiquimod, podophyllin, 5-fluorouracil, bleomycin, physical ablation, and investigational immunotherapies.
Referance :
1) Hand book of kidney transplantation 6th edition
· What is your differential diagnosis?
· Although there is no confirm history of induction with strong immunosuppression with ATG or other for AMR, which increases the risk of opportunistic infection which could increase the risk of carcinoma.
However according to history and the picture of lesion the differentials could be,
· Anogenital squamous cell carcinoma,
· Non-melanomic skin cell cancer,
· Basal cell carcinoma,
· Kaposi sarcoma
· Genital warts.
· How do you confirm the diagnosis?
· A good history for HIV infection, viral serology, induction therapy, sexual history.
· Thorough examination,
· Excision biopsy for histopathological confirmation,
· Viral serology,
· Radiological examination, ultrasound, CT with contrast chest , abdomen, and pelvis, PET scan.
· What is the treatment?
Needs multidisciplinary approach.
Dermatologist, nephrologist, plastic surgeon, histopathologists’ opinion.
· According to definite diagnosis, however, will proceed with surgical excision,
· Cryotherapy,
· Electrodessication,
· Laser with carbondioxide,
· Surgical excision.
· Immunosuppression drugs modification.
· Does this condition affect other parts of the body?
· Depends on diagnosis, usually skin cancers metastasis rarely.
· Because there are certain infections causes’ perianal, cervical, scrotum and other orogenital regions, while, some infection could be the risk of carcinoma which involves gastrointestinal tract and skin.
· What are the clinical presentations of this disease?
· Could be painless,
· Discomfort, itchy, otherwise could be asymptomatic until ulceration, and distant metastasize.
Refrences;
1. Up To Date; Condylomata Acuminata(Anogenital warts);Management of external condylomata acuminata in adults.
2. https://escholarship.org/content/qt6g70h18h/qt6g70h18h_noSplash_af7ac317ac59cf58ec1859725f4a5da9.pdf.
3. https://jamanetwork.com/journals/jamadermatology/article-abstract/558605.
What is your differential diagnosis?
The differential diagnosis for these warts would be
What do you confirm the diagnosis?
What is the treatment?
Does this condition affect other parts of the body?
Males:
penile skin
meatus
distal penile urethra
Females:
Cervix and vagina
What are the clinical presentations of this disease?
Chin‐Hong, P.V., Reid, G.E. and AST Infectious Diseases Community of Practice, 2019. Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical transplantation, 33(9), p.e13590.
DD:
1- inflammatory wart
2-drug induced wart
3-skin cancer
diagnosis can be confirmed by skin biopsy
treatment is excisional biopsy for treatment and diagnosis
yes, any part of the body can be affected
CP bleeding, itching, pain
Anal warts
Melanoma
Anal cancer
Excisional biopsy
Cryotherapy and surgical removal and histopathology to confirm diagnosis
palpable swelling with itching and bleeding
· What is your differential diagnosis?
Genital warts , Condyloma Acuminata
Verrucous carcinoma.
BCC.
Epidermolytic acanthoma.
Molluscum contagiosum.
· What do you confirm the diagnosis?
· Excisional biopsy.
· What is the treatment?
MANGEMENT:
Imiquimod.
Removal of the affected areas by surgery with cold electrosurgical unit, electrocoagulation or cryotherapy.
Liquid nitrogen cryotherapy is currently widely used, being very effective in patients with few injuries. When it comes to numerous injuries, the use of the CO2 laser is preferred, as it allows the most precise.
· Does this condition affect other parts of the body?
Anogenital, valval, labium, cervical, scrotum. , hands, or disseminated in immunosuppressed patient.
· What are the clinical presentations of this disease?
Most as mass with pruritus or bleeding.
1-Anal warts
2-Condylomata accumulata
3-Anorectal cancer
4-Anal polyp
5-Heamorrhoids
Detailed history and examination. This includes immunosuppression history, viral infection and sexually transmitted diseases. Also, any other lesions in the body. Any systemic symptoms.
Then we need to take tissue biopsy to confirm the diagnosis.
Check for associated viral infection.
Check for other lesions colonoscopy and endoscopy.
What is the treatment:
Treatment options for HPV-associated disease in kidney transplant recipients depend on the size, location and grade of the lesion.
Main treatment strategy is surgical removal then reduction of immunosuppression after confirmation of diagnosis.
Involvement of oncologist, pathologist and colorectal surgeon.
If confirmed as warts:
Therapy may be either patient applied (salicylic acid, imiquimod), or
Provider applied (cryotherapy).
Cryotherapy can be repeated every three weeks. Imiquimod is typically applied once daily before bedtime, three times a week.. Given the high incidence of nonmelanoma and other cancers, we recommend biopsy if any lesions look atypical or do not respond to therapy.
Yes, it can affect the colon, other parts of GIT, other skin parts.
Presentation usually, asymptomatic, rarely with pain and itching,
References :
1-Semin Nephrol. 2016 September ; 36(5): 397–404. doi:10.1016/j.semnephrol.2016.05.0161
What is your differential diagnosis?
It will include:
· Anogenital wart/ Condylomata accumunata
· Anal Cancer
· Hemorrhoids
· Melanoma
What do you confirm the diagnosis?
MDT approach- Involve dermatologist and colorectal
Proctoscopy to see any internal lesions
Incision or excision biopsy
HPV Serology
Anal Pap Smear
What is the treatment?
It will be sensible to adopt MDT approach. I will consult dermatology, Colorectal team, and review biopsy results.
Treatment options include_
Cryotherapy , topical salicylic acid.
Reduction and modification of immune suppression ( Consideration should be given to risk of rejection and close monitoring will be required. )
Does this condition affect other parts of the body?
It can affect hands , perioral region , genital areas , feet and plantar areas
What are the clinical presentations of this disease?
It can be asymptomatic or present with bleeding and pruritus.
Krüger-Corcoran D, Stockfleth E, Jürgensen JS,et al. Management [Human papillomavirus-associated warts in organ transplant recipients. Incidence, risk factors, management]. Hautarzt. 2010 Mar;61(3):220-9. German.
What is your differential diagnosis?
What do you confirm the diagnosis?
What is the treatment?
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
Patients with warts may complain of itching, burning, bleeding and pain. Those with large genital warts may have a sense of fullness.
However, many patients have no symptoms.
References
Human papillomavirus in Transplant Recipients Peter V. Chin-Hong, MD, MAS, John B. Lough, BA, EdM, Juan A. Robles, BA
Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice
5. A 31-years old renal transplant recipient developed this lesion in his anal region 4 years after successful treatment of acute AMR. He is currently on Tacrolimus (trough 8 ng/ml), MMF 750 mg bd and prednisolone 5 mg od. The lesion is itchy.
concerns/ issues: –
– treated for acute AMR
– developed anal lesion 4years after acute AMR treatment
– current meds – Tacrolimus (trough 8ng/mL), MMF 750mg BD, Prednisone 5mg OD
What is your differential diagnosis? (1)
– genital warts are a risk factor for subsequent HPV-related anogenital malignancies (1)
– anogenital cancers account for 2-3% of cancers in transplant recipients and present on average 84 to 112 months post-transplant (2, 3)
What do you confirm the diagnosis?
– histopathologic examination of the anal cytology and/ or biopsy specimens
– cytology is considered the initial screening test and patients with abnormal cytology are subjected to high-resolution anoscopy (HRA) for examination and biopsy of suspicious lesions
– assess spread to the abdomen, pelvis, chest through imaging
What is the treatment? (4)
– requires a multidisciplinary approach
– in situ anogenital cancers can be managed with: –
– consider reduction in immunosuppression as this may result in resolution of in situ carcinomas i.e., reduce MMF dose or switch to mTORi, target trough level of 4-5ng/mL, maintain prednisone at 5mg OD
– wide local excision for invasive tumors
– since recurrences are frequent, post-treatment surveillance with high-resolution anoscopy (HRA) and biopsy of suspicious lesions should be done
– anal cytologycan be used as an adjunctive test to confirm lesion clearance
– prevention with HPV vaccination is key
Does this condition affect other parts of the body?
– anogenital tract i.e., cervix, vagina, vulva, penile, scrotum, perianal skin, perineum
– other areas e.g., nasal, oral, lips, tongue, conjunctival, laryngeal warts
What are the clinical presentations of this disease?
– Risk factors: – anal HPV, sexual behaviour, HIV status, iatrogenic immunosuppression
– can be asymptomatic
– local symptoms e.g., per rectal bleeding, pain, difficult defecation, altered stool patterns, growths, pruritus, discharge, tenesmus, irritation, burning sensation
– urinary symptoms if the tumor invades the bladder or the prostate i.e., hematuria, obstructive and irritative urinary symptoms
References
1. Larsen HK, Thomsen LT, Haedersdal M, Dehlendorff C, Schwartz Sørensen S, Kjaer SK. Risk of genital warts in renal transplant recipients-A registry-based, prospective cohort study. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2019 Jan;19(1):156-65. PubMed PMID: 30080315. Epub 2018/08/07. eng.
2. Adami J, Gäbel H, Lindelöf B, Ekström K, Rydh B, Glimelius B, et al. Cancer risk following organ transplantation: a nationwide cohort study in Sweden. British journal of cancer. 2003 Oct 6;89(7):1221-7. PubMed PMID: 14520450. Pubmed Central PMCID: PMC2394311. Epub 2003/10/02. eng.
3. Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. The New England journal of medicine. 2003 Apr 24;348(17):1681-91. PubMed PMID: 12711744. Epub 2003/04/25. eng.
4. Euvrard S, Kanitakis J, Chardonnet Y, Noble CP, Touraine JL, Faure M, et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Archives of dermatology. 1997 Feb;133(2):175-8. PubMed PMID: 9041830. Epub 1997/02/01. eng.
What is your differential diagnosis?
· Buschke-Lowenstein tumor (BLT) known as verrucous carcinoma or giant condyloma
Itis an intermediate lesion between benign condyloma and SCC and is a highly differentiated verrucous carcinoma of the anogenital region
It is manifested as a slow-growing, large, cauliflower-like tumor with locally destructive behavior.
It is associated with HPV6 and HPV11.
It’s malignant transformation (estimated rate of 56%) without propensity for metastasis, Rate of recurrence after excision is high (66%)
overall mortality of approximately 20%
· Anogenital warts due to Human papilloma virus 90% are caused by nononcogenic HPV types 6 or 11. HPV types 16, 18, 31, 33, and 35 also are occasionally detected in anogenital warts with foci of high-grade squamous intraepithelial lesion (HSIL), particularly among immunocompromised cases.
· HPV-associated malignancies as = squamous cell carcinomas (SCCs)
=melanomas
= adenocarcinomas
What do you confirm the diagnosis?
Detailed history including the sexual history of the case
Patients with external anal warts might also have intra-anal warts so inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy ,colonscopy and biopsy will be needed to exclude precancerous lesions
Imaging studies CT and MRI for assessment of the local and regional extension
The relative risk for developing Anal Cancer is 10 times greater among renal transplant recipients than that of the general population . HPV16 has an association with anal cancer and is found in approximately 70% of Anal Cancer lesions
What is the treatment?
MDT team has to be involved along with dermatological and surgical consultation
A wide radical excision, followed by reconstructive surgery, seems to be the optimal therapeutic strategy for BLT management
for extensive tumors, preoperative chemotherapy or radiotherapy can be used to promote tumor shrinkage, rendering the debulking procedure safer .
Follow-up visits are necessary due to the high risk of recurrence
Or Imiquimod 3.75% or 5% cream or Podofilox 0.5% solution or gel or Sinecatechins 15% ointment or Cryotherapy with liquid nitrogen or cryoprobe or Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%–90% solution for warts lesions
intralesional bleomycin, and cidofovir; however, primary prevention with HPV vaccination remains the most effective strategy.
long-term intra-lesional IFNα2b therapy was tried but less favourable outcomes
Reduction of immunosuppressive therapy ,with cautious monitoring for rejection recurrence
Does this condition affect other parts of the body?
Genital areas and oral cavities
Non-genital sites includes common warts (verrucae vulgaris), plantar warts (verrucae plantaris), and flat warts (verrucae plana).
What are the clinical presentations of this disease?
It presents as a slow-growing cauliflower-like mass in the genital or anorectal area, with relatively slow infiltration into deeper tissues .
It starts from a long-standing condyloma acuminatum, which can grow to sizes of more than 10 cm in diameter.
Tumor growth may be rapid in immunocompromised individuals . Non-sexual transmission
via fomites is possible.
Infection with low-risk HPV types usually remains asymptomatic or benign, and regress spontaneously.
Low-risk α-HPVs can cause common warts and tree man syndrome (TMS)
Other low-risk α-HPVs, such as HPV-6 and HPV-11,are associated with condylomas, but may contribute to the formation of giant condyloma acuminata with destructive local progression .
High-risk α-HPVs are HPV-16, -18, -31,-33, -35, -39, -45, -51, -52, -56, -58, -59, -66, -68, and -70. They are the main risk factor of developing HPV-induced malignancies as HPV-16 is responsible for the majority of HPV-induced cervical cancer, oropharyngeal and anogenital squamous cell carcinoma (SCC)
β-HPVs infection, and sometimes HPV-3 from the α genus can lead to Epidermodysplasia verruciformis (EV), which is rare , it presents with profuse flat warts or scaly, reddish, brownish, or achromic plaques.
β-HPVs with a high oncogenicity as HPV-5, are co-factors of cutaneous SCC development .
γ-, µ-, and ν-HPVs all present skin tropism and are associated with benign common warts or plantar myrmecia
Reference
-Reusser NM, Downing C, Guidry J, Tyring SK. HPV Carcinomas in Immunocompromised Patients. J -Clin Med. 2015;4(2):260-281. Published 2015 Jan 29.
-H. K. Larsen et al. Risk of Anogenital Warts in Renal Transplant Recipients Compared with Immunocompetent Controls: A Cross-sectional Clinical Study. Acta Derm Venereol 2021; 101: adv00497
-Anogenital warts .Sexually Transmitted Infections Treatment Guidelines, 2021. Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention
-Purzycka-Bohdan, D.; Nowicki, R.J.; Herms, F.; Casanova, J.-L.; Fouéré, S.; Béziat, V. The Pathogenesis of Giant Condyloma Acuminatum (Buschke-Lowenstein Tumor): An Overview. Int. J. Mol. Sci. 2022, 23, 4547
What is your differential diagnosis?
*Wart at the anogenital region.
*Carcinoma
*Kaposi sarcoma
*Melanoma
What do you confirm the diagnosis?
• Excisional biopsy
What is the treatment?
It should be managed as multidisciplinary team between Nephrologist, Dermatologist, Surgeon and oncologist .
-Crayotherapy
-Electrical
-Laser
-Surgical
Also immunosuppressive medications should be modified as Sirolomus can be used instead of Tacrolimus
Does this condition affect other parts of the body?
Yes, it can affect oral , genital , hands .
What are the clinical presentations of this disease?
It may be asymptomatic lesions, or may be associated with itching or bleeding
Reference :
Ramírez-Fort MK, Khan F, Rady PL, Tyring SK (eds): Human Papillomavirus: Bench to Bedside. Curr Probl Dermatol. Basel, Karger, 2014, vol 45, pp 98-122
https://doi.org/10.1159/000358423
Diffrential diagnosis:
This is a fleshy grey growth,clauliform like ,most probably this is anal Condyloma Acuminatum ( genital warts).
Others to be considered:
How to confirm the diagnosis:
Treatment:
Medical:
Dose this condition affects other parts of the body?
Yes. Warts can be seen in vagina, vulva and penis
HPV can cause cervical cancers and also cancers of vulva,vagina,penis and oropharyngeal cancers.
clinical presentation of this disease:
usually genital warts are painless but may be itchy.
Warts can be seen in penis and in females in vagina and vulva.
References:
1.Skin cancer image gallery by American cancer society.
2. Human Papilloma Infection in Solid Organ Transplantion: Guidelines from the American Society Transplantation- 2019.
3. Mona Saraiya etal.US Assessment of HPV Types in Cancers. JNat Cacer Inst. 2015,June 107(6).
◇ What is your differential diagnosis?
◇ What do you confirm the diagnosis?
▪︎Proper history and examination. According to this scenario of post- transplant recipient on immunosuppression. The provided image shows a small, dark brown and irregular skin – this most likely secondary to HPV infection.
▪︎We can consult a dermatologist
▪︎To confirm the diagnosis and to rule out neoplasms a biopsy can be taken. If there is condyloma acuminatum, the histopathology will show acantosis, papillomatosis, hyperceratosis, paraceratosis and koilocytosis [1]
◇ What is the treatment?
▪︎We can manage the case according to the diagnosis.
▪︎ If condyloma acuminatum is confirmed then the treatment will be as follow:
– First-line patient-applied therapies include imiquimod, podophyllotoxin, and sinecatechins.
– First-line clinician-administered treatments are cryotherapy, trichloroacetic acid, surgical excision, electrosurgery, and laser therapy [2].
◇ Does this condition affect other parts of the body?
▪︎Sexually transmitted HPV types fall into two groups, low risk and high risk. Low-risk HPVs mostly cause no disease. However, a few low-risk HPV types can cause warts on or around the genitals, anus, mouth, or throat.
◇ What are the clinical presentations of this disease?
▪︎ Warts on or around the genitals, anus, mouth, or throat.
▪︎High-risk HPVs can cause several types of cancer. The precancerous cell changes caused by a persistent HPV infection at the cervix rarely cause symptoms, which is why regular cervical cancer screening is important.
▪︎Precancerous lesions at other sites in the body may cause symptoms like itching or bleeding. And if an HPV infection develops into cancer, the cancer may cause symptoms like bleeding, pain, or swollen glands.
____________________________
References
[1] Eliane Pedra Dias. et al. Condyloma acuminatum: its histopathological pattern
[2] Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in adult males . up to date.
Condylomata acuminata are exophytic cauliflowerlike lesions that are usually found near moist surfaces as in the perianal area
DD
-Genital warts mostly due to genital infection with HPV.
-malignant variant is the giant condyloma, or Buschke-Löwenstein tumor, generally regarded as a verrucous carcinoma.
-SCC.
What do you do to confirm the diagnosis?
-The diagnosis of most cutaneous and external genital warts can be made on clinical examination or with application of acetic acid and biopsy.
-In the case of genital intraepithelial neoplasia, determining the extent of disease is essential.
-This involves careful inspection, as well as colposcopy.
-Detection of human papillomavirus (HPV) DNA.
-CT or MRI can be used to determine extensive anogenital papillomatosis that has spread into the pelvis.
– tissue biopsy is to detect presence of neoplasia
What is the treatment?
There is no single curative treatment for condylomata acuminata.
Eradication or reduction of symptoms is the primary goal of treating warts
Warts may recur after treatment because of activation of latent virus present in healthy skin adjacent to the lesion.
Treatment is not recommended for subclinical anogenital or mucosal human papillomavirus (HPV) infection in the absence of coexistent dysplasia.
No evidence demonstrates that treatment eliminates HPV infection or that it decreases infectivity.
Treatment is mainly by direct ablation of the lesions (eg, surgical excision, chemical ablation,laser, and cryotherapy).
In case of dysplastic lesions elimination is the goal in treating squamous intraepithelial lesions (SILs).
-Pharmacologic Therapy
Two broad categories of medications are effective in treating HPV disease:
Immune response modifiers – These include imiquimod and interferon alfa and are primarily used in treatment of external anogenital warts or condylomata acuminata
Cytotoxic agents – These include the antiproliferative drugs podofilox, podophyllin, and 5-FU, as well as the chemodestructive or keratolytic agents salicylic acid, trichloroacetic acid (TCA), and bichloracetic acid (BCA)
Does this condition affect other parts of the body?
Anogenital warts may be observed in the perianal area, vaginal introitus, vagina, labia, and vulva.
Nonanogenital mucosal disease Warts have been discovered in the nares, mouth, larynx, and conjunctiva.
HPV types 6 and 11 are associated with respiratory papillomas
What are the clinical presentations of this disease?
Clinically, it may be asymptomatic or presents with discomfort, pruritus and bleeding from the lesion.
– Other presentations depend on the involved site as involvement of urethra might hematuria and urinary obstruction.
– The most common presenting symptoms of squamous cell carcinoma (SCC) of the anus are rectal bleeding and sensation of a mass.
Reference
Human Papillomavirus (HPV) Clinical Presentation.uptodate 2020
DD:
· Perianal skin cancer, genital warts& adenocarcinoma
Diagnosis: Through biopsy:
HPV 6 and 11
Treatment:
based on the biopsy
Duration of symptoms would guide therapy including:
· Topical therapy Surgical excision Cryotherapy
Affection of other parts of the body
Affection of other parts like hands, oral cavity & genitalia.
Clinical presentation:
essentially asymptomatic but may present with pruritus or bleeding
What is your differential diagnosis?
1-Anal warts, also known as Condyloma accuminata (itchy), are caused by infection with the human papillomavirus (HPV).
2–Anorectal papilloma.
3–Anogenital cancers; Anal cancer; (SCC)
4-Kapoci Sarcoma .
What do you confirm the diagnosis?
1-Clinical approach;
History (Sexual history ,history of skin or anogenital lesion ).
Clinical examination ;External skin examination and external anogenital examination .
2–HPV Genotyping & HIV screening is recommended.
3-Tissue biopsy ;
Biopsy and tissue histology to rule out underlying intraepithelial neoplasia or cancer is not mandatory before initiating therapy but is recommended when the patient is immunocompromised like our patient.
4-CT / MRI scan on abdomen and pelvis is recommended to assess local nature of the disease.
5-Lower and upper GI endoscopy for possible metastasis or primary.
What is the treatment?
General principles ;
1- Treatment options for HPV-associated disease in kidney transplant recipients depend on the size, location and grade of the lesion .
2-Overall we prioritize treatment of high-grade pre malignant disease (CIN II or III and AIN II or III) over treatment of low-grade lesions.
3- Symptomatic treatment ;
Is needed to relief of anxiety ,for cosmesis,to ameliorate blockage (if large), treatment of bleeding and itching ,to prevent superinfection if ulcerated.
4-Reduce immunosuppression if possible.
This may be done in refractory disease, or if therapy is not tolerated (adverse effects) or practical (disease is extensive). Theoretically a switch from calcineurin inhibitors to mTOR inhibitors such as sirolimus can help particularly if malignant transformation has occurred .
Anal intraepithelial neoplasia (AIN)
As in the presenting case ;
1-In general AIN I is not treated as there is low malignant potential.
2- Some patients with AIN I may be treated for symptomatic or psychological benefit.
3- AIN II and AIN III are treated to prevent anal cancer.
Size and location influence the modality of treatment ;
1-Intraanal lesions <1 cm2 at the base can be treated with 80% trichloroacetic acid, topical 5-fluorouracil or cryotherapy. AIN can sometimes with treated with imiquimod 5% cream .
2- If the lesion is larger or of higher grade, outpatient infrared coagulation or HRA-assisted intraoperative fulguration are options used.
3- If lesions of any grade are very large and not causing the patients symptoms, we may decide to follow patients closely rather than remove disease. This is because of the associated morbidity of removing proportionately large areas of tissue such as pain, anal stenosis and anal incontinence.
Anal cancer ;
The main modality of treatment for anal cancer is chemoradiation as it can cure the majority of patients while preserving the anal sphincter.
Does this condition affect other parts of the body?
1-Cutaneous and anogenital warts.
2-Cervical and anal intraepithelial neoplasia.
3-Head and neck and other cancers.
What are the clinical presentations of this disease?
HPV-associated cervical and anal cancer as well as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) do not usually present with clinically identifiable lesions. Many of these lesions can only be visualized by colposcopy or high resolution anoscopy.
Cutaneous warts;
Are easily identifiable in general. They appear as well circumscribed exophytic papules with normal adjacent skin, and may be pedunculated or flat. They range in size from a few millimeters to several centimeters, with some coalescing to form plaques. Warts occur on any epithelial surface: plantar, palmar and anogenital areas are common.
Anogenital warts;
Typically present with a characteristic “cauliflower” appearance (condyloma acuminata).
Kidney transplant patients;
have a similar appearance as in immunocompetent individuals. However, they may be more common, recur more often, appear larger and more numerous. Patients may complain of itching, burning, bleeding and pain. Often patients may have no symptoms.
Reference ;
1-https://onlinelibrary.wiley.com/journal/16006143Human Papillomavirus Infection in Solid Organ Transplant Recipients.
2-. Sillman FH, Sentovich S, Shaffer D. Ano-genital neoplasia in renal transplant patients. Ann Transplant. 1997;2(4):59–66. [PubMed] [Google Scholar].
3. Cranston RD, Hirschowitz SL, Cortina G, Moe AA. A retrospective clinical study of the treatment of high-grade anal dysplasia by infrared coagulation in a population of HIV-positive men who have sex with men. Int J STD AIDS. 2008;19(2):118–20. [PubMed] [Google Scholar]
4. Stier EA, Goldstone SE, Berry JM, Panther LA, Jay N, Krown SE, et al. Infrared coagulator treatment of high-grade anal dysplasia in HIV-infected individuals: an AIDS malignancy consortium pilot study. J Acquir Immune Defic Syndr. 2008;47(1):56–61. [PubMed] [Google Scholar]
5. Pineda CE, Berry JM, Jay N, Palefsky JM, Welton ML. High-resolution anoscopy targeted surgical destruction of anal high-grade squamous intraepithelial lesions: a ten-year experience. Dis Colon Rectum. 2008;51(6):829–35. discussion 35-7. [PubMed] [Google Scholar]
What is your differential diagnosis?
1) Anogenital wart due to papilloma virus infection(also called condyloma acuminatum, genital warts, and venereal warts..
2) Anogenital squamous cell carcinoma is an important differential diagnosis to consider as the high-risk and low-risk HPV types are both STIs and can be transmitted together.
3) Anogenital skin cancer(Merkle cell carcinoma, SCC, BCC or Melanoma skin cancer).
4) Seborrheic keratoses
What do you confirm the diagnosis?
1. Anogenital warts are usually diagnosed clinically.
2. Skin biopsy is sometimes necessary to confirm the diagnosis of viral wart, particularly if there is concern of anogenital cancer(Excisional biopsy).
3. It may be in need to confirm the presence or absence of HPV.
What is the treatment?
1. MDT including consultation with a colorectal specialist, dermatologist and microbiologist.
2. Treatment is directed to the macroscopic (e.g., genital warts) or pathologic precancerous lesions caused by HPV(1).
a) Subclinical genital HPV infection typically clears spontaneously; therefore, specific antiviral therapy is not recommended to eradicate HPV infection.
b) If HPV infection persists, genital warts, precancers, and cancers of the cervix, anus, penis, vulva, vagina, head, or neck might develop.
3. Treatment options:
a) Cryotherapy with liquid nitrogen.
b) Surgical removal: Curettage and scissor or scalpel excision.
c) Trichloracetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90% solution.
d) Laser ablation.
4. Prevention of anogenital HPV transmission(1):
a) Transmission of anogenital warts to a new sexual partner can be reduced but not completelmay prevented by using condoms.
b) Three HPV vaccines can prevent diseases and cancers caused by HPV(1).
c) Patients with anogenital warts and their sex partners should be screened for other sexually transmitted diseases including gonorrhea and chlamydia infection, syphilis, vaginitis, hepatitis B virus infection and HIV infection.
Does this condition affect other parts of the body?
1) HPV infection may occur in the following anogenital sites: Vulva, Vagina, Cervix, Urethra, Penis, Scrotum, Anus.
2) The same HPV types can also be found in lesions around the lips, the oral mucosa or conjunctiva.
3) Oncogenic, high-risk HPV infection (e.g., HPV types 16 and 18) causes the majority of cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers(1).
What are the clinical presentations of this disease?
Exophytic cauliflowerlike lesions that are usually found near moist surfaces. Presentation may be as follows(2):
1. often asymptomatic.
2. These lesions are generally not painful, but they can be associated with pruritus.
3. bleeding may be observed if the lesions become confluent and are irritated by clothing.
4. Lumps on the vulva, perianal area, or periclitoral area.
References
1. CDC; Centre for Disease Control and prevention Sexually Transmitted Infections Treatment Guidelines, 2021https://www.cdc.gov/
2. Medscape; Human Papillomavirus (HPV) Clinical Presentation Updated: Feb 20, 2020 Author: Peter A Gearhart, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD.
What is your differential diagnosis?
-Anogenital wart.
-Anorectal carcinoma
What do you confirm the diagnosis?
-Excisional biopsy
What is the treatment?
-Cryotherapy can be used. Response rates are high, clearance occurs about 75% of the time with few adverse sequelae.
-Electrodesiccation (smoke plume may be infective) and curettage have been used.
-Surgical excision has the highest success rate and lowest recurrence rate. Initial cure rates are 63-91%.
-Carbon dioxide laser treatment is used for extensive or recurrent warts.
Does this condition affect other parts of the body?
–Oral, laryngeal, or tracheal mucosal lesions (uncommon) presumably transfer through oral-genital contact.
What are the clinical presentations of this disease?
-Painless bumps, pruritus, and discharge are the chief complaints .. Involvement of more than one area is more common.
-Urethral bleeding or urinary obstruction (uncommon) may be the presenting complaint when the wart involves the meatus.
-Vaginal bleeding during pregnancy may be due to condyloma eruptions. Coital bleeding also may occur.
Reference:
– Delaram Ghadishah. Genital Warts .Medscap. Oct 16, 2018 .
Differential Diagnosis;
· Perianal skin cancer
· Genital warts
· Adenocarcinoma
Diagnosis
· Biopsy
· HPV 6 and 11
Treatment
According to biopsy
Duration of lesion and symptoms associated would guide therapy including and not limited to;
· Topical therapy
· Surgical excision and
· Cryotherapy
Dose this condition affect other parts
Can affect other parts like hand oral cavity and genitals.
Clinical presentation
Mainly asymptomatic but can present with pruritus or Bleeding
I wish you could type references
1-What is your differential diagnosis?
Cauliflower lesion:
-Skin wart with HPV infection (HPV 6 and HPV 11).
-Anal warts, also known as Condyloma accuminata (itchy), are caused by infection with the human papillomavirus (HPV).
-Anogenital cancers; Anal cancer; (SCC); which caused by persistent infection with high-risk human papillomavirus (HPV).
-Anorectal papilloma.
-Perianal hematoma.
-Perianal hidradenitis suppurativa.
-Molluscum contagiosum.
-Polyps.
-Skin tags.
-Thrombosed external piles.
-Pemphigus verrucous / vulgaris.
-Kapoci Sarcoma (more common in homosexuals with AIDS).
2-What do you confirm the diagnosis?
–History of immunosuppression intensity.
-Sexual history is important since in patients with anal SCC, it was found that around half of gay men and less than one third of women and straight men had a history of anorectal condyloma.
-Clinical assessment by palpating the tumor and the groin.
-Biopsy and tissue histology to rule out underlying intraepithelial neoplasia or cancer is not mandatory before initiating therapy but is recommended when the patient is immunocompromised like our patient.
-HPV Genotyping & HIV screening is recommended.
-CT / MRI scan on abdomen and pelvis is recommended to assess local nature of the disease.
– Lower and upper GI endoscopy for possible metastasis or primary.
-Positron emission tomography (PET)/CT scan.
3-What is the treatment?
MDT management in ASCC (dermatologist, nephrologist, oncologist and surgeon).
Reduction of immunosuppression;
-Reduction of immunosuppression can cause resolution of the In situ tumor.
-Reduce MMF to 500 mg bid. OR switch MMF to mTOR.
-Tacrolimus should be reduced to attain a trough of 4-6 ng/ml (keep it towards 5 ng/ml).
-According to the pathology.
Human papillomavirus;
-Imiquimod , 5-flurouracil, liquid nitrogen, electrocautery, Cytodestructive therapies, and surgical management options consist of ablative and excisional procedures.
Squamous cell carcinoma;
-Chemotherapy and replacement of CNI by mTOR.
Anal cancer;
-Depending on the histopathology.
-Adjuvant radiation therapy or chemotherapy.
Genital warts;
-Topical 5 percent imiquimod is effective in immunocompromised patients.
4-Does this condition affect other parts of the body?
Yes,
-It can affect many parts of the body if its cause is HPV1 such as (Cervical, perianal region, perineum , vulva , vagina , Penis , scrotum , lips, mouth, tongue, throat , hands , and etc.
-But if HPV2 it affect mainly genital parts.
-If it is ASCC may affect rectum and colon.
5-What are the clinical presentations of this disease?
-Clinically, disease can be silent or associated with local symptoms of the lesion such as itching, bleeding from the lesion and pain.
-Mild bleeding, Burning sensation, Discomfort, Genital itching, or irritation.
-Anal involvement may present with pain and difficulty defecation, involvement of urethra might present with dyspareunia, hematuria and feature of urinary obstruction.
–Urinary symptoms if the tumour invades the bladder or prostate
–Genital warts: painless but itchy, burning sensation and irritation, disfiguring.
-Perinal carcinoma: pain, bleeding .
-Anal carcinoma: tenesmus, alternating constipation and watery diarrhea , bleeding per rectum.
-ASCC: bleeding from the bottom (rectal bleeding) itching and pain around the anus.
-Change in bowel habit; alternating watery with hard feces and tenesmus.
-Mentally, the patient may have depression.
–References;
-Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404. doi: 10.1016/j.semnephrol.2016.05.016. PMID: 27772624; PMCID: PMC5116324.
-Up To Date; Condylomata Acuminata(Anogenital warts);Management of external condylomata acuminata in adults.
That is a well-structured and well-referenced reply
What is your differential diagnosis?
This is a cauliflower shaped papular lesion in anal area. With the patient’s background, its most likely, Genital wart (condyloma acuminatum) caused by the human papillomavirus (HPV) types 6 and 11
What do you confirm the diagnosis?
Usually diagnosed by visual examination. Invasive tests not needed. But biopsy is recommended if there is uncertainty about the diagnosis or if the patient is immunocompromised. Pigmented and ulcerated lesions should also be considered for biopsy.
Nuclear changes typical of HPV infections (nuclear enlargement with perinuclear clearing) is diagnostic.
What is the treatment?
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
HPV infection may be latent, subclinical, or clinical.
It may take the pathway of low viral-load infection without clinical disease, or high viral-load infection with clinical disease.
This may manifest as genital warts or as low- or high-grade intraepithelial lesions
REF:
That is a well-structured and well-referenced reply
OUR CASE;
31yr old KTR.
Itchy anal lesions 4 yr post tx for acute AMR.
Meds – Tac(trough 8ng/ml),MMF 750mg BD,PDL 5MG OD
DX.
Anogenital wart from HPV possibly types 6 +/- 11
Risk ; Immunosuppressive use.
Association with malignancy ; High risk HPV genotype linked to head, anogenital, neck, cervical, vulva, vaginal, and penile cancer.
DDX.
DIAGNOSIS.
Tissue biopsy; Share or scissors biopsy to remove a large sample for histology.
TREATMENT.
-Post transplant patients are on immunosuppressive meds which predisposes them to recurrences and difficulty treatment as one has to ensure a balance on immunosuppressive meds to avert graft dysfunction esp if they get malignant and treatment has to be instituted.
-An MDT ;Dermatologist/Oncologist/Gynecologist/Urologist are needed for evaluation, tx and follow up. The lesion should be managed by the aforementioned team to avert resistance, manage recurrence and monitor for any malignant transformation or pre malignant lesion.
-Pre treatment ,pt should be evaluated for internal involvement ;Urethral involvement with bladder obstruction( A urologist will be helpful),Vaginal and cervical involvement(Speculum exam),Anal canal involvement( Anoscopy to be done)
-Treatment options;
>Imiquimod, podophyllotoxin, sinecatechins.
>Cryotherapy,Trichloroacetic acid,Bichloroacetic acid and surgical approach(extensive, large, bulky plaques or nodular lesions),
-Tx approach in immunocompromised is similar to immunocompetent with the former having difficulties in treatment, large duration of treatment and need of close follow up.
DOES IT AFFECT OTHER BODY PARTS?
-Yes ; Penis, Vagina, Urethra, Skin etc.
CLINICAL PRESENTATION.
-The lesion can be single/multiple, cauliflower shaped, fungating or even lobulated, itchy with varied discoloration-white, erythematous, brown etc. It might vary in size from a millimeter to several centimeters.
-Anal involvement may present with pain and difficulty defecation, involvement of urethrae might present with dyspareunia, hematuria and feature of urinary obstruction.
-Mentally, the patient may be depressed.
REFERENCES.
1.Uptodate – Condylomata Acuminata(Anogenital warts) in adults ;Epidemiology,pathogenesis,clinical features and diagnosis.
2.Uptodate – Condylomata Acuminata(Anogenital warts);Management of external condylomata acuminata in adults.
3.E.J Kwak et al; Papilosquamous infection in Solid Organ Transplant recipient ;American Journal of Transplantation.16 Dec 2019.
That is a well-structured reply.Typing the whole sentence in bold or in capitals amounts to shouting, however.
I will correct that Prof.
What is your differential diagnosis?
This post kidney transplant patient has itchy perianal cauliflower like mass with history of successful treatment of AMR and high level of CNI ,the differential diagnosis is:
-Anogenital warts or giant condylomata acuminata due to human papillomavirus with or without malignant transformation .
-Anal cancer
-Kaposi sarcoma
-Perianal melanoma
-Hemorrhoids
How do you confirm the diagnosis?
Excisional or incisional biopsy after proper assessment by MDT including dermatologist, oncologist and surgeons to confirm diagnosis and to rule out malignancy .
Human papillomavirus (HPV) testing of warts is not routinely indicated for diagnosis. Testing does not confirm the diagnosis and does not influence management of condylomata acuminata
What is the treatment?
Treatment is an MDT approach depending on the confirmed diagnosis.
The selection of therapy should be individualized and based upon consideration of the extent of the disease, patient preference, cost, adverse effects, treatment availability, and the response to previous treatments.
Options of treatments are according to confirmed diagnosis could be topical creams or ointments( Salicylic acid, lactic acid ,podofilox solution or gel (0.5%), imiquimod cream (5%) ,cryotherapy , laser ,surgical excisions and chemotherapy in case of malignancy. Immunosuppressants may need to be modified according to diagnosis and response of treatment like use of sirolimus instead of prograf ..
Recently primary prevention of anogenital warts and malignancies related to HPV is emerging with prophylactic quadrivalent (HPV-6, -11, -16, -18) and bivalent (HPV-16, -18) vaccines. These vaccines consist of HPV L1 virus-like particles which induce high anti-L1 serum-neutralizing antibody concentrations. Dermatologists and venereologists, general practitioners, nephrologists and pediatricians should cooperate with gynecologists to vaccinate young women and men in order to increase vaccination rates.
Does this condition affect other parts of the body?
Yes it may appear in hands, genital area in males and females and perioral regions .
What are the clinical presentations of this disease?
It may present as an asymptomatic lesion which may be the main concern other symptoms are ,pruritus and bleeding .
Reference :
2.Ramírez-Fort MK, Khan F, Rady PL, Tyring SK (eds): Human Papillomavirus: Bench to Bedside. Curr Probl Dermatol. Basel, Karger, 2014, vol 45, pp 98-122
https://doi.org/10.1159/000358423
3. Clin Transplant 2019 Sep;33(9):e13590. doi: 10.1111/ctr.13590. Epub 2019 Jun 20.
4.Sirolimus-based immunosuppression for treatment of cutaneous warts in kidney transplant recipients September 2011Iranian Journal of Kidney Diseases 5(5):351-3
That is a well-structured and well-referenced reply.
Thank you prof Ajay Sharma
What is your differential diagnosis?
Anogenital warts typically present with a characteristic “cauliflower” appearance
(condyloma acuminata), HPV-associated anogenital wart or anogenital cancer is related to the duration of intense IS regardless of the age, like our indexed case he was treated on the line of AMR 4 years back and is currently on intense triple maintenance IS with high CNI trough level and MMF 750MG bid
What do you confirm the diagnosis?
MDT approach and get dermatology consultation, cytopathologist, transplant team, anorectal surgical team backup
examine for other skin lesions including head and neck, feet
HPV serology
Lesion excisional biopsy
anal Pap test is the first step preferred by a polyester swab over a wet swab. For visualization of the transformation zone with abnormal anal cytology by the cytopathologist
Anoscope, A bright light with a hand lens or a colposcope may be helpful.
Pap smear and cytology in case of the female genital wart with internal inspection for cervical lesions
Molecular-based methods including HPV DNA PCR
What is the treatment?
Treatment based on the site size, nature of the lesions, single, multiple
Anogenital warts prevention is preferred by giving the HPV vaccination and for treatment either use cryotherapy or salicylic acid, reduction of IS including modification from MMF to CNI minimization with sirolimus taken into consideration the risk of rejection and need close monitoring
In the case of anal cancer, the best treatment includes chemoradiation fluorouracil plus mitomycin (45). A cisplatin-based regimen is reserved for uncommon
patient with metastatic disease.
Does this condition affect other parts of the body?
Yes, we should examine him thoroughly for other cutaneous skin lesions in the head, neck, feet, palmar or plantar warts
What are the clinical presentations of this disease?
May be asymptomatic or they can complain of pain, burning to itch, or bleeding (1).
References
1. Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404. doi: 10.1016/j.semnephrol.2016.05.016. PMID: 27772624; PMCID: PMC5116324.
.
I appreciate your scientific approach
· What is your differential diagnosis?
The index patient is a 31 year old kidney transplant recipient with history of treated AMR 4 years back now presenting with an itchy papular lesion in the anal region with irregular surface. The differential diagnosis in this scenario is anogenital wart (condyloma acuminata) which is caused by human papilloma virus (HPV), or anal malignancy – anal intraepithelial neoplasia (AIN) and anal cancer, or non-melnoma skin cancer (1).
· What do you confirm the diagnosis?
A thorough clinical examination of the entire genital tract should be done. Presence of perianal wart should prompt evaluation for detecting any intra-anal wart (1). A biopsy of the lesion followed by histopathological examination will confirm the diagnosis.
· What is the treatment?
Treatment involves removal of the anogenital wart by local application of salicylic acid, podofilox solution, trichloroacetic acid, podophyllin resin, or imiquimod. Cryotherapy can also be used, and can be repeated once in 3 weeks (1). Failure to respond to local treatment would warrant referral to dermatologist, or colorectal specialist. Reduction of immunosuppression can be considered with shift from MMF to mTOR inhibitors (1).
· Does this condition affect other parts of the body?
Any external anogenital wart may indicate presence of internal HPV related lesions, hence detailed evaluation of the anogenital tract is important (1). In females with anogenital warts, per speculum examination should be done.
· What are the clinical presentations of this disease?
Anogenital warts present as exophytic, flesh or gray colored multifocal lesions in the anogenital region, which can be asymptomatic, or associated with itching. They may present with abnormal bleeding, pain, and dyspareunia (1).
References:
1) Chin-Hong PV, Reid GE; AST Infectious Diseases Community of Practice. Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13590. doi: 10.1111/ctr.13590. Epub 2019 Jun 20. PMID: 31077438.
That is a well-structured reply.
1- Cauliflower lesion:
2- Confirm diagnosis by excisional biopsy together with HPV DNA testing
3- Management: according to the pathology
reduce immunosuppression, shift to sirolimus based IS
excision
topical medication: 5-flurouracil, imiqumid cream.
4- Effect of the lesion:
Local: It can obliterate the anal canal, configuration
associated colonic papilloma if its anal papilloma
condyloma accuminata: is localy aggressive but not metastasis
Malignant lesion (SCC): can metastasis
5- clinical presentation:
Genital warts: painless but itchy, burning sensation and irritation, disfiguring.
Perinal carcinoma: pain, bleeding .
Anal carcinoma: tenesmus, alternating constipation and watery diarrhea , bleeding per
rectum.
Reference:
1- Schöfer H, Tatti S, Lynde CW, Skerlev M, Hercogová J, Rotaru M, Ballesteros J, Calzavara-Pinton P. Sinecatechins and imiquimod as proactive sequential therapy of external genital and perianal warts in adults. International journal of STD & AIDS. 2017 Dec;28(14):1433-43.
2- Larsen HK, Thomsen LT, Haedersdal M, Dehlendorff C, Sørensen SS, Kjaer SK. Risk of genital warts in renal transplant recipients—a registry-based, prospective cohort study. American Journal of Transplantation. 2019 Jan 1;19(1):156-65.
That is a well-structured and well-referenced reply.
An excision and pathologic evaluation are needed. This may be wart due to HPV or squamous cell carcinoma. Waarts can be seen in other regions as well. Surgical excision and or cryotherapy may be needed. Decreasing immunosuppression and shifting MMF to mTOR inhibitors like Everlolimus is needed.
short and sweet
A- This patient is immune suppressed with high trough level of Tac and raised ,fleshy ,ithy ,hyperpigmented lesion mostly genital wart (condylomata acuminate) caused by HPV
B- DD
1- squamous cell carcinoma
2-actinic keratoses
3-molliscm contagiosum
4- neurofibromatosis.
C- To confirm the diagnosis
1-Dermatological consultation , detect HPV infection through Filter hybridization (Southern blot and slot blot hybridization), in situ hybridization and PCR. Excitional biopsy .
D- Treatment:
– decrease the dose of IS
– specific treatment : Cryotherapy, surgical excision and CO2 laser treatment
Pennycook KB, McCready TA. Condyloma Acuminata. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
I like your clinical approach
Its a large cauliflower-like lesion on anogenital mucosa and surrounding skin
Differential Diagnosis of the lesion:
1]Perianal wart.
2] Molluscum Contagiosum
3] Condylomata lata of Syphilis.
4] Seborrheic Keratosis
5] Melanocytic Naevus
6] Squamous cell carcinoma.
Diagnosis:
Clinical examination is important in determining the nature of lesion. itching is common in genital wart. Lesion biopsy is not commonly required. however, it indicated in immunocompromised patients, failure of therapy, atypical lesion such as ulcerated or hard lesion.to differentiate it from squamous cell carcinoma.
Human Papilloma virus HPV: is the culprit virus in this context
HPV typing is crucial in certain circumstances to verify the identity of HPV . HPV 6-10 are common phenotype of HPV 16, 18,31, 33 and 36 are associated with intra epithelial invasive squamous cell carcinoma. Therefore HPV typing are indicated in atypical presentation of wart.
Treatment:
Podofilox.
Imiquimod.
cryotherapy.
lazer
surgical excision.
Reference:
1] CHARLES M. KODNER, M.D., AND SORAYA NASRATY, M.D.Management of Genital Warts.Am Fam Physician. 2004;70(12):2335-2342
I like your clinical approach
👉 Tranaplant recipient with potent IS as tacrolimus and MMF with such skin lesion, we must suspect
1_ anal cancer either squamous cell carcinoma of peranal skin or adenocarcinoma with skin infiltration.
2_ genital wart caused by human papilloma virus (HPV).
👉 confirmation of diagnosis is by tissue biopsy together with HPV PCR.
👉 treatment includes:
_ MDT (dermatologist, oncologist, radiologist , pathologist, nephrologist and transplant team).
_Reduction of immunosupression (decrease dose of MMF to 500 mg bid, and decrease level of TAC to around 5).
_if genital wart …local therapy as cauterization, surgical excision and laser).
_ in case of peranal SCC….local therapy plus or minus chemo and radiotherapy
_assesment of metastasis by CT chest, abdomen and pelvis is essential.
_Basic investigations as CBC, liver function and renal function tests.
👉 other sites of affection:
_genital warts affect oral cavity, vulva, vagina , cervix, penis and scrotum.
_anal carcinoma can affect colon and rectum
👉 Clinical presentation:
_genital warts …skin papules , painless but itchy, burning sensation and irritation, disfiguring.
_perinal carcinoma…pain, bleeding .
_anal carcinoma….tenesmus, alternating constipation and watery diarrhea , bleeding per rectum.
References:
Patel H, Wagner M, Singhal P, Kothari S. Systematic review of the incidence and prevalence of genital warts. BMC Infect Dis 2013; 13:39.Fleischer AB Jr, Parrish CA, Glenn R, Feldman SR. Condylomata acuminata (genital warts): patient demographics and treating physicians. Sex Transm Dis 2001; 28:643.
That is a well-structured reply.
History
====================================================================
What is your differential diagnosis?
====================================================================
What do you confirm the diagnosis?
====================================================================
What is the treatment?
Treatment by location of wart
Cytotoxic agents for warts
Immunomodulators for warts
Physical ablation of warts
Antiviral agents for warts
====================================================================
Does this condition affect other parts of the body?
====================================================================
What are the clinical presentations of this disease?
====================================================================
Reference
That is a well-structured and well-referenced reply.
Many thanks Prof.Sharma
What is your differential diagnosis?
What do you confirm the diagnosis?
What is the treatment?
1- Reducing the dose of Tacrolimus with a target trough level of 5 ng/ml OR conversion to Sirolimus.
2- Reducing the dose of MMF by 50 %
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
I wish you could type references as well
A 31-years old renal transplant recipient developed this lesion in his anal region 4 years after successful treatment of acute AMR. He is currently on Tacrolimus (trough 8 ng/ml), MMF 750 mg bd and prednisolone 5 mg od. The lesion is itchy.
What is your differential diagnosis?
DD:
DD: A single dome shaped, cauliflower-shaped lobulated hyper pigmented Anal flesh, gray-colored, itchy skin lesion, (condyloma acuminata) is most likely anogenital wart due to HPV infection, Differential diagnosis of anogenital wart lesions in immunocompromised patient on immunosuppression:
Condyloma acuminata (anogenital wart), seen in HPV infection.
Seborrheic keratoses
Molluscum contagiosum
Squamous cell carcinoma
Kaposi sarcoma
Lichen planus
What do you confirm the diagnosis?
-Dermatology / surgical consult.
-Excisional Skin Biopsy => to confirm the diagnosis and to rule out malignancy.
-HPV (6 & 11) are detected in most cases of CA.
What is the treatment?
Reduction of immunosuppression
MMF should be reduced to 500 mg bid
CNIs: Tacrolimus should be reduced to attain a trough of 5-7 ng/ml
Definitive treatment:
Topical therapies, cryotherapy, and surgical excision or laser therapy are available treatment options.
Radiation therapy (RT) and chemotherapy.
Local treatment (surgery or local RT [electrons]) is used only when the lesion is very separate from the anal verge and is a discrete skin lesion.
Local antiviral therapy by cidofovir in HPV related condylomas acuminate.
Does this condition affect other parts of the body?
Yes: Any Skin parts, GIT, GUT, LNs, Chest, head , penis, vulva, vagina, cervix, perineum, and the anal region.
Pan CT with contrast => Head, chest, abdomen and pelvic for better evaluation and management.
What are the clinical presentations of this disease?
Asymptomatic,
Itching, bleeding, and pain
References:
– UpToDate
– Euvrard S, Kanitakis J, Chardonnet Y, et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Arch Dermatol 1997; 133:175.
– Singh R, Nime F, Mittelman A. Malignant epithelial tumors of the anal canal. Cancer 1981; 48:411.
– Schneider TC, Schulte WJ. Management of carcinoma of anal canal. Surgery 1981; 90:729.
That is a well-structured reply. Typing ‘uptodate’ as a reference is not a complete reply in a scientific write-up.Typing the whole sentence in bold amounts to shouting, however.
What is your differential diagnosis?
human papillomavirus
Pemphigus verrucous / vulgaris
Basal cell carcinoma
squamous cell carcinoma
anal cancer
What do you confirm the diagnosis?
Biopsy
What is the treatment?
Human papillomavirus – Imiquimod and resection of lesions. Decrease CNI dose by 50% and switch MMF to mTOR
Pemphigus verrucous / vulgaris – Replacement of CNI for mTOR
Basal cell carcinoma – Replacement of CNI for mTOR
Squamous cell carcinoma – Chemotherapy and replacement of CNI by mTOR
Anal cancer – depending on the histopathology
Does this condition affect other parts of the body?
Yes, it is enough to be exposed to the virus and there is the possibility of warts occurring in other places, depending on the exposure, especially if it is mucous.
What are the clinical presentations of this disease?
May be asymptomatic, pruritic, cause bleeding, oncogenic
I like your clinical approach
Thank you, Professor
What is your differential diagnosis?
The anal skin lesions seen more in females, infection with human papillomavirus (HPV), lifetime number of sexual partners, genital warts, cigarette smoking, receptive anal intercourse, and infection with HIV.
DDx:
What do you confirm the diagnosis?
By an excisional biopsy.
What is the treatment?
Usually treated similarly to anal canal cancers, with radiation therapy (RT) and concurrent chemotherapy. However, local treatment (surgery or local RT [electrons]) is used only when the lesion is very separate from the anal verge and is a discrete skin lesion.
Local antiviral therapy by cidofovir has been effectious in HPV related condylomata accuminata.
Does this condition affect other parts of the body?
It could affect other parts of skin, inguinal lymph nodes, and can be detected in other parts of gastrointestinal tract, mandate chest abdomen and pelvic CT with contrast for better evaluation and management.
What are the clinical presentations of this disease?
Usually asymptomatic, but may be of local irritating symptoms, itching, bleeding and pain.
Ma be seen in other parts of skin in the body.
References:
(1) UpToDtae- classification, epidemiology of anal cancer.
(2) Bonatti H, Aigner F, De Clercq E, Boesmueller C, Widschwendner A, Larcher C, Margreiter R, Schneeberger S. Local administration of cidofovir for human papilloma virus associated skin lesions in transplant recipients. Transpl Int. 2007 Mar;20(3):238-46. doi: 10.1111/j.1432-2277.2006.00430.x. PMID: 17291217.
(3) Nissen NN, Barin B, Stock PG. Malignancy in the HIV-infected patients undergoing liver and kidney transplantation. Curr Opin Oncol. 2012 Sep;24(5):517-21. doi: 10.1097/CCO.0b013e328355e0d7. PMID: 22759736; PMCID: PMC4283559.
Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404. doi: 10.1016/j.semnephrol.2016.05.016. PMID: 27772624; PMCID: PMC5116324.
That is a well-structured and well-referenced reply.
What is your differential diagnosis?
– HPV associated Condyloma acuminate
– Anogenital cancer.
– Anal intraepithelial neoplasia.
– Skin cancer: Non-melanoma skin cancer.
– Kaposi sarcoma.
The picture showed a well circumscribed exophytic papules, fleshy skin colored with cauliflower appearance.
The appearance of the lesion, its location typical of anogenital wart Condyloma acuminate
SOT recipients have a higher risk of HPV infection than the general population. HPV is associated with both benign lesions and premalignant/malignant neoplasms in a variety of site
The appearance of any anogenital wart in the KTR should warrant further investigation as:
-External anogenital lesions (which are usually benign) may indicate the presence of HPV-associated lesions that are internal.
-Immunocompromised patients may have preneoplastic lesions that are clinically indistinguishable from usually benign anogenital warts.
-The risk of cancer is higher compared to general population.
Anogenital cancer
*SIR of HPV-associated cancers in transplant patients:
-Cancers of the cervix (SIR 2.1)
-Vulva and vagina (SIR 22.8)
-Penis (SIR 15.7)
-Anus (SIR 4.9).
*Transplant recipients with HPV cancers were also found to have these cancers at an earlier average age compared to the general population.
*HPV Types 16 and 18 ( high risk type) are the most common HPV types found in cervical cancer, accounting for 70% of these malignancies.
Cutaneous and anogenital warts
-The prevalence of warts is linked directly to the duration of immunosuppression with sharp increases over time.
-A recent Danish population based study reported a cumulative incidence of genital warts as high as 15%‐20% in certain subpopulations of SOT
-The hazard ratio for genital warts in the KTR was 3.4 compared with controls.
-One study of organ transplant recipients attending a dermatology clinic described a prevalence of anogenital warts of 2.3%.
– KTRs have a similar appearance as in immunocompetent individuals. However, they may be more common, recur more often, appear larger and more numerous
– HPV type 6 and 11 (low-risk) do not cause invasive cancer, they are associated with anogenital warts
– KTR have higher diversity of HPV types compared to general population.
What do you confirm the diagnosis?
-Any lesion with an atypical appearance should be biopsied for definitive diagnosis.
– All women with anogenital warts should have a speculum examination and pap smear.
-Anoscope for intra anal wart.
-CT abdomen and pelvic to assess any metastases.
What is the treatment?
Treatment will be guided by the biopsy finding.
General consideration:
-Reduce immunosuppression especially in refractory and disease is extensive).
-Switch from CNI to mTOR inhibitors such as sirolimus can help particularly if malignant transformation has occurred.
Genital wart:
– local application of (salicylic acid, imiquimod)
– Cryotherapy can be repeated every 3 weeks.
AIN:
In general AIN II and AIN III are treated to prevent anal cancer.
Size and location influence the modality of treatment.
Intraanal lesions <1 cm2 at the base can be treated with 80% trichloroacetic acid, topical 5-fluorouracil or cryotherapy or imiquimod 5% cream
If the lesion is larger or of higher grade, outpatient infrared coagulation or HRA-assisted intraoperative fulguration
Anal cancer
-The main modality is chemoradiation as it can cure the majority of patients while preserving the anal sphincter.
– Common chemotherapy regimens include fluorouracil plus mitomycin
-A cisplatin based regimen is reserved for the uncommon patient with metastatic disease
Does this condition affect other parts of the body?
– Oral condyloma acuminata are typically present on the tongue and lip.
– Anogenital lesions may be found on the penis, vulva, vagina, cervix, perineum, and the anal region
What are the clinical presentations of this disease?
Condyloma acuminate:
-Usually asymptomatic, may also be found incidentally during routine examinations.
-They may occasionally cause bleeding, pruritus, and pain.
-Patients will generally present concerned about the appearance of the lesions, as they often cause psychological and psychosexual distress
References:
-Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404. doi: 10.1016/j.semnephrol.2016.05.016. PMID: 27772624; PMCID: PMC5116324.
-Chin-Hong PV, Reid GE; AST Infectious Diseases Community of Practice. Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13590. doi: 10.1111/ctr.13590. Epub 2019 Jun 20. PMID: 31077438.
-Pennycook KB, McCready TA. Condyloma Acuminata. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-
That is a well-structured reply.
What is your differential diagnosis?
What do you confirm the diagnosis?
-incisional or excisonal biopsy (require MDT disccions)
What is the treatment?
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
mostly asyptomatic
may present with irritiative symptoms or bleeding
That is a well-structured short and sweet reply.
Thanks sir
Differential diagnosis of warty anogenital lesion in immunocompromised patient on immunosuppression:
–Condyloma acuminata also known as anogenital warts, which are manifestations of HPV infection that occur in individuals with anogenital HPV infection.
–seborrheic keratoses
-Molluscum contagiosum
-Anal neoplasms.
-To confirm diagnosis:
-From the current scenario of immunosuppressed patient and the presented image which most probably secondary to HPV infection, lesion can be diagnosed with physical examination with expertise physicians.
–Biopsy: A biopsy should be performed to confirm the diagnosis and to rule out malignancy.
-HPV types 6 and/or 11 are detected in most cases of CA.
What is the treatment?
Usually Treatment can be delayed in children, adolescents, and young, healthy adults, as lesions often resolve spontaneously over months to years. Treatment should be commenced with lesions that persist for more than two years if the lesions are symptomatic, or for cosmetic purposes and including:
Topical therapies, cryotherapy, and surgical excision are available treatment options. Surgical options include electrosurgery, curettage, scissors excision, and laser therapy.
Does this condition affect other parts of the body?
Oral condyloma acuminata ,Anogenital lesions may be found on the penis, vulva, vagina, cervix, perineum, and the anal region.
What are the clinical presentations of this disease?
usually asymptomatic, sometimes can cause bleeding, pruritus, and pain. Patients will generally present concerned about the appearance of the lesions.
That is a well-structured reply. Typing the whole sentence in bold amounts to shouting, however.
DD
Diagnosis
Investigation
Treatment
Reduce immunosuppressive medications.
Consider mTOR inhibitors
A combination of:
Radiotherapy and chemotherapy without surgery preserve the anal sphincter and allows defecation without incontinence of feces. Abdominoperineal resection with a colostomy is performed if initial treatment is unsuccessful.
Other possible locations of cancer includes; the cervix, vulva, vagina and penis.
Prevention
Health education
Vaccination against HPV
Reference
Anal cancer | DermNet (dermnetnz.org)
This is a repeat of what you have already uploaded down below.
My response is same:
That is a well-structured reply. Typing ‘DermNet’ as a reference is not a complete reply in a scientific write-up.
What is your differential diagnosis?
Anal flesh, gray-colored, itchy skin lesion, cauliflower appearance (condyloma acuminata) is most likely anogenital wart due to HPV infection
Other differential diagnoses include:
1. Squamous cell carcinoma
2. Anal cancer
3. Nevi
4. Herpes simplex
5. Familial benign pemphigus
What do you confirm the diagnosis?
Tissue biopsy of any suspicious genital warts, as high-grade squamous epithelial neoplastic lesions are common in these patients and may be clinically indistinguishable from genital warts
What is the treatment?
· In transplant recipients, warts may be more extensive, more prone to recurrences and slower to respond to treatment
· The following should be referred to a dermatologist, gynecologist (if the patient is a female with anogenital lesions) or a colorectal specialist (for anal lesions) for evaluation and treatment
1. Patients with multiple warts
2. warts on mucous membranes (anal, rectal, vaginal, cervical warts)
3. failure to respond to standard therapy
4. Possible malignant transformation
· Spontaneous regression of warts is less common in transplant recipients
· May be resistant to treatment (patients should be counseled that multiple treatment sessions and different treatment modalities may be required over a prolonged period before a sustained response is achieved)
· Treatment can be classified as either patient applied or health care provider applied
· Patient applied:
1. Salicylic acid, lactic acid
2. Podofilox solution or gel (0.5%)
3. Imiquimod cream (5%)
· Health care provider applied:
1. Cryotherapy
2. Podophyllin resin
3. Trichloroacetic acid, bichloroacetic acid
· Surgery is reserved for the removal of large, bulky lesions and/or those that are refractory to treatment
· No role of antiviral treatment
· Reduction of immunosuppression in extensive disease (limited reports of response)
· Treatments for warts vary by site of involvement (e.g. highly keratinized skin vs. mucous membranes; nongenital vs. genital skin)
Does this condition affect other parts of the body?
Yes. Skin, rectum, vulva, vagina, cervix, penis
What are the clinical presentations of this disease?
· The prevalence of warts is as high as 50-92% in patients who have been transplanted 4-5 years ago
· May be asymptomatic or complain of itching, burning, bleeding and pain
· anogenital wart in the kidney transplant recipient should warrant further investigation for the following reasons:
1. External anogenital lesions (which are usually benign) may indicate the presence of HPV-associated lesions that are internal. Women with external lesions, for example, should have a speculum examination to look for possible vaginal or cervical lesions
2. any lesion with an atypical appearance (external or internal) should be biopsied
References
1. Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404. doi: 10.1016/j.semnephrol.2016.05.016. PMID: 27772624; PMCID: PMC5116324.
2. E. J. Kwak. K. Julian. Human Papillomavirus Infection in Solid Organ Transplant Recipients. American Journal of Transplantation, 16 December 2009.
I like your clinical approach
The most difference diagnosis in this case
Condyloma lata resemble condyloma acuminate in being raised lesions but there are differences:
a) condyloma acuminata are cauliflower-like, while condyloma lata are smooth
b) condyloma acuminata are dry, while condyloma lata are moist
c) condyloma acuminata are bulky while, condyloma lata are flat
Other differential diagnoses
What do you confirm the diagnosis?
Digital rectal examination is the most important clinical examination technique in case of suspected anal carcinoma.
The first-choice treatment
On treatment the rash resolves first; it may take a few months for condyloma lata and about a year for moth-eaten alopecia to resolve completely.
What are the clinical presentations of this disease?
cutaneous manifestations
mucous membrane involvement
hair / nail changes.
The common manifestations of secondary syphilis are
rash (75–100%),
lymphadenopathy (50–80%)
mucocutaneous lesions like mucous patches and condyloma lata (40–50%).
Hair loss may be only in 3 to 7% of patients
Other symptoms common at this stage include fever, sore throat, malaise, weight loss, headache, meningismus and enlarged lymph nodes.
My answer depends on the picture. However, the history of this patient (previous treated AMR , the level of tacrolimus) may indicate the high risk of activated HPV infection and its related diseases such as condyloma or SCC
I like your clinical approach
nodular fleshy-like appearance lesion in the anal region.
1-anogenital warts.
2-non melanoma skin cancer(scc).
3-condyloma Lata
4- skin tuberculosis
5- Kaposi sarcoma
I like your clinical approach.Typing the whole sentence in bold amounts to shouting, however.
What is your differential diagnosis?
Differentials include:
=============================
What do you to confirm the diagnosis?
Indications for biopsy:
HPV testing:
=============================
What is the treatment?
The aim of treatment:
Factors impacting treatment:
Treatment regimens
Patient-applied therapies include:
Provider-administered:
Prevention
=============================
Does this condition affect other parts of the body?
=============================
What are the clinical presentations of this disease?
Reference
That is a well-structured reply. I like your clinical approach.
Lesion shown is well-defined papule present with a characteristic “cauliflower” appearance (condyloma acuminata).
DDx
anogenital warts
anal intraepithelial neoplasia (AIN)
anal cancer
molascum contagiosum
non melanoma skin cancer
clinical manifestation
· Usually asymptomatic anxiety cosmetic problem, pain bleeding or difficulty defecation in case of anal warts
· HPV-associated cervical and anal cancer as well as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) do not usually present with clinically identifiable lesions.
Does this condition affect other parts of the body?
In female patient cervix vulva and vagina , in male: penis
Diagnosis
· System review searching for other system affection
· Clinical examination including cervical vulval and vaginal exam in case of female patients
· Biopsy
· high-resolution anoscopy
· molecular based methods such as DNA hybrid capture and PCR on clinical specimens
· Pap screening is the most important strategy for diagnosis.
Prevention
There are three prophylactic HPV vaccines currently available a– Cervarix, a bivalent vaccine, targeting HPV types 16 and 18
b- Gardasil, a quadrivalent vaccine, targeting types 16 , 18, as well as types 6 and 11.
a- Gardasil 9 which covers the same types as in the quadrivalent vaccine as well as 5 additional types (high-risk HPV types 31, 33, 45, 52, 28)
b- All vaccines have shown >90% efficacy in preventing CIN and genital warts from the types included in the vaccine
c- The schedule is generally three doses – time 0, and at months 2 and 6
treatment
treatment options for HPV-associated disease in kidney transplant recipients depend on
the size,
location and
grade of the lesion
as general principal, priority of treatment is for the high-grade pre malignant disease (CIN II or III and AIN II or III) over treatment of low-grade lesions.
However, there may be some circumstances in the kidney transplant patient where treatment of low risk lesions may be recommended:
1) For relief of anxiety in the patient
2) for cosmesis
3) To ameliorate blockage (if large), bleeding, itching or to prevent superinfection if ulcerated.
Immunosupessant modulation
switch from calcineurin inhibitors to mTOR inhibitors such as sirolimus can help particularly if malignant transformation has occurred
For cutaneous wart
Soak the lesion with (salicylic acid, imiquimod), applied once daily before bedtime, three times a week. This can be repeated for up to 16 weeks. Or
(cryotherapy) repeated every three weeks.
Then paring down presoaked skin using a pumice stone, nail file, emery board or scalpel.
NB: in kidney transplant more cycles of treatment may be needed in case if response is not satisfactory
: Any atypical lesion should be biopsied
Anal intraepithelial neoplasia
Accoding to grading
AIN I treatment offered only on psycological bases
AIN II and AIN III are treated to prevent anal cancer.
1) Intraanal lesions <1 cm2 at the base can be treated with 80% trichloroacetic acid, topical 5-fluorouracil or cryotherapy.
2) Larger lesion can be treated by outpatient infrared coagulation
3) Sometimes if the lesion is so large and asymptomatic no need for treatment and close observation is an alternative
Anal cancerThe main modality of treatment for anal cancer is chemoradiation
Ref:
Chin-Hong PV. Human Papillomavirus in Kidney Transplant Recipients. Semin Nephrol. 2016 Sep;36(5):397-404.
That is a well-structured reply. I like your clinical approach.
This patient has a single dome shaped, cauliflower-shaped lobulated hyper pigmented lesion
The differential diagnosis include:
Diagnosis
The diagnosis is made by the location of the lesion and the physical appearance of the lesion
A good history and physical examination is important to assess for other areas prone to warts
For this patient, anoscopy is important
However, if the diagnosis is in doubt, a biopsy – a shave or a scissor procedure – can be done
Treatment
Therapy can be:
1.Medical therapy:
Useful for patients with limited disease. There are two types of medical therapies:
2.Surgical Therapy – consists of ablative and excision procedures. The choice of method should depend on the availability of equipment and the surgeons experience and personal preference. They include:
Other parts of the body that can be affected by this condition include:
Penis
Vulva
Perineum
Groin
Suprapubic skin
Clinical Presentation:
Usually asymptomatic
Can present with pain, pruritus, bleeding, difficulty in defacation
CDC Sexually Transmitted Infections Treatment Guidelines 2021
Uptodate
That is a well-structured reply. Typing ‘uptodate’ as a reference is not a complete reply in a scientific write-up.
DD
Diagnosis
Investigation
Treatment
A combination of:
Radiotherapy and chemotherapy without surgery preserve the anal sphincter and allows defecation without incontinence of feces. Abdominoperineal resection with a colostomy is performed if initial treatment is unsuccessful.
Reference
Anal cancer | DermNet (dermnetnz.org)
That is a well-structured reply. Typing ‘DermNet’ as a reference is not a complete reply in a scientific write-up.
What is your differential diagnosis?
1- Perianal skin cancer
– Anogenital cancers accounts for around 2-3% of malignancies that occur after solid organ transplantation (1-3)
– Usually it occurs after 7-9 years after transplantation (4)
– Four types of tumors arise in the anal region:
1- Anal tumors arising from the 3 types of lining mucosa (glandular, transitional, and squamous) they cannot be seen in their entirety with gentle traction on the buttocks, and
most of cases are SCC
2- Perianal skin cancers arising within the perianal hair-bearing skin, they can be seen in their entirety with gentle traction on the buttocks within 5 cm of the anus.
3- Adenocarcinomas arising from glandular elements within the anal canal ( rare)
4- Primary rectal SCCs ( very rare)
The most probable diagnosis in this case is perianal skin cancers such as SCC, Bowen’s disease or Paget disease as they presents with pruritic lesion.
2- Genital wart
Diagnosis, assessment and clinical staging (TNM)
What is the treatment?
Reduction of immunosuppression
Definitive treatment
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
References
1- Adami J, Gäbel H, Lindelöf B, et al. Cancer risk following organ transplantation: a nationwide cohort study in Sweden. Br J Cancer 2003; 89:1221.
2- Penn I. Cancers complicating organ transplantation. N Engl J Med 1990; 323:1767.
3- Penn I. Cancers of the anogenital region in renal transplant recipients. Analysis of 65 cases. Cancer 1986; 58:611
4- Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med 2003; 348:1681.
5- Daling JR, Weiss NS, Hislop TG, et al. Sexual practices, sexually transmitted diseases, and the incidence of anal cancer. N Engl J Med 1987; 317:973.
6- Euvrard S, Kanitakis J, Chardonnet Y, et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Arch Dermatol 1997; 133:175.
7- Singh R, Nime F, Mittelman A. Malignant epithelial tumors of the anal canal. Cancer 1981; 48:411.
8- Schneider TC, Schulte WJ. Management of carcinoma of anal canal. Surgery 1981; 90:729.
9- Schraut WH, Wang CH, Dawson PJ, Block GE. Depth of invasion, location, and size of cancer of the anus dictate operative treatment. Cancer 1983; 51:1291.
That is a well-structured and well-referenced reply
-What is your differential diagnosis?
These anogential lesions in kidney transplant recipient after 4 years is highly suspicious for anogenital warts or condylomata acunimnata. Complete physical examination is needed to rule out the disease in other part of the body e.g penis, skin, oral cavity. Differential diagnosis are:
-What do you confirm the diagnosis?
Approach ;Take history and physical exam, consider other STDs e.g., HIV, gonorrhea, chlamydia, syphilis. Order the following tests:
-What is the treatment?
Treatment lines for warts are:
1.Ablative therapy:
2.Immune-based therapy:
3.Vaccination
-Does this condition affect other parts of the body?
-What are the clinical presentations of this disease?
Note; Lesions may regress spontaneously, remain static or progress
Source; Medscape
That is a well-structured reply. Typing ‘Medscape’ as a reference is not a complete reply in a scientific write-up.
Thank you prof
based on the picture shown , history of patient and the lesion site skin warts due to HPV is my first diagnosis .
Differential Diagnosis :
1-Condyloma latum.
2-Seborrheic keratoses.
3-Benign nevi.
4-Molluscum contagiosum.
5-Neoplasm .
6-Squamous papilloma .
Genital warts are often diagnosed by appearance. Sometimes a biopsy might be necessary.
The clinical lesions may be visibly obvious, but in some cases (latent lesions) may require testing for viral DNA. The majority of HPV infections are latent, and most clinical lesions present as warts rather than a malignancy.
1-Pap tests.
2-HPV test.
Medications to eliminate warts are typically applied directly to the lesion and usually take many applications before they’re successful. Examples include:
Common symptoms of general warts may appear as a small bump,cluster of bumps ,or stem like protrusion .
they commonly affect vulva and cervix in women and penis or scortum in men.
they may appear around the anus .
Refference :
1-Bradbury M, Xercavins N, García-Jiménez Á, Pérez-Benavente A, Franco-Camps S, Cabrera S, Sánchez-Iglesias JL, De La Torre J, Díaz-Feijoo B, Gil-Moreno A, Centeno-Mediavilla C. Vaginal Intraepithelial Neoplasia: Clinical Presentation, Management, and Outcomes in Relation to HIV Infection Status. J Low Genit Tract Dis. 2019 Jan;23(1):7-12. [PubMed].
2-
Kobayashi K, Hisamatsu K, Suzui N, Hara A, Tomita H, Miyazaki T. A Review of HPV-Related Head and Neck Cancer. J Clin Med. 2018 Aug 27;7(9) [PMC free article] [PubMed].
3-
I appreciate your clinical approach
Renal allograft recipients are at high risk of developing anal HPV infection and neoplasia. Few studies addressed the risk of anal cancer in renal transplant patients and reported a modest rise in the relative risk of anal cancer. Kidney recipients have anal cancer rates that are three times higher than the general population in Australia and New Zealand. High-risk human papillomavirus (HPV) genotypes are implicated in the majority of anal cancers.
Earlier studies using biopsy tissue found that anal HSIL, LSIL, and cancer were significantly more prevalent in kidney transplant recipients (20.3%) compared with age-matched controls (0.7%).
Differential diagnosis:
Cancer:
1- Squamous cell carcinoma
2- Adenocarcinoma
3- Kapoci Sarcoma (more common in homosexuals with AIDS)
Or genital warts (HPV)
Biopsy of the lesion is the primary diagnostic tool to confirm the diagnosis.
Full physical exam is a must, to look for other lesions especially in the genital area
Sexual history is helpful in identifying, at higher risk, patients for AIN (anal intraepithelial neoplasia)- Homosexual gay
CT imaging with IV contrast is diagnostic for distant metastasis in metastatic cancers. Other imaging modalities such as MRI, PET scan can also be used.
In the context of immunosuppression, treatment begins with lowering the dose of immunosuppressive drugs, in particular MMF. CNI dose showed also be within the lower therapeutic trough level.
Sirolimus-based CNI-free regimen is the best choice when cancer is diagnosed, owing to the antiproliferative effect of mTORi.
Excisional biopsy with removal of whole lesion is the standard for superficial lesions/In-situ cancers. Alternatively, electro-cauterization or laser therapy can be used. In deep lesions or metastatic lesions, chemo, radiotherapies alone or in combination with surgery is used.
In physical exam, we have to check other areas in particular genital area (cervix, vulva, scrotum, rectum, penis) for other lesions.
Clinically, disease can be silent or associated with local symptoms of the lesion such as itching, bleeding from the lesion and pain.
1-Ogunbiyi OA, Scholefield JH, Raftery AT, Smith JH, Duffy S, Sharp F, Rogers K. Prevalence of anal human papillomavirus infection and intraepithelial neoplasia in renal allograft recipients. Br J Surg. 1994 Mar;81(3):365-7. doi: 10.1002/bjs.1800810313. PMID: 8173899.
2-Patel HS, Silver AR, Northover JM. Anal cancer in renal transplant patients. Int J Colorectal Dis. 2007 Jan;22(1):1-5. doi: 10.1007/s00384-005-0023-3. Epub 2005 Aug 16. PMID: 16133005.
3-Rosales BM, Langton-Lockton J, Cornall AM, Roberts JM, Hillman RJ, Webster AC. Transplant Recipients and Anal Neoplasia Study: Design, Methods, and Participant Characteristics of a Prevalence Study. Transplant Direct. 2019 Mar 4;5(4):e434.
I appreciate your clinical approach
What is your differential diagnosis?
1- Anal squamous cell cancer (ASCC) which caused by persistent infection with high-risk human papillomavirus (HPV).
2-Genital wart .
3-External hemorrhoid.
4-Perianal hematoma.
What do you confirm the diagnosis?
1-HPV Genotyping.
2- Cytopathology.
What is the treatment?
MDT management in ASCC (Dermatologist, nephrologist, oncologist and others).
Reduction of immunosuppression.
Topical creams (e.g.imiqumoid), 5-fluorouracil.
Cryocutaery
Laser ablation.
In multiple warts, systemic treatment such as systemic retinoid.
Does this condition affect other parts of the body?
Yes, it can affect many parts of the body if its cause is HPV1 such as Cervical, mouth, hands, penis and etc.
But if HPV 2 it affect mainly genital part.
If it is ASCC may affect rectum and colon.
What are the clinical presentations of this disease?
ASCC: bleeding from the bottom (rectal bleeding) itching and pain around the anus.
Genital wart: Flesh-colored or grey growths around your vagina, anus, or upper thigh with itchy and bleeding.
References:
1-Rosales BM, Langton-Lockton J, Cornall AM, Roberts JM, Hillman RJ, Webster AC. Transplant Recipients and Anal Neoplasia Study: Design, Methods, and Participant Characteristics of a Prevalence Study. Transplant Direct. 2019;5(4):e434. Published 2019 Mar 4. doi:10.1097/TXD.0000000000000873.
2-Risk of Anogenital Warts in Renal Transplant Recipients Compared with Immunocompetent Controls: A Cross-sectional Clinical Study, Helle K. Larsen, Louise T. Thomsen, Merete Hædersdal, Trine Thorborg Lok, Jesper Melchior Hansen, Søren Schwartz Sørensen and Susanne K. Kjaer.
3- Rosales, Brenda Maria MPH1; Langton-Lockton, Julian MBBS, MRCP, DTM&H, DipHIV, DipGUM, DFSRH2; Cornall, Alyssa M. PhD3,4; Roberts, Jennifer M. FRCPA5; Hillman, Richard J. MD, FRCP6; Webster, Angela Claire MBBS, MM (ClinEpid), PhD, FRCP, FRACP1,7; on behalf of the TAN Study Group. Transplant Recipients and Anal Neoplasia Study: Design, Methods, and Participant Characteristics of a Prevalence Study. Transplantation Direct 5(4):p e434, April 2019. | DOI: 10.1097/TXD.0000000000000873
I appreciate your clinical approach
What is your differential diagnosis?
Anal warts, also known as condyloma acuminate, are caused by infection with the human papillomavirus (HPV).
External hemorrhoid
Perianal hematoma
Perianal hidradenitis suppurativa
Molluscum contagiosum
Anal cancer
What do you confirm about the diagnosis?
Providers use the following tests to diagnose genital warts:
A dermatologist can diagnose genital warts by examining warts during an office visit. Sometimes a dermatologist will remove a wart or part of it and send it to a laboratory. This can confirm that a patient has genital warts.
What is the treatment?
Does this condition affect other parts of the body?
What are the clinical presentations of this disease?
Warts look like rough, skin-colored, or whitish-grey growths on your skin. Genital warts often have a bumpy cauliflower look, but some are flat. Genital warts aren’t usually painful. Occasionally, they cause:
Some warts are very small. Still, you can typically feel or see them. Sometimes warts cluster together in groups or get very large and take on a stalk-like appearance. Most warts begin as tiny, soft growths and may be unnoticeable.
UP-TO-DATE
That is a well-structured reply. Typing ‘uptodate’ as a reference is not a complete reply in a scientific write-up.Typing the whole sentence in bold amounts to shouting, however.
What is your differential diagnosis?
How do you confirm this diagnosis?
Other important investigations will be
What is the treatment?
This will require a multidisciplinary approach involving, a surgeon, medical oncologist, radiation oncologist, and transplant nephrologist
Other parts of the body affected
Clinical presentation
References
Reference Continue
That is a well-structured and a brief reply. Typing ‘uptodate’ as a reference is not a complete reply in a scientific write-up.
Thanks, prof
correction noted
What is your differential diagnosis?
1- Perianal skin cancer
Anogenital cancers accounts for around 2-3% of malignancies that occur after solid organ transplantation. (1-3)Usually it occurs after 7-9 years after transplantation. (4)Four types of tumors arise in the anal region:
Anal tumors arising from the 3 types of lining mucosa (glandular, transitional, and squamous) they cannot be seen in their entirety with gentle traction on the buttocks, and most of cases are SCC.Perianal skin cancers arising within the perianal hair-bearing skin, they can be seen in their entirety with gentle traction on the buttocks within 5 cm of the anus.Adenocarcinomas arising from glandular elements within the anal canal ( rare)Primary rectal SCCs ( very rare)The most probable diagnosis in this case is perianal skin cancers such as Bowen’s disease or Paget disease as they presents with pruritic lesion like our case.
2- Genital wart
Diagnosis, assessment and clinical staging (TNM)
History of immunosuppression intensitySexual history is important since in patients with anal SCC, it was found that around half of gay men and less than one third of women and straight men had a history of anorectal condyloma (5).Clinical assessment by palpating the tumor and the groinBiopsy of the lesion is mandatory for confirmation of the diagnosis and histopathology assessmentHIV screening is recommendedCT or MRI abdomen and pelvis is recommended to asses local nature of the diseaseCT chest is recommended to exclude secondary metastasisPositron emission tomography (PET)/CT) scan.Tumor marker assessment (like CEA) is not recommended to be done in localized anal SCCWhat is the treatment?
A- Reduction of immunosuppression
Reduction of immunosuppression can cause resolution of the In situ tumor (6)MMF should be reduced to 500 mg bidTacrolimus should be reduced to attain a trough of 5-7 ng/ml (keep it towards 5 ng/ml).B- Definitive treatment
In situ anogenital cancers can be treated with electrocautery, laser therapy, or topical fluorouracil. Invasive tumors needs local excision with safety margin with lymphadenectomy for tumors >1 mm thick together with adjuvant therapy in some patients (radiation therapy (RT), chemotherapy.Does this condition affect other parts of the body?
It can involve the anus, perianal region, perineum, vulva, penis or scrotumThe lesions are usually multiple and extensive, around 30% of females with anogenital cancer have concurrent cervical cancer.What are the clinical presentations of this disease?
Rectal bleeding occur in around half of the patients and it represents the most common symptoms of anal cancer, it may be misdiagnosed as hemorrhoids with subsequent delay in the diagnosisAnorectal painSensation of rectal mass occur in one third of casesAround 20 % of cases are asymptomatic (7-9)Clinically, lesions appears as pigmented papules that may be confused with anal wartPrurutis can occur in tumors of the perianal skin, such as Bowen’s disease or Paget diseaseReferences
1- Adami J, Gäbel H, Lindelöf B, et al. Cancer risk following organ transplantation: a nationwide cohort study in Sweden. Br J Cancer 2003; 89:1221.
2- Penn I. Cancers complicating organ transplantation. N Engl J Med 1990; 323:1767.
3- Penn I. Cancers of the anogenital region in renal transplant recipients. Analysis of 65 cases. Cancer 1986; 58:611
4- Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med 2003; 348:1681.
5- Daling JR, Weiss NS, Hislop TG, et al. Sexual practices, sexually transmitted diseases, and the incidence of anal cancer. N Engl J Med 1987; 317:973.
6- Euvrard S, Kanitakis J, Chardonnet Y, et al. External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment. Arch Dermatol 1997; 133:175.
7- Singh R, Nime F, Mittelman A. Malignant epithelial tumors of the anal canal. Cancer 1981; 48:411.
8- Schneider TC, Schulte WJ. Management of carcinoma of anal canal. Surgery 1981; 90:729.
9- Schraut WH, Wang CH, Dawson PJ, Block GE. Depth of invasion, location, and size of cancer of the anus dictate operative treatment. Cancer 1983; 51:1291.
That is a well-structured reply
Any reply?
(i) viral lesions: warts, herpes simplex 1 and 2, herpes zoster and genital warts
(ii) mycotic lesions: dermatophytosis and onychomycosis
(iii) precancer/neoplasia: actinic keratoses, dysplastic naevi, basal cell carcinomas, melanoma
(iv) benign lesions: seborrhoeic keratosis.
Histopathological examination along with staining including fungal .
physical therapies (cryotherapy, electrosurgery, laser vaporization)
chemical therapies (salicylic acid, podophyllum, trichloroacetic acid) systemic and topical retinoids
Immunomodulatory therapy, which includes contact immunotherapy with DCP6 and squaric acid dibutylester .
Most important is decrease of immunosuppression by stopping MMF and conversion of tacrolimus with everolimus.
Genital warts are soft growths on the skin and mucous membranes of the genitals. They may be found on the penis, vulva, urethra, vagina, cervix, and around and in the anus.
Most types of HPV cause “common” warts. These warts can grow anywhere on the body and are often found on the hands and feet.
Cutaneous and anogenital warts
Cervical and anal intraepithelial neoplasia
Head and neck and other cancersAnogenital cancer
Human Papillomavirus in Kidney Transplant RecipientsPeter Chin-Hong,