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Dr Samarendra Mahapatro, Dr Subhranshu Sekhar Kar, Dr Rajani Dube, Dr Sitanshu Sekhar Kar 09 March 2018
Keywords
Maggots,condyloma,human papilloma virus
Author & Affiliation
INTRODUCTION
Condyloma acuminata(mucous membrane warts) are moist fleshy and papillomatous lesions that occur on the perianal mucosa,labia,vaginal introitus,perianal raphe, shaft, corona and glans penis.They are the epidermal manifestation of Human papilloma virus (HPV).More than 100 types of HPVs have been identified till date 1 out of which more than 30types invade genital areas (1). Depending on site of location,symptoms vary and in untreated cases complications like pain,bleeding and superinfection occur.This is what occurred in this case with obstructive features in anal region and superinfection with maggots.
CASE HISTORY
A 2 year old male child of lower socio-economic class family was brought to the out patient department with complaints of a mass over perianal region,difficulty in defecation and passage of maggots for a period of 6 months.The mass was a black cauliflower mass which was progressively increasing in size with itching & occasional bleeding on being scratched.Past history suggested that he was being treated with homeopathic medicines without any relief.
He was the second child of his parents,born out of a non-consanguinous marriage,his mother was 26years old and father 30 year old.He was born by full term normal vaginal delivery.The antenatal,intranatal and postnatal periods were uneventful.His developmental milestones were normal till this age.
On examination,he had average body built,height 80c.m.,weight 10 k.g., respiratory rate- 30/min., regular,abdominothoracic, pulse rate-96/min regular, blood pressure-80/60 mmHg and the child was afebrile.He had mild degree of pallor. Respiratory, cardiovascular, gastrointestinal and central nervous system revealed no abnormality.On local examination of perianal area,the mass was cauliflower like and of size 5 X 4.5 X 2.5 cm3, nonfriable, fleshy and almost covering the anal opening.It was superinfected with maggots.No warts or mass were found in any other area.Complete blood count and urine examination were normal.The father and mother were examined for similar lesions along with family members and all were found to be noninfected.
Pathologic examination of lesion was found to be consistent with condyloma acuminata.
This case was treated initially with antibiotics and turpentine oil.After disinfecting the mass,the whole lesion was surgically excised.On 3 month and 6 month follow-up,there was no recurrence of the mass found.
DISCUSSION
Condyloma acuminata refers to an epidermal manifestation attributed to the epidermotropic human papilloma virus (HPV).More than 100 types of HPVs have been identified till date by sequence homology(1).Strains are almost species specific and about 30 of HPV types have been identified from genital tract specimens.90% of condyloma acuminata are related to HPV types 6 and 11.These two types are the least likely to have a neoplastic potential.HPV infection in genital area are mostly sexually transmitted.
Most people will experience infection with HPV at some time in their life.The prevalence of viral warts in children and adolescents in the United Kingdom has been between 3.9 to4.9% (2). There is no evidence of a sex difference in wart prevalence. The STD clinics data shows the prevalence to be 4-13%. The exact incubation time is unknown but most investigators believe that the incubation period is 3 months. Thus genital HPV infection is now the most common STD. In paediatric age group (>3 years),sexual abuse must be considered as a possible underlying problem.However,in age group (<3 years),infection by direct manual,indirectly by fomites or vertical transmission may be possible (3). Condyloma acuminata is often asymptomatic and the clinical findings depend on the site of epithelial & mucosal infection (4). The genital warts may be found throughout perineum around the anus,vagina and urethra,as well as the cervical,intravaginal and intraanal areas. Although rare,lesions caused by genital genotypes can also be found on other mucosal surfaces such as conjuctiva,gingiva and nasal mucosa. Laryngeal papillomata may occur through vertical transmission. External genital warts may be flat,domeshaped,keratotic pedunculated and cauliflower shaped;they may occur singly,in clusters or as plaques (1). On mucosal epithelium,the lesions are softer. The lesions may be pruritic and painful,cause burning with micturition,be friable and bleed or become superinfected.Condyloma acuminata must be diffferentiated from other warty conditions like epidermodysplasia verruciformis,Bowenoid papulosis,focal epithelial hyperplasia, epithelioma cuniculatum and verrucous carcinoma which are all HPV linked and also from non-HPV linked conditions like corns,lichen planus,epidermal naevi,molluscum contagiosum and condyloma lata (1,4).
Diagnosis of warts is usually based on clinical examination but can be suggested by the histological appearances of acanthotic epidermis with papillomatosis, hyperkeratosis and parakeratosis with elongated rete ridges often curving towards the centre of the wart. Dermal capillary vessels may be prominent and thrombosed.There may be large keratinocytes with eccentric pyknotic nuclei surrounded by a perinuclear halo (koilocytes).
Most common warts resolve spontaneously over time and donot need treatment. But warts in adults,in those with a long duration of infection and in immunosupressed patients are less likely to resolve spontaneously and are more recalcitrant to treatment (5,6,7). Different types of warts and those at different sites may need differing treatments (8). The treatment modalities available are the use of salicylic acid (9),podofilox 0.5% solution,Imiquimod 5% cream, formaldehyde (10), Bleomycin (11), Retinoids (12), glutaraldehyde,Interferon and cimetidine etc. & the ablative treatments like cryotherapy (9),Laser therapy (13,14) and loop electrosurgical excision.
With all forms of therapy,lesions commonly recur and approximately 50% require a second or third treatment.Combination therapy doesnot improve response but may increase complications.So,periodic followup is recommended.
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