A 43-year-old man comes to the office due to increasing discomfort and pain with sitting for the past several months. He also has had occasional perianal pruritus. Physical examination shows multiple, cauliflower-shaped, verrucous growths measuring 1 to 2 cm on the perianal skin. Histopathologic examination of one of the lesion reveals hyperplastic papillary squamous epithelium with parakeratosis, nuclear irregularity, and "perinuclear halos" of cytoplasmic vacuolization. Which of the following additional studies is most appropriate for this patient at this time?

Question

A 43-year-old man comes to the office due to increasing discomfort and pain with sitting for the past several months.  He also has had occasional perianal pruritus.  Physical examination shows multiple, cauliflower-shaped, verrucous growths measuring 1 to 2 cm on the perianal skin.  Histopathologic examination of one of the lesion reveals hyperplastic papillary squamous epithelium with parakeratosis, nuclear irregularity, and "perinuclear halos" of cytoplasmic vacuolization.  Which of the following additional studies is most appropriate for this patient at this time?

Quizplus · Accepted Answer

11ec160b_3868_db9d_9249_4f0ba29d9704_MD0001_00 Condylomata acuminata (anogenital warts [AGW]) are characterized by pink or skin-colored plaques, papules, and verrucous lesions on the genitalia, perineum, or perianal skin. AGW are caused by human papillomavirus (HPV), primarily types 6 and 11. The diagnosis is usually apparent on clinical examination, but biopsy is often helpful for large or atypical lesions. Histopathologic features include papillary architecture with thickening of the stratum corneum (hyperkeratosis), epidermal hyperplasia (acanthosis), nuclear irregularity, and perinuclear vacuolization (koilocytosis). AGW are associated with an increased risk for HIV infection. AGW and HIV share common risk factors; both are frequently acquired via sexual contact and have an increased prevalence in men who have sex with men. In addition, patients with immune suppression (eg, transplant immunosuppression, HIV infection) have increased incidence of AGW and frequently have multiple, widespread lesions. Conversely, large, friable AGW lesions likely confer increased susceptibility to acquiring HIV infection. Therefore, HIV testing is recommended. (Choice A) Pinworm (Enterobius vermicularis) infection is confirmed on microscopy after sampling the perianal area for eggs with an adhesive paddle or cellophane tape. This condition can present with severe pruritus but does not cause verrucous lesions. (Choice B) Colonoscopy with terminal ileoscopy is used to evaluate for ileocolonic Crohn disease. Patients commonly have perianal involvement, but typical findings include painful abscesses and draining fistulae. (Choice C) Condylomata lata are a manifestation of secondary syphilis, which can be confirmed by direct visualization of Treponema pallidum on darkfield microscopy of the tissue or exudate. Although condylomata lata may present as verruciform lesions resembling AGW, biopsy typically reveals a dense lymphoplasmacytic infiltrate. (Choice D) Portal hypertension can lead to dilation of peripheral portosystemic collaterals. Involvement of the rectal submucosal veins (connecting the inferior mesenteric and iliac systems) can cause rectal varices, which present as enlarged veins resembling internal hemorrhoids. External verrucae are more consistent with AGW. Educational objective: Condylomata acuminata (anogenital warts) present as pink- or skin-colored plaques, papules, and verrucous lesions on the genitalia, perineum, or perianal skin; they are caused by human papillomavirus, primarily types 6 and 11. These lesions are associated with increased risk for HIV infection, and HIV testing is recommended. __________ References: Condylomata acuminata (anogenital warts) contain accumulations of HIV-1 target cells that may provide portals for HIV transmission. (http://www.ncbi.nlm.nih.gov/pubmed/30137482)

A 43-Year-Old Man Comes to the Office Due to Increasing