00:01
Alright, I think it's time
we moved on to case number 2.
00:05
A 23-year-old man now presents to your office,
concerned about some bumps on his penis.
00:11
He noticed them several
weeks ago in the shower.
00:13
He tried rubbing alcohol, God knows why,
and then a topical antifungal, to no avail.
00:19
These lesions are not itchy or painful, he denies any
fevers or chills, no dysuria, no penile discharge.
00:26
His social and family history
is essentially non-contributory,
except that he has been sexually active with
5 female partners in the past 12 months.
00:35
Review of systems is negative, his vital
signs are over the normal limits.
00:39
And then on exam of his genitourinary system, he has
numerous, nontender, skin colored, fleshy papules,
scattered on the shaft and base of his penis.
00:49
No mucosal involvement and
no inguinal lymphadenopathy.
00:53
So, highlighting a few key features here,
the time course appears to be subacute.
00:58
He noticed them several weeks ago.
01:00
In terms of the pattern of skin involvement, it is
asymmetric involvement exclusively of his genitalia.
01:06
Skin inflammation, they're nontender,
there don't appear to be pustules
so doesn't sound there's much skin inflammation.
01:13
And lastly, systemic involvement -
we're not seeing any.
01:16
So, that's basically what we've got at this point.
01:20
Alright, let's take a look at
our differential diagnosis.
01:23
Condyloma acuminata, acrochordon, genital
herpes, verruca vulgaris and chancres.
01:30
Well that's a mess of Greek and Latin.
01:32
Let's see if we can make our way through it all.
01:34
First off, condylomata acuminata,
that's a fancy term for genital warts.
01:40
The etymology actually means pointed, round
tumor which distinguishes a genital wart
from the more flat appearance of plantar and
common warts which are also caused by HPV.
01:52
In any event, these asymptomatic
lesions are incredibly common.
01:56
In fact, they're the most common sexually
transmitted disease above all else
and they manifest on the shaft of the penis.
02:02
They're more common in sexually active men and
women so this one clearly is gonna stay on our list.
02:10
Next stop, acrochordon.
02:12
What's with the fancy words?
Okay, an acrochordon is the official term for a
skin tag which is depicted here in our image.
02:20
It's a fleshy papilloma that most
often occurs in flexural creases,
like the nape of the neck, the axilla, the groin.
02:26
We should probably keep this one on our list for now.
02:30
Genital herpes, finally some english.
02:33
Genital herpes is typically
caused by herpes simplex virus 2,
though it can also be caused by HSV 1.
02:40
It's relatively common viral infection
with myriad skin manifestations
but the lesions of HSV 2 are more of
the painful vesicular or ulcerative type
rather than our patient's painless, fleshy papules.
02:54
So I think we can safely take HSV-2
and genital herpes off the list.
03:01
And here we're back to the latin.
03:02
Verruca vulgaris
This is a fancy word for common wart.
03:07
Common warts is one subtype of cutaneous warts.
03:11
The others of which include plantar warts and flat warts,
we've already mentioned another type of wart above.
03:16
Cutaneous wart is an umbrella term for warts caused by
HPV that are not occuring in the anogenital region
which is we've already discussed
are called condylomata acuminata.
03:27
see above.
03:28
Hence, since our patient's lesions are
in fact in the anogenital area,
if they were gonna have any kind of wart,
it would be condylomata acuminata.
03:37
So we can safely take verruca
vulgaris off of our list.
03:41
A bit of taxonomy goes a long way.
03:44
Lastly, chancre.
03:46
A chancre is the classic
lesion of primary syphilis.
03:50
Now it starts as a painless papule, similar
to our patient at the site of inoculation.
03:56
though it eventually progresses to a painless ulcer.
04:00
It'd be unusual to have multiple lesions
like we have on our patient and also,
you'd more likely have some
accompanying lymphadenopathy.
04:07
Now, while the chancre represents
the primary syphilis lesion,
the spirochete bacterium of
syphilis, Treponema palliidum,
soon goes systemic even as the
ulcer heals over several weeks.
04:18
So, patients develop some systemic manifestations.
04:21
And later, secondary syphilis can occur with a diffuse, classic,
maculopapular rash eruption on the trunk and extremities,
including the palms and soles.
04:30
It's really not sounding at all like what our
patient has had for the past several weeks,
so I think we can safely take
off chancre and syphilis.