Vulvar condyloma lata as a first presentation of syphilis

A 39-year-old woman was referred to our gynecology clinic for painful genital lesions that had begun 4 months earlier. Her medical history included a substance use disorder and recent occurrence of painful mouth ulcers, which resolved without treatment. The physical examination showed verrucous, friable and erythematous lesions extending from the labia majora to the anus (Figure 1A). Unfortunately, secondary syphilis presenting with condyloma lata was not considered in the differential diagnosis, which included malignancy and Behçet syndrome (given the history of mouth ulcers). We performed a biopsy, pathological examination of which showed many spirochetes (Figure 1B). Syphilis chemiluminescence assay was positive, and a rapid plasma reagin titre (RPR) was reactive at 1:64 dilutions. A β-human chorionic gonadotropin test and screening test results for HIV Ab/Ag, hepatitis B and C, Chlamydia trachomatis and Neisseria gonorrhoeae were negative. We administered 1 dose of penicillin G benzathine (2.4 MU intramuscularly) and offered counselling and support for partner notification. At 4-month follow-up, the patient’s lesions had almost completely resolved (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.230159/tab-related-content). The RPR titre was 1:8 dilutions, confirming treatment success.1

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Figure 1:

Vulvar condyloma lata in a 39-year-old woman, presenting as verrucous, friable and erythematous lesions extending from the labia majora to the anus (A). Spirochetes surrounded by plasma cells, seen with immunohistochemistry staining within the superficial mucosa and lamina propria (B).

In 2021, 11 268 cases (30/100 000 population) of syphilis were reported in Canada, a 116% increase from the 4132 cases reported in 2017.2 This increase has been particularly pronounced among women (729%, compared with 96% for men), especially among those aged 15–39 years, for whom the rate reached 41.8/100 000 in 2021.2 Between 2018 and 2021, 216 cases of congenital syphilis were confirmed in Canada, a sharp rise from the 1–10 cases per year between 1993 and 2017.3

Early recognition of syphilis may be challenging. Populations experiencing barriers to care are at risk for a late or missed diagnosis. Clinicians should be aware of various manifestations, including the highly infectious mucocutaneous lesions of condyloma lata. A genital examination is required to identify lesions suspicious of infectious syphilis.