BALANITIS ----------- Heres a tough one in real time: This patient was admitted this afternoon. 30 yo Oriental-American male, uncircumcised, with onset of penile complaints following episode of unprotected oral sex in January '96. Pt denies trauma or known history of prior STD's in self or partner. Pt is o/w healthy except for seasonal allergies for which he intermittently uses Claritin. Pt initially noted "small tender bump" at urethral meatus with mild peri-meatal redness. Pt seen at that time by primary MD who did HSV titer (which was negative) and empirically treated with Famvir (no response). Pt next seen by Infectious Disease service. U/A, urine culture, chlamydia titer all negative; empiric trial of Doxycycline unsuccessful. Pt referred to Urology (urine tests again negative) with no diagnosis made; pt then referred to joint Derm/Urology Genital Disease Clinic and was first personally seen about one month ago. At that time, pt had obvious erythema around the meatus and the entire area was tender. There was also a small cluster of 2-3 mm papules with a orange-ish or golden tint at 4-5 o'clock at the meatal edge; these were not umbilicated or vesicular and were not any more tender than the general area. The foreskin was completely easily retractable and no other lesions were seen; there were no palpable inguinal nodes and no urethral discharge. The proximal urethra was nontender. Initial impression was of bacterial balanitis of unclear origin. Pt was treated with Dicloxacillin x 10 days (along with Zeasorb AF) and seen back at 2 weeks. Pt reported increased tenderness but no other change in PE (confirmed by exam). Pt then given trial of topical aqueous gentian violet with plan to biospy if no response. After 1 week on gentian violet, pt called for urgent appointment because "getting worse". PE now reveals ulceration and erosion with purulence at former site of papules, mild erythema and marked tenderness of entire glans, and violaceous/dusky hue to proximal glans (NOT gentian violet stains). Pt also now has pea-sized tender left inguinal node. Pt has been admitted with plan to "cool off" with IV antibiotics (Cipro per ID rec's) and then go ahead with biopsy, urethroscopy and possibly circumcision. Pt has now been seen by eight physicians, two of whom have extensive experience with male genital lesions and one of whom has been a urologist for over 40 years, and none of them have ever seen anything like this. Any help regarding diagnosis and/or treatment would be greatly appreciated. Daniel Mark Siegel MD --------------------- Recommend Biopsy...also culture for Chancroid (need to warn lab in advance)....other possibilites are lymphoma (consider marker studies as well as molecular biology studies), LyP and leukemia cutis....probabley also worth doing AFB cultures....is this KS (what is the pts HIV status). Of course, an RPR should be thrown in. Rick Sharpe MD -------------- Certainly, you have already thought of this: Condylomata Buschke-Loewenstein (verrucous carcinoma of genital area) and HLA-testing. The first, because of the incipient papulous texture, the ulcerative and purulent (superinfected?) erosion and the pea-sized lymph node. The second, because of the association of balanitis circinata with HLA B-27. A biopsy will surely shed light on it. Andreas Orou MD --------------- The biopsy will be done. Remember, this went from minimal erythema to frankly exudative very rapidly and balanitis circinata is a good thought. Clinically, it is not verrucous carcinoma. I have seen many of those and none looked like this. Daniel Mark Siegel MD --------------------- ? deep fungus - atyp mycobacteria - ? CMV (I think this has been reported after oral sex) - ?DLE; doubt GA / Sarcoid / MF Biopsy is your best bet. KC Smith MD FRCPC ----------------- My first choice - since you've ruled out almost everything imaginable - would be a fixed drug eruption. It certainly doesn't sound like erosive LP or BP. Robert I. Rudolph, M.D., FACP ----------------------------- I would second the suggestion to requestion the patient about possible fixed drug eruption. I had a patient with a similar history, but with the lesion on the scrotum; it turned out to be due to oil of Wintergreen used in the Snuff he'd been using to stop smoking. It resolved when he stopped the Skoal brand product , and returned with re-challenge. John Uhlemann MD ---------------- ...?fixed drug sine drug? I know I'm making up a new one, but can recollect a past case or two that have made me wonder if this entity exists. Theoretically, why does the offending chemical *have* to be a "drug?" Mike Eichwald MD ---------------- A good thought but I could elicit no other "drugs"; specifically tobacco with or without flavoring, cinammon toothpastes, laxatives, new items in the diet. He is getting better, the acute process is settling down and as the erosion is immediateley adjacent to the meatus, we have all agreed (derm-ID -urology) to biopsy after what appears to be a secondary infection settles down. Daniel Mark Siegel MD ---------------------- Alsays have to consider factitial injury (by self or consort) in cases like this. I always photograph cases like this - makes it a lot easier to tell how they are doing, and to make a case for factitial if necessary as time goes on. KC Smith MD FRCPC ----------------- Re the recalcitrant balanitis, two ideas. Did anyone look for yeast (especially since his partner might have had oral thrush)......unless the gentian violet would have ruled that out (I'm from the azole generation). The case reminds me of one that presented to me when I was a resident doing a stint at our student health services. A man presented with recalcitrant balanitis, and was seen on multiple occasions, each time treated with a different drug. His frequency of visits began to make me quite uncomfortable, so, I "turfed" him to the other derm resident, a male. The other resident saw him for about to minutes, and stepped out of the office with the diagnosis and treatment. He recommended the patient restrict his masturbating for at least two weeks! The patient stated he masturbated atleast three times a day, and would be unable to stop. That was the last we saw of him. Diane Thaler MD --------------- I would second the suggestion to requestion the patient about possible fixed drug eruption. I had a patient with a similar history, but with the lesion on the scrotum; it turned out to be due to oil of Wintergreen used in the Snuff he'd been using to stop smoking. It resolved when he stopped the Skoal brand product , and returned with re-challenge. John Uhlemann ------------- --------------- CASE DISCUSSION --------------- I did not biopsy a horrendous circinate balanitis today. the patient has a history of erosive seronegative arthritis. He has also developed a 2 cm irregular greyish minimal erosion right palate, and an oval minimal 2.5 cm greyish white plaque left palate-not healing 5 days post hot coffee burn and subsequent blister. I did inject him with sterile saline to check for pathergy, and considered Reiters, Behcets, fusospirochetes, yeast etc. Diane Thaler ------------ This case does not sound like it, but I consider fixed drug eruptions in similar cases of penile erosions. Biopsy would be good. Jerry Eisner ------------ Forgot to tell you that was part of the differential. You are correct-he took TMP Sulfa for several days before he noticed the rash. He is not sure about the timing. I took him off the TMP Sulfa and dont die....I put him on empiric Doxy for fusospirochetes, Reiters, arthritis, and anything else I might think of before Monday when I will have to biopsy him. Diane Thaler ------------ Check HIV Status and Swab for HSV. Rhette Drugge ------------- You are correct. I should have. Even though it wasn't a painless or otherwise classical syphilitc lesion. I hope I catch it on the biopsy if it's there. How will the Doxy have messed up the VDRL and FTA (I used to know these things, and I still could look it up....) ? Diane Thaler ------------ The erosive circinate balanitis I biopsied was lichen planus and it cleared on the empiric doxycycline prescribed 4 days prior to the biopsy. The roof of the mouth cleared in 4 days. I have no explanation, just follow up. Diane Thaler ---------------