Acquired vulval lymphangiectases mimicking genital warts

Introduction

Acquired cutaneous lymphangiectasia (ACL) sometimes arises following damage to the deeper lymphatic vessels. The known causes for ACL include scarring after some surgical procedures, keloid formation, chronic infections or radiotherapy which cause alterations in the connective tissue and obstruction of the lymphatic vessels. Clinically ACL resembles lymphangioma circumscriptum, which is a developmental defect of the deep dermal and subcutaneous lymphatics. The lesions may start oozing after trivial trauma, and not only be a cause for concern, but also provide a route for entry to the pathogenic organisms.

We describe a case of acquired cutaneous lymphangiectasis of the vulva mimicking genital warts that followed removal of the inguinal nodes for probable tubercular lymphadenitis.

Case Report

A 48-year- old woman developed papulo-nodules on the vulva for the last 5 years. She had difficulty during intercourse but was otherwise healthy. Oozing used to occur during and / or soon after intercourse and the vulva would often become swollen and tender. This would subside after a course of antibiotics. Twelve years ago, she had undergone an operation in the inguinal region for the removal of some nodules, the details of which were not known. Examination revealed multiple, firm translucent to milky white, warty papules solitary at places but mostly grouped [Figure - 1] on the vulva and the mons pubis along with mild vulvar edema. On puncturing a lesion with a fine needle, straw-colored fluid came out. Scars were present in both the inguinal regions. Complete analysis on blood, liver and renal function tests, urinalysis, and stool examinations were normal or negative. Gynaecological workup and untrasonography of the pelvic organs revealed no abnormality. A skin biopsy revealed multiple dilated channels in the dermis lined by a single layer of edothelial cells [Figure - 2]. A few channels had deposition of an eosinophilic material and a few polymorphs. Thrombosis of a few vessels with deposition of fibrinod material was also present.

A wide excision of the lesions (vulvectomy) led to complete recovery and there was no recurrence during a follow up of 1 year.

Discussion

Congenital lymphangioma and acquired lymphangiectasias are clinically indistinguishable. The differentiation however is possible on the basis of history because lymphangiomas are present since birth or early childhood, while acquired cutaneous lymphangiectasia develop later and probably result from injury and damage to the deep collecting channels in the conection tissue leading to build up of the lymph in the superficial vessels and subsequent formation of the lesions. The literature has reports of 23 case of vulval lymphangiectases.[1] Most of them followed surgery/radiotherapy for carcinoma of the cervix or vulva, tubercular inguinal lymphadenitis, or Crohn′s disease of the vulva. In 6 cases the cause could not be ascertained. The most common presentation was thin-walled vesicles filled with a clear fluid. Rarely, they may develop a hyperkeratotic appearance,[2] and often misdiagnosed and treated as viral warts before the correct diagnosis is established. This variation in the morphology is explained on the basis of a gradual tissue organization, probably enhanced by the presence of lymphoedema.[3],[4] Lymphoedema as in our case, has been observed in only a few cases. Recurrent cellulitis has also been reported earlier. The interval between the surgery and the lymphangiomatous lesions may be several years. Our patient underwent a wide vulvectomy and had no recurrence during a follow up period of 1 year.