Intraoral giant condyloma acuminatum

Introduction

The condyloma acuminatum is a benign epithelial proliferation that occurs most frequently on the mucous membranes of perianal and genital areas of men and women.[1] The causative agent of this lesion is papova group viruses.[2] Condylomata acuminata are now thought to be one of the four most common sexually transmitted diseases and second only to genital herpes among the sexually transmissable viruses.[3] Intraoral condyloma acuminatum is rare[4] and has been reported most commonly in the temperate and developed parts of the world. This case is reported because of extreme rarity of the condition and also to focus attention on the nonsexual means of transmission.

Case Report

A 50-year-old man presented in the Dermatology department of Govt. Medical College, Faridkot in March, 1999 with a warty growth of size 5 x 7 cms. covering right half of inner mucosal surface of lower lip which had seedings on the apposing surface of lower gum for the last one year [Figure - 1]. Lesion started as a white pea sized papule in the vestibule portion of oral cavity. It persisted and enlarged slowly for one year to acquire the present size. Both patient and his wife denied history of marital or extra - marital sexual contact for the last 1½ years. About one and a half years back, patient had undergone surgical bone plating under spinal anaesthesia after fracture of both bones of the right lower leg.

On examination, warty growth had pinkish white colour and granular surface with fissures extending into underlying mucous membrane. Surrounding mucous membrane also gave a whitish hue. Genitalia, rectal mucosa and perianal skin were normal with no warty growth. Examination of patient′s wife failed to detect any genital or skin warts.

All the routine investigations were done. All values were within normal limits. VDRL test and ELISA test for HIV 1 and 2 on blood of patient and his wife gave negative results. Biopsy specimen from growth showed parakeratosis, papillomatosis and acanthosis. There was marked koilocytosis of the superficial layer of epithelium. The epithelial papillae were supported by a fibrovascular core with dilated capillaries. Basal layer showed occasional mitosis. These histological features were consistent with those of condyloma acuminatum.

Topically 20% podophyllin in tincture benzoin was applied to the warty growth for three consecutive applications at weekly intervals. Warty growth did not show any sign of regression. Electrocautery of the lesion was done four times at fortnightly interval. Warty growth showed regression up to 75%. As the warty growth had not disappeared completely and was recurrent after electrocauterisation, it was decided to go for surgical excision.

Discussion

Condyloma acuminatum has been reported to affect the mucous membranes of the gingiva, cheeks, lips and hard palate. This is quite understandable as the oral cavity has a mucocutaneous junction similar to vagina and anus. Some patients with condyloma acuminatum had concurrent genital or anal warts. Some gave a history of oral sex with partners with condylomata acuminata. There were no warts on the genitalia or skin of the patient or his wife. Neither there was any marital or extramarital sexual contact for the last one and a half year nor the patient was in a position to have sexual contact as he was confined to bed for last 1½ years. In this case acquisition of lesions remains an enigma. As there was no history of sexual contact and no other lesions were found on the body, other possible modes of transmission of this virus have to be considered. Transmission of HPV by anogenital contact is clearly possible but non-sexual transmission may also occur.[6] Evidence has suggested that skin and genital warts may be caused by different agents and that skin warts appear to be acquired from environmental sources such as public bathing facilities.[7] Genital warts are acquired sexually with peak occurrence in third decade of life. Further studies are needed of the mode of transmission of papova viruses especially in relation to warts. Meanwhile, nonsexual modes of transmission of this virus may be a real possibility especially when condyloma acuminatum occurs at extragenital sites.