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An otherwise healthy 39-year-old uncircumcised male presented to our dermatology department with a 1-week history of an asymptomatic penile dermatosis (figure 1). The rest of the physical examination was unremarkable, and there was no lymphadenopathy. He was in good general health and denied local trauma or possible irritants. The patient had been evaluated via telemedicine with a urologist 2 days prior, where a diagnosis of balanoposthitis was made. Venereal Disease Research Laboratory (VDRL) serology and herpes simplex virus mucosal swab PCR taken that same day were negative. He had taken one oral dose of fluconazole 150 mg and applied tacrolimus 0.1% ointment two times a day.
The patient was instructed to come back if the problem did not subside. He returned 2 weeks later due to the appearance of an asymptomatic maculopapular exanthem (figure 2). There was painless lymphadenopathy in the inguinal folds and axillae. His penile lesions were unchanged. A diagnosis of secondary syphilis with a concomitant primary syphilitic balanitis (balanoposthitis) of Follmann (SBF) was made. He was treated with benzathine penicillin G 2.4 million units intramuscularly twice with a 1-week interval (according to local guidelines). A second VDRL performed that day was 1:16, with a positive microhemagglutination assay–Treponema pallidum test (MHA-TP). HIV serology was negative. Complete resolution was seen within 7 days of his first dose.
In 1948, Follmann was the first to suggest that primary syphilis could present as a balanitis.1 SBF is an under-recognized type of primary syphilis that may present with a broad spectrum of signs affecting the glans penis and inner prepuce, including erythema, erosions, crust, oedema, paraphimosis, exudate or scale.2 A previous, concurrent or subsequent chancre and lymphadenopathy have been described.3 Patients may be asymptomatic or painful.4 Concomitant primary and secondary syphilis can be seen in approximately 9% of cases (figure 3).5 At one time, this was thought to be a classical feature of syphilis in HIV infection but recent research suggests otherwise.6
Non-treponemal tests may be negative in the early stages of primary syphilis in up to 30% of patients, as in our case; however, dark field microscopy or PCR (if available) could potentially confirm the diagnosis.5
The differential diagnosis of acute balanoposthitis includes mycotic infections, usually candidosis, that generally responds well to a single dose of fluconazole. Genital herpes must be excluded, especially if the presentation is painful or recurrent. Contact dermatitis could explain the clinical appearances; however, a history of irritants/allergens and pruritus/pain is usually present. Fixed drug eruption demands the identification of a pharmacologic culprit; it is characteristically recurrent. The existence Zoon’s balanitis’ as clinicopathological entity is currently under debate; however, erosions are not part of the classical image, and some improvement would have been expected with topical tacrolimus.7 The appearance of a disseminated maculopapular rash was crucial to our diagnosis, as well as the reactive VDRL test and excellent response to penicillin.
Syphilis is a great imitator in all of its stages. Patients with balanoposthitis might benefit from serologic screening, particularly if non-responsive to standard treatment.
Primary syphilis can manifest as balanoposthitis and can be concurrent with secondary syphilis.
Syphilis is a great imitator in all of its stages (including primary), and a high degree of suspicion is needed.
All patients with balanoposthitis might benefit from serological screening, for syphilis, particularly if non-responsive to conventional treatment. And treponemal screening should be repeated if the balanoposthitis persists.
Contributors JAN has contributed to the following: substantial contributions to the conception and design of the work; as well as the acquisition, analysis and interpretation of data for the work; drafting the work; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. CBB, CB and JTB have contributed to the following: substantial contributions to the conception or design of the work; revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.