Squamous cell carcinoma of penis with bullous pemphigoid masquerading as lymphogranuloma venereum
A 60-year-old unmarried male, presented with a history of multiple ulcers over his right groin of 4 months duration. It started as a painless swelling over the right groin, which evolved into multiple ulcers with foul swelling discharge. One month later, he developed a similar swelling in the left groin. There was no history of trauma at the site. Patient denied history of sexual exposure and there was no history of genital ulcer. He does not give history of arthralgia, loss of weight, or loss of appetite. Bowel and bladder habits were normal.\nThe patient also gave history of multiple blisters over the trunk and extremities of 1 month duration. There was no history of oral erosions or drug intake prior to the onset of lesions.\nOn general examination, the patient was moderately built and nourished, there was no pallor, icterus, pedal edema, or generalized lymphadenopathy. His systemic examination was normal.\nExamination of the right inguinal region showed three tender excavating ulcers of sizes 6 × 8, 5 × 7, and 3 × 5 cm, respectively, located adjacent to each other with rolled out, everted edges, and foul smelling purulent, blood-stained discharge. Enlarged, grouped, and matted tender inguinal lymphnodes of sizes 5 × 7 cm were felt below the ulcer. Examination of the left inguinal region also revealed enlarged, grouped, tender inguinal nodes of size 8 × 6 cm present both above and below the inguinal ligament giving the appearance of “Groove sign of Greenblatt” []. External iliac lymph nodes were not palpable.\nGenital examination revealed phimosis. A firm, indurated, non tender mass of size 3 × 2 cm was felt through the prepucial skin on the glans penis, located on the 11’o-clock to 2’ o-clock position. There was no lymph edema of penis. Per-rectal examination was normal.\nMultiple tense bullae filled with clear fluid and erosions were present over upper limbs, lower limbs [], and trunk. A tense bulla was present over the shaft of penis, which eroded later. Nikolsky's sign and bulla spreading sign were negative. There were no oral erosions.\nWith the above clinical findings, a differential diagnosis of lymphogranuloma venereum (LGV) or SCC of penis with regional metastasis associated with bullous pemphigoid (BP) occurring as a para neoplastic phenomenon were considered.\nDark field smear was negative for Treponema pallidum. Tissue smear was negative for Donovan bodies. Gram's stain was negative for gonococci. IgG antibody for Chlamydia trachomatis (serovars L1, L2, L3) was negative. VDRL for syphilis and ELISA for human immunodeficiency virus (HIV) 1 and 2 were nonreactive. Mantoux was also negative. No abnormality was seen in his urine microscopy and pus culture reports. His laboratory investigations revealed anemia. Other blood counts, liver and renal function tests were normal. Tzanck smear taken from the bulla did not show acantholytic cells. His chest x-ray and ultra sound of the abdomen were normal.\nWedge biopsy of the ulcer in the right groin and from the penile growth showed ulcerated hyperplastic epidermis with severe dysplasia. The dysplastic epithelial cells invade the basement membrane forming nests with keratin pearls, consistent with keratinizing SCC of penis []. Skin biopsy taken from a tense bulla over the trunk, showed a sub epidermal bulla with mild lymphocytic infiltrate in the upper dermis consistent with BP.\nHence, a diagnosis of keratinizing SCC of penis with regional lymphnode metastasis and BP was confirmed. Patient was referred for surgical opinion and management.