INTRODUCTION

Viral warts are caused by human papillomaviruses (HPVs), which infect both keratinized and non-keratinized squamous epithelia. They are transmitted through direct skin-to-skin or sexual contact. The global prevalence of genital warts (GWs) is common among individuals aged 20–24 years [1]. Syphilis is a chronic sexually transmitted infection caused by Treponema pallidum, transmitted predominantly through sexual contact. The WHO estimates about 7.1 million new syphilis cases annually among individuals aged 15–49 years worldwide [2]. In India, rising trends of syphilis are reported in recent years, particularly among men who have sex with men (MSM) [3,4].

CASE REPORT

A 19-year-old unmarried male presented to the Dermatology Outpatient Department with a three-month history of multiple, asymptomatic, raised lesions in the genital region. There was no history of dysuria, urethral discharge, fever, malaise, or other systemic complaints. Although he initially denied any sexual exposure, further questioning revealed multiple unprotected sexual encounters over the preceding 6 months, the most recent occurring two weeks prior with a known male partner. These encounters involved peno-anal and peno-oral contact, in both insertive and receptive roles. He also reported that his partner had multiple other sexual partners. Cutaneous examination revealed numerous verrucous papules and plaques arranged in a cauliflower-like configuration over the glans penis, coronal sulcus, preputial area, and scrotum, consistent with genital warts (Fig. 1a). Additionally, a single, firm, non-tender ulcer with an erythematous rim was noted on the glans penis (Fig. 1b). Multiple, discrete, non-tender, mobile, non-matted, shotty lymph nodes were palpable in the bilateral inguinal region. Examination of the oral cavity, perianal region, palms, and soles was unremarkable. Serological evaluation showed a reactive VDRL test and a positive TPHA. Screening for HIV, hepatitis B (HBsAg), and hepatitis C (HCV) was non-reactive. Correlating the clinical findings with the patient’s sexual history and serological results, a diagnosis of dual sexually transmitted infections—genital warts (HPV infection) coexisting with primary syphilis—was established. The patient was admitted and treated with a single dose of intramuscular benzathine penicillin G 2.4 million units (administered as 1.2 million units in each buttock). The patient was advised regular follow-up for planned management of genital warts.

Figure 1: a) Numerous verrucous papules and plaques arranged in a cauliflower-like configuration over the glans penis, coronal sulcus, preputial area, and scrotum, consistent with genital warts. b) Single, firm, non-tender ulcer with an erythematous rim noted on the glans penis.

DISCUSSION

Syphilis is a systemic sexually transmitted infection caused by Treponema pallidum, and its wide range of clinical presentations has led to it being called a great imitator. Genital warts, in contrast, are benign epithelial proliferations caused predominantly by low-risk human papillomavirus (HPV) types 6 and 11. The disruption of mucosal integrity by one STI facilitates the acquisition and transmission of another pathogen [5]. In the present case, the occurrence of genital warts and primary syphilis may be attributed to unprotected sexual exposure and multiple partners, both recognized risk factors for dual infections. Studies have shown that individuals with one STI have a 2–5-fold higher risk of acquiring another infection, including Treponema pallidum, Neisseria gonorrhoeae, and HIV [6].

The presence of genital warts may mask early syphilitic lesions, delaying diagnosis. By damaging the genital epithelial barrier and triggering inflammation, STIs facilitate the accumulation of HIV target cells and create a microenvironment conducive to HIV entry and infection [7]. This underscores the importance of comprehensive STI screening, including syphilis serology, HIV testing, and HPV evaluation, in any patient presenting with genital lesions. Effective management requires simultaneous treatment of all identified infections, counseling regarding safe sexual practices, and partner notification and screening to prevent reinfection and community spread.

CONCLUSION

This case is unique due to the coexistence of primary syphilis and genital warts in an adolescent male MSM—an uncommon presentation in the Indian literature. It underscores the increasing trend of early high-risk sexual behavior among youth and the potential for multiple concurrent STIs. The sequential appearance of lesions suggests mucosal compromise, facilitating dual infection. This case emphasizes the need for routine, comprehensive STI screening and targeted sexual health education in adolescents.

REFERENCES

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2.  World Health Organization. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Geneva:WHO;2021.

3.  Risbud A. Human immunodeficiency virus (HIV) &sexually transmitted infections (STIs) in India. Indian J Med Res. 2011;134:663-71.

4.  Sharma VK, Khandpur S. Rising trends of syphilis and other sexually transmitted infections in India:A review. Indian J Sex Transm Dis AIDS. 2020;41:123-8.

5.  Wasserheit JN. Epidemiological synergy:Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis. 1992;19:61-77.

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