Management of giant condyloma acuminatum on HIV/AIDS patient with limited healthcare facilities

Giant Condyloma Acuminatum (GCA) or Buschke-Lowenstein Tumour (BLT) is a unique variant of condyloma acuminatum. It usually appears in the form of a cauliflower tumour around the anogenital area with growth characteristic of aggressively pushing the dermal tissue below.1–3 The prevalence of this tumour in the general population is about 0.1%. At present, GCA cases' incidence tends to increase due to the increased rate of Human Immunodeficiency Virus (HIV) infection. GCA is more common in males than females, with a ratio of 2.3:1. In women, GCA appears more frequently in the area of vulva and sometimes in the perianal site. Histologically, GCA is similar to ordinary condyloma acuminatum, but GCA has an aggressive and destructive nature that is not found in a usual case of condyloma acuminatum.1,2,4 Only a few instances of condyloma acuminatum develop into GCA, with the most critical risk factors are immunodeficiency and anogenital sexual intercourse with multiple partners.5 Abstract Giant Condyloma Acuminatum (GCA) or Buschke-Lowenstein Tumour (BLT) is a unique variant of condyloma acuminatum. The incidence of this disease tends to increase due to the increasing prevalence of Human Immunodeficiency Virus (HIV) infection. Until now, there is no therapeutic guideline for GCA, and many therapeutic options are not available for one in limited healthcare facilities. We present one case of GCA in an HIVpositive woman treated in health centers with limited facilities in a rural area. We treat the patient by doing sitz bath with povidone-iodine 1%, simple excision with electrocautery for the tumour, adequate analgetics, regular wound care and zinc supplementation acts as immunotherapy. Complications of wound infection by candida caused the lengthy hospitalization of the patient. After discharge, the patient came for control every week; no other lump arises again, and the wound was getting better. A combination of conservative and surgical treatment followed by regular wound care can lead to a good result in the GCA case, even with minimal healthcare facilities.

Published by: Indoscholar Publishing Services (www.indoscholar.com) Although GCA cases include benign tumours, often in therapy, there are difficulties due to the size of the tumour, local invasion, and the increased rate of recurrence. Until now, there is no specific therapy guideline for GCA. Many treatment options, both medically and surgically, can be found in the literature with different results. 6 Many therapeutic options mentioned in the research require modalities that are often not available in rural areas.
We present one case of GCA in HIV-positive women treated in health centers with limited healthcare facilities in a rural area.

Case report
A twenty-eight years old woman came with a complaint of a pubic lump for six months, a lump resembling a cauliflower, large, flesh-colored, easily bleeding, and foul-smelling. The lumps initially appeared small, then grew more prominent, reaching the current size within four months. Pain was felt, especially when sitting. The patient admitted a history of multiple sex partners.
On physical examination, we found multiple verrucous tumours resembling cauliflower shape, blackish-grey with white spots, foulsmelling, easily bleeding with a size of 20 x 14 cm and a thickness of 5 cm covering the mons pubis area, labia majora, labia minora, vagina, inguinal and perianal.   Published by: Indoscholar Publishing Services (www.indoscholar.com) The patient was discharged on the 41 st day postoperatively with an excellent general condition; dry wounds and granulation were seen.
The patient came to control every week, and we did not find any signs of recurrence. The patient was recommended to routinely control every week until the third month postoperatively or suddenly if a lump arises again.

Discussion
Giant condyloma acuminatum (GCA) is a local mass with a slow, destructive, and large invasive growth pattern. Clinically, the mass is exophytic, with the shape of a cauliflower, which has a benign appearance on histopathology but can invade local tissue. 1 Giant condyloma acuminatum is a sexually transmitted disease that very rarely occurs. The incidence of this tumour is only 0.1% of the entire population. 2 A common problem for this case is that the large size of the tumour shows aggressive characteristics, with a high recurrence rate and has significant potential for malignant transformation.

Figure 5. Wound appearance two weeks after surgery
While GCA is histologically a benign tumour, which macroscopically resembles condyloma acuminatum, it may be difficult to distinguish between these two conditions, especially in the early stages of the disease. 7,8,9 Like ordinary condyloma acuminatum, Human Papilloma Virus (HPV) is the leading cause of this disease, especially types 6 and 11, while HPV types 16 and 18 are less frequent causes.
The decline in the immune system is one of the contributing factors of the disease. 2 In each case of GCA, the patient's immunological status must be examined. Serological testing for sexually transmitted infections, including HIV, syphilis, hepatitis B, and hepatitis C is mandatory. 6 In this case report, HIV infection caused a more severe disease of the human papillomavirus so that the lesions became more prominent and more invasive. Simple excision is also supported by Coreia's study, which suggested that minimally invasive techniques such as electrocautery can be safer and more cost-effective than surgery. However, these techniques limited only to noninvasive tumour cases and can be considered a good treatment option with a good response. The weakness of this technique is that patients usually have moderate depigmentation and few superficial atrophic scars. 3,6,8 After surgery, we administered analgesics and antibiotics as prophylaxis for postoperative infections. In the acute phase, the first three days, the patient was given a 2 mg morphine loading dose followed by 0.8 mg/hour plus an intravenous 30 mg of ketorolac preparations every 8 hours and oral paracetamol at a dose of 500 milligrams every 6 hours. By giving the analgesic, the patient became comfortable, and the pain felt was minimal. General anesthesia, regional analgesia, and infection control are priorities in all surgical treatments. Adequate local anesthesia and prescription of mild analgesics will minimize discomfort during the procedure and wound Published by: Indoscholar Publishing Services (www.indoscholar.com) healing. 11,12 Because of limited local anesthesia agents we had in our healthcare facilities, we optimize the analgesic drug use to comfort the patient while in treatment. We give two types of broadspectrum antibiotics considering the patient's low immune status caused by HIV infection. Unfortunately, we cannot do bacterial culture and sensitivity tests in our hospital, so we choose two empirical broadspectrum antibiotics, ceftriaxone, and metronidazole, to cover gram-negative, gram-positive, and anaerobic bacterial infection that may infect the postoperative wound.
We had to do regular wound care every other day because there is excessive debris in the postoperative wound and minimalized vaginal discharge that can interrupt the skin tissue's granulation process. The current principal for topical wound management is to eliminate the things that can inhibit wound healing by keeping the wound clean, to retain moisture, and protect the wound surface. 13 We usually start wound care by rinse the wound with natrium chloride 0.9% solution, then disinfect the wound with a povidone-iodine solution; we also do the vaginal hygiene procedure to remove excessive vaginal discharge.
After that, we remove the necrotic tissues and debris that occurred, and then we give topical antibiotic ointment and cover the wound with sufratulle before moist dressing was applied. Topical antibiotics are accepted as a safe and effective treatment for the treatment of wounds because it can reduce the possibility of temporary infections and keep the wound environment moisturized. 13 In this case, moist gauze was also provided in addition to wound care to maintain moisture and protect the wound surface. In a study conducted by Clare et al., 14 It was concluded that the risk of infection after surgery was reduced using topical antibiotics compared to the group given antiseptics or control groups. Topical antibiotics that can be used to accelerate wound healing in America and Europe, including one of them are gentamicin (Garamycin). 13,15 This patient had vaginal discharge caused by candida, which could disrupt the healing process of the wound. For this reason, a dose of 1000 mIU nystatin was administered intravenously to the patient to treat the cause, so that wound healing was not disturbed by fungal infections.
In this case, the patient is known to be HIV positive. Antiretroviral therapy was not administered yet because the patient's adherence to taking medicine is still not good. We decided to give zinc tablets at 10mg/kg/day as an immunomodulators. Zinc is an essential element for immune function. Zinc also has unique antiviral activity by crossing the double helix of viral DNA, thus inhibiting viral replication; and then, by deactivating viral surface glycoproteins to interfere with penetration into susceptible host cells. Zinc deficiency has been shown to cause decreased immunity to skin infections. 17,18 HIV causes immune system depression by mainly affecting T cells responsible for the body's ability to defend itself against foreign organisms. In HIV infection, zinc plays a unique role as an antioxidant, immune modulator, and maybe a direct antiviral agent. In-vitro zinc is found to inhibit cell death mediated by tumour necrosis factor, a cytokine associated with cell apoptosis and wasting syndrome in HIV. 18 Zinc can also be used for several dermatological conditions, including warts due to modulation actions on the function of macrophages and neutrophils, natural killers of cell or phagocytic activity, and various inflammatory cytokines. The administration of oral zinc with a dose of 10 mg/kg/day for two months is a modality effective for cases of recalcitrant warts. In a study conducted by Mrinal et al., 19 mentioned that oral sulfate zinc (10 mg/kg/day) given for two months at warts produced complete cleansing in 61% of patients in one month and 87% of patients after two months of therapy.