Diagnosis at first glance: bladder parachute in an HIV-infected patient

Abstract

The endocervical cytology and the histology of the biopsies revealed low-grade dysplasia with acanthosis and hyperkeratosis (Figure 1) as well as the presence of abnormal cells in the stratum granulosum with irregular nuclei and large cytoplasmic vacuoles (koilocytes) (Figure 2). These findings are virtually always associated with human papillomavirus (HPV) infections. Papillomavirus virions consists of a doubledstranded supercoiled circular DNA molecule, enclosed within a capsule of viral protein with no outer membrane. There are three main types of lesions caused by HPV: cutaneous (plantar warts, Verruca plantaris), epidermal (epidermodysplasia verruciformis) and genital (flat condylomas, giant condyloma (with or without Squalous malignancy) or Buschke–Lowenstein tumor, condylomata acuminata (CAB) and high-grade squamous intraepithelial lesion). HPV is transmitted by physical contact with infected individuals or with objects contaminated by the infectious virus. The main mode of transmission of genital HPV is sexual contact. The HPV types 6 and 11 are responsible for 90% of cases of condylomata acuminata. This patient represents the second case of CAB of the bladder with recurrent urinary infections in an HIV-infected patient. Bladder and urethral (5–23%) infiltrations by HPV have been described in immunosuppressed patients. The prevalence of CAB in HIV patients is unknown, and only one previously reported case was found in the reviewed literature (MEDLINE 1966–2000). The method of choice for diagnosing HPV is nucleic acid hybridization; however, cytologic or histologic verification of HPV-related disease was considered sufficient until recently. Deeper biopsies are required in the case of wide lesions, in order to eliminate malignancy and avoid invasive cancer of the cervix. Initially, local lesions warrant conservative modes of treatment such as transurethral resection, electrocoagulation, and intracavitary chemotherapy; however, radical excision of the bladder is the elective therapy in cases of diffuse injury. Recurrences and/or malignancies are frequent, and a close follow-up of the course of the lesions is mandatory.