The clinical manifestations in the

The clinical manifestations in the current study included a circumscribed salinomycin lesion in an unclothed area without evidence of dissemination or cellular immunity deficiency. A tissue culture of C neoformans var. neoformans and a good response after 1 month of treatment were consistent with a diagnosis of PCC. Although no clear source of infection was identified, chronic scratching was a plausible portal of entry. Even in immunocompetent patients, a chronic course of indolent but unprotected scratching wounds should always raise the suspicion of atypical infections, including PCC.
Introduction Giant condyloma acuminatum (GCA), also known as the Buschke–Löwenstein tumor, is a rare sexually transmitted disease associated with human papilloma virus (HPV) infection, mostly Type 6 or 11. The tumor is typically located on the glans penis. However, GCA may be discovered on any anogenital mucosal surface, including the vulva, vagina, anus, rectum, and scrotum. These tumors are characterized by rapid growth, large size, local invasion, lack of spontaneous resolution, poor response to conservative therapy (e.g., cryotherapy), and a high recurrence rate. The risk of neoplastic transformation into squamous cell carcinoma has been reported. In 1925, Buschke and Löwenstein reported a GCA as a benign carcinoma-like condyloma acuminatum. In 1965, the first case of anorectal GCA was reported by Dawson et al. Several authors have suggested that GCA is a type of low-grade squamous cell carcinoma, but others disagree. The controversy centers on the clinically malignant growth pattern that, nonetheless, shows benign histological features. The characteristic histological feature is a well-differentiated hyperplastic epithelium with minimal atypia. Hyperkeratosis and parakeratosis with a prominent granular layer and koilocytic changes have also been noted. An endophytic growth pattern with increased mitotic activity in the basal layer is evident, but this excludes the basement membrane and neural or vascular invasion. Traditional therapy includes surgical excision, CO2 laser treatment, fulguration, chemotherapy, radiotherapy, and immunotherapy.
Case presentation A 56-year-old Taiwanese man was admitted to the dermatology inpatient ward at Kaohsiung Medical University Hospital. A mass had been present over the anal region for the past 9 months (Figure 1A), and the patient reported associated pain and changes in bowel habits; he also had difficulty walking and defecating. Dermatologic examination revealed a flesh-colored, cauliflower-like tumor mass involving the anal area, and some verrucous papules scattered across the buttocks and scrotum. The tumor measured 10 × 5 cm2. Skin biopsy revealed severe hyperkeratosis, papillomatosis, and parakeratosis with koilocytic changes. Increased mitotic activity was observed, but without any malignant changes. In addition to exophytic growth, endophytic invasion was apparent, with an intact basement membrane. Mild lymphocyte infiltration and blood vessel proliferation were apparent over the upper dermis (Figure 2). To avoid anal function impairment, topical photodynamic therapy was performed. After gentle abrasion of the keratosis, we applied 16% methyl aminolevulinate (Metvix; Galderma, Watford, Herts, UK) to the lesions and surrounding 5–10 mm of perilesional normal skin by occlusion with a polyvinyl chloride dressing. After 3 hours, the dressing was removed and the lesion was irradiated using a light-emitting diode (LED) (Aktilite CL16; Galderma). The peak emission of 630 nm was used and the total dose was 37 J/cm2. After this single treatment session, a month was allowed to elapse. At the second consultation (1 month after the first treatment), the tumor size was found to be reduced and the patient received a second application of photodynamic therapy (Figure 1B). Another month elapsed, and we then applied Metvix and examined the lesion. We used the FotoFinder dermoscope dynamic (FotoFinder Systems GmbH, Bad Birnbach, Germany; www.fotofinder-systems.com/dermoscope), which can detect the red fluorescence of protoporphyrin IX accumulation in an infected area after the uptake of aminolevulinate.