[Question #4685] Is my growth a HPV wart or Syphilis lesion?

27 months ago

I had a single sexual encounter with a gay male who has multiple active partners. Our acts were: oral, rimming, dry-humping, kissing, and cuddling - no anal involved. He was my only partner as of the past six months. 

A month after, I found a lesion on the head of my penis. It was fleshy at first, but it became a slightly raised wart-like circle. When examined by a doctor, and he said it looked like an HPV- wart.

My second doctor said it looked almost like syphilis, but when I told her about the previous diagnosis, she then agreed with the HPV diagnosis. She prescribed me Imiquimod. I got an STD test and results were negative for full panel. She also gave me Doxycycline just to be safe.

I used Imiquimod for 6 weeks and the Doxycycline until gone. My lesion grew a dark dot in the center. This dot became rough and leathery, then it fell off, leaving a tiny crater-like ring. Over time the lesion healed with no recurrences and no other warts.

During that six-week period, I experienced other symptoms that I voiced to my doctor: chronic headaches, fatigue, flu-like symptoms, itchy rashes on arms, legs, and waist. These lasted for 3-4 weeks. She dismissed these as colds and unrelated sickness.

I spoke with the male partner and he said that he recently tested positive for stage 1 syphilis, which he got from another partner who was in stage 2 syphilis. He also claims that he received the HPV shots. I took this news to a 3rd doctor and he scheduled a second blood test for syphilis. This test came back positive. When I told the dermatologist about my sickness symptoms during the time of my wart, he thinks the growth may actually be from a syphilis infection.

I'm looking for your opinion: Do you believe my lesion would be HPV-related or caused by syphilis?

Thank you.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
Welcoem to the forum/ Thanks for your question.

First, genital warts rarely if ever appear within a month of catching HPV. Generally it takes 2-6 months. So if it is or was a wart, it was from a previous sexual exposure. But I'm betting against warts -- most new genital warts are multiple, rarely only one; and it sounds like the response to imiquimod wasn't very dramatic. Most warts clear up rapidly and entirely within 3-4 weeks of that treatment. Of course as a sexually active gay man, you can assume you have been infected with genital or anal area HPV, probably several times; it's rare for any sexually active person to not have HPV. So no big surprise either way.

Much more important, it sounds like you have syphilis, if I correctly understand that your more recent syphilis blood test was positive. Since your earlier test was negative, it is apparent you caught the syphilis around the time of your exposure to your infected partner, so it all comes together. An atypical aspect is that you went on to develop the positive result despite taking doxycycline -- that might have aborted the infection before a positive blood test developed. However the main thing now is that you need treamtnet with long acting penicillin (benzathine penicillin) -- I assume that has been done or will be done very soon. Anyway, having syphilis is a far more important issue for you than HPV or warts. Syphilis kills or cripples; warts and HPV generally are minor inconveniences.

In view of this, it is possible your initial genital lesion ideed was syphilis, as your dermatologist suspects. Your description is not typical, however, and probably you'll never know for sure. But another aspect to all this is that if you had sex with anyone else after the exposure described in the opneing line of your question, those person(s) also need to be informed and evaluated for (and pobably treated for) syphilis.

I hope this information is helpful, and that you have been treated for syphilis. Let me know if anything isn't clear.

27 months ago
Thanks for your response. 

Yes I can confirm that my second test came back positive for syphilis, whereas my first one from earlier (a part of the full STD screening) came back negative. Perhaps I had taken the test in too quickly in response to the lesion (I took this STD screening about a month or 1.5 months after my interaction with that partner).

When I asked my dermatologist: "Why did my test come back positive for syphilis after I had already been treated with 2 weeks of Doxycycline?" his explanation - at a rudimentary level - was that the test detects for antibodies present in the body in response to the syphilis infection. Having those antibodies present doesn't mean the infection is necessarily still there, but rather that it had been there previously and the antibodies will be present for quite some time due to the immune response. He said he would consider me treated since I took the Doxycycline, but still recommended I get tested at 6 months and 12 months in the future for syphilis again. I asked my second doctor, the one who prescribed me the Doxycycline, and she also said I could be considered treated. 

Also -- I forgot to mention one symptom I had during my 'sickness' phase, which was having extremely swollen lymph nodes, especially near by groin. This info seemed to interest my dermatologist and its what may have caused him to re-evaluate my HPV diagnosis onto a syphilis one, as he said HPV infections don't normally cause that.

1. So just to confirm, you would recommend a penicillin shot, even though I took 2 weeks of Doxycyline earlier from my second doctor?

2. How long after receiving syphilis treatment may I consider myself non-infectious and cured?

3. Out of curiosity, since this has been about 4 months since my exposure to syphilis, do you believe I had have any irreversible damage done to my organs or body yet? Or did I catch this and respond in-time before that develops?

Thanks Dr. Handsfield.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
The timing indeed is a bit peculiar. I'm wondering whether your postive test is quite weakly positive, and whether you might have been infected a long time ago, witih a false negative result on the first test. The likelihood of this depends laregely on exactly what syphilis test(s) were done each time, such as enzyme immunoassay (EIA, ELISA), sometimes listed on lab reports as IgG (or IgG/IgM); or rapid plasma reagin (RPR) or venereal disease research laboratory test (VDRL). If you can let me know exactly what test was done and the precise reported result each time, we can sort this out.

If these results seem to confirm a new infection, and if you took doxycycline for at least 2 weeks in a dose of 100 mg twice daily, I would agree with your dermatologist that no additional treatment is needed. If it appears to be a chronic infection, then it would have to be 4 weeks of doxycycline for reliable cure. In that event, you also would need a lumbar puncture (spinal tap) to rule out asymptomatic neurosyphilis. My guess (and my hope) is that this will sort out as most likely a new infection, i.e. 2 weeks doxy OK and no LP needed.

1) No need for penicillin at this time, if you had 2+ weeks of doxy.

2) You were non-infectious within 1-2 days of the first dose of doxycycline.

3) Almost certainly no lasting damage. Even if it turns out to likely be a chronic infection, without significant symptoms, it is unlikely you have suffered any sort of serious outcome.

I look forward to hearing the blood test details, if you'd like to work things out in more detail. If you choose not to do this on the forum, at least discuss all this with your dermatologist and/or other doctor(s); or consider consultation with an infectious diseases or STD specialist. With any of those,  you could consider printing out this thread as a framework for discussion.
27 months ago
Hello Dr. Handsfield,

I have some results to your questions:

I've asked the clinics about the two syphilis tests that were performed and they were both RPR tests, spaced 2.5 months apart.

Unfortunately, I was not able to gather specific result numbers, as the clinics were asking me to fill in medical release forms (but I would be willing to gather those if that is important) -- I'm responding now since it would have required me a lot of effort to show up in-person to both clinics which would've taken me a week or two to complete around my schedule. 

Regarding my tests, I took the first RPR test about 2 months after my exposure to the partner who carried syphilis, and that one was labeled as "negative" on my reports. I took the second RPR test 2.5 months after the first one (so 4.5 months after initial exposure) and this one came back "positive". If it means anything, it also says "T palladium Antibodies - LC" on the first test. The second test I couldn't get detailed information from the nurse.

Regarding my Doxycycline treatment, I wasn't able to obtain the prescription due to financial/timing difficulties, and only began taking them about a month after my initial diagnosis. Basically, my antibiotic treatment did not happen immediately, there was a period my new syphilis may have been left to take its own course.

1) I know that I've been considered cured at this time, but would there be any harm in requesting my doctor to prescribe me another 2 weeks of Doxycyline just to be completely sure I am cured? 

2) Additionally, would there be any harm in getting a penicillin shot at this point for the same reason as above (to be sure I am cured).

3) The lumbar puncture sounds rather frightening, but if you feel that it would be a good idea for my safety to get that procedure I'll look into it. Based on the information so far, how much would you encourage me to seek getting that done?

I undertand this is also my final allotted response on this thread, but I may consider buying another response if you believe it's important I stay engaged on this.  Thanks for all your help!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
Regardless of what the doctor or clinic said, the first test apparently was an IgG test, not RPR (indicated by the terminology "T. pallidum antibodies"). Some clinics or offices may request RPR when they submit a specimen, but most labs automatically do IgG first and RPR only if the IgG is positive. In any case, the timing is inconsistent witih the exposure -- that is, if you had acquired syphilis, either IgG or RPR would definitely be positive at 2.5 months. If the genital lesion occurred during that same interval, that negative blood test also proves it was not a chancre or other syphilitic lesion.

The IgG tests sometimes give false positive results. Probably the lab already worked that out. If positive, the lab probably did an RPR and perhaps another test (e.g., TPHA or other). Neither RPR alone nor IgG alone ever is sufficient to diagnose syphilis -- the result always must be confirmed by additional testing. My guess that was done and negative, but you'd have to sort that out with the doctor or clinic. If syphilis WAS confirmed when the second blood test(s) were done, then you acquired it sometime after the exposure described above. If things remain unclear after you discuss it again with the doctor or clinic, then it would be reasonable to have anohter blood test at this time, and then rely on that result going forward.

1) Since you probably didn't have syphilis at all, I see no need for additional treatment. And even if you did, almost certainly it was recently acquired and hence no need for more than 2 weeks treatment.

2) Same for penicillin. No need.

3) LPs aren't something to do for fun, but really no big deal. When we do them in my STD clinic, I tell patients that the overall discomfort and stress level is comparable to the average dental visit. And serious side effects are extremely rare. In any case, you definitely don't need one, so no worries.

I think you can safely let this go with no further worries about syphilis -- but follow your doctor's advice if any uncertainty remains. Or, as implied above, consider consulting with an infectious diseases or STD specialist.

I hope the discussion has been helpful. Best wishes.