EP239 - Pilonidal Disease in Association with Condyloma Acuminata in an Immunosuppressed Patient: Report of a Case and Review of the Literature

Purpose/Background: HPV infection is characterized by high prevalence and incidence rates, with anogenital condylomas being one of the conditions frequently managed by colorectal surgeons. However, the association between condyloma acuminata and pilonidal disease, has been scarcely documented in the scientific literature. To date, only two cases have been reported in HIV-positive patients with malignant degeneration, as well as two cases in immunocompetent patients—one related to a Buschke-Lowenstein tumor and the other to an inverted verrucous carcinoma (1-3). This lack of documentation underscores the exceptional nature of this association. Therefore, the objective of this study is to report the rare coexistence of condyloma acuminata within a fistulized pilonidal sinus in a patient undergoing immunosuppressive therapy.

Methods/Interventions: A 33-year-old female patient with a history of renal transplantation 4 years ago due to chronic kidney disease secondary to renal hypoplasia, and anal condylomatosis treated with electrofulguration 2 years ago. The patient presents for evaluation of surgical resection of anal condylomas previously managed with imiquimod, reporting pruritus in a sacrococcygeal lesion with one year of evolution. Proctological examination reveals anal condylomatosis with acetopositive lesions measuring up to 2 cm, along with a 3 cm exophytic lesion in the natal cleft, accompanied by an adjacent fistulized pilonidal sinus containing multiple papillomatous lesions. (Fig. 1) A diagnosis of chronic pilonidal disease associated with condyloma acuminata is established. Following endoanal ultrasound to rule out fistulous extension to the anal canal or rectum, surgical intervention using the Bascom procedure is performed. Histopathological analysis confirms pilonidal disease associated with condyloma acuminata, with no evidence of malignancy. (Fig. 2)
The patient was followed up for 8 months postoperatively, demonstrating favorable progression without requiring further surgical interventions or hospitalizations related to the condition.

Results/Outcomes: Pilonidal disease in immunocompromised patients, whether due to HIV or transplantation, has been insufficiently studied. This clinical case is notable for lacking malignant degeneration, unlike previously reported cases where pilonidal disease associated with condyloma acuminata in immunocompromised patients exhibited malignant degeneration. This contrasts with the lower incidence of malignancy in immunocompetent individuals.
The duration of pilonidal disease as a risk for malignant transformation is around 20 years in immunocompetent patients, compared to 10 years in those with HIV (1). One case of malignant degeneration following renal transplantation showed only 2 years of evolution (5). In our case, the brief disease course prior to treatment may have been protective, highlighting the importance of timely intervention. Up to 40% of renal transplant patients develop skin cancer after 15 years, suggesting that early surgery could protect against such outcomes in this area (6).

Conclusion/Discussion: Based on the findings presented in this case report, which showed no evidence of malignancy, it may be suggested that the coexistence of immunocompromise and HPV in pilonidal disease are risk factors for progression to carcinoma, with time being a key factor in its prevention. This highlights the need for future research to enable timely diagnosis and treatment in this patient population.

Figure 1.
Pilonidal Disease with condyloma acuminata

Figure 2.
A) Pilonidal sinus biopsy showing squamous epithelial tissue and marked acanthosis. Magnification 5x B) Squamous epithelium showing coilocytes with irregular nuclei, nuclear hyperchromasia, binucleation and periniclear halos in superficial keratonocytes. High magnification 40x. C) Squamous epithelium with papillary exophytic squamous hyperplasia and hyperkeratosis. Magnification 5x