Background Follman balanitis as an initial presentation of primary syphilis is well described and syphilis is a known cause of lymphocoele. Inguinal buboes are commonly seen in chancroid and lymphogranuloma venereum but not in syphilis. We report an unusual case of syphilis presenting with balanitis, lymphocoele and bubo together.
Case report A 24-year-old man presented with a painless lump in the right groin for 2 weeks and a swelling and red spot on the glans penis for 2 days. He had three casual male partners all within the UK in the preceding 3 months and had an episode of unprotected insertive anal intercourse 2 months before, with no episodes of vigorous intercourse or masturbation. There was a 2 cm fluctuant non-tender lymph node in the right groin, a non-tender cord-like swelling under the coronal sulcus on the same side and a well defined erythematous patch with an infiltrated base on the glans. No other local or systemic signs. A dark field microscopy preparation from the balanitis was negative; one from the lymph node aspirate showed characteristic motile spirochaetes typical of Treponema pallidum; a positive Treponemal EIA-IgM and RPR (titre of 1:4) confirmed a diagnosis of syphilitic bubo with Follman balanitis and lymphocoele. The lymph node aspirate on gram staining showed pus cells. Chlamydia NAAT (SDA) was negative from the balanitis and lymph node aspirate. The rest of the STI screen including HIV serology was negative. He was treated with Benzathine penicillin 2.4 m IU IM weekly for 2 weeks with clinical resolution. All three contacts had been informed.
Discussion (1) Balanitis is a common presentation in GUM clinics and this case highlights the importance of including syphilis in the differential diagnosis. (2) Early syphilis can cause lymphocoele and inguinal bubo. (3) Aspiration of lymph nodes for dark field microscopy examination enabled point of care diagnosis and facilitates early treatment and partner notification.