Bowen's disease on two different unrelated anatomical sites (genitals and nail) in succession in an immunocompromised patient

Abstract

Bowen's disease (BD) is a premalignant condition. Its exact etiology is unknown but chronic arsenic and sun exposure, and human papillomavirus infection is known predisposing factors. Pigmented lesions of BD represent 1.7%-5.5% of all BD cases. BD in the nail unit is challenging due to its varied clinical presentations such as fissure, ulceration, warty lesion, paronychia, onychocryptosis, and nail dystrophy. We present the case of a 43-year-old married, immunocompromised male (HIV), with a CD 4 count of 478, on tenofovir, atazanavir boosted with ritonavir regimen, known diabetic presented with multiple asymptomatic discrete, rounded, hyperpigmented verrucous papules on both surfaces of shaft of penis and scrotum and a single, 4 cm × 3 cm, irregular, smooth surfaced, hyperpigmented plaque, on the base of the penis extending to the upper part of the scrotum of 1-year duration with history of multiple unprotected sexual exposures with unknown female partners. Regional lymphadenopathy and systemic complaints were absent. Biopsy from hyperpigmented verrucous papule and hyperpigmented plaque was consistent with verruca vulgaris and pigmented Bowen's disease, respectively. The patient was lost to follow-up. Ten months later, he presented with longitudinal melanonychia with a subungual hyperpigmented mass protruding beyond the distal nail margin near the lateral nail fold of the right middle finger nail with an absent Hutchinson's sign. Longitudinal excisional biopsy of nail lesion was consistent with BD. He was started on 5-fluorouracil 5% for BD of genitals and podophyllin application for verruca vulgaris with remarkable improvement in both the lesions and there is no recurrence of nail lesion after 9 months of excision.

Keywords: Bowen's disease; longitudinal melanonychia; pigmented variant.

Figure 1

(a and b) Multiple, discrete, rounded, hyperpigmented verrucous papules, ranging from 3 to 5 mm on dorsal and ventral surfaces of the shaft of the penis. (c) Single, 4 cm × 3 cm, irregular, smooth surfaced, hyperpigmented plaque, on the base of the penis extending to the upper part of the scrotum. (d) (H and E, ×40): Biopsy from hyperpigmented plaque showed acanthotic epidermis with atypical keratinocytes spanning the full thickness of the epidermis giving rise to a windblown appearance with intact basement membrane and dermal melanophages. (e) (H and E, ×400): Biopsy from hyperpigmented plaque showed atypical keratinocytes with intact basement membrane and dermal melanophages

Figure 2

(a and b) The right middle finger nail showed a longitudinal melanonychia involving < 1/4^th of the nail with a subungual hyperpigmented mass protruding beyond the distal nail margin. (c) (H and E, ×40): Longitudinal excisional biopsy of nail lesion showed thickened nail plate, acanthotic epidermis, and atypical keratinocytes spanning the entire epidermis. (d) (H and E, ×400): Longitudinal excisional biopsy of nail lesion showed atypical keratinocytes