Syphilitic Balanitis of Follmann-A Rare Case Report

Syphilitic balanitis of Follmann is a rare presentation of primary syphilis. It can occur before or after the appearance of primary chancre and some time without any associated primary chancre. We are reporting a case of syphilitic balanitis of Follmann, in a 23 years old heterosexual male, who presented with balanitis associated with single indurated lesion over coronal sulcus and few superficial ulcers over prepuce.


Introduction
S yphilis is a sexually transmitted disease with natural evolution through different clinical stages: primary stage, secondary stage, a latent stage and tertiary stage. Primary syphilis classically presents as a solitary, indurated, painless chancre. Atypical presentations, such as herpetiform ulcerations, balanitis and balanoposthitis can also be encountered. 1,2,3 We are reporting here a case of syphilitic balanitis of Follmann (SBF) with primary chancre.

Case Report
A 23-year-old unmarried male presented with erythema over glans penis, erosions over prepuce and coronal sulcus for 12 days. On physical examination, there was a single indurated lesion over coronal sulcus and multiple erosions without induration over prepucial skin were present. (Figure 1 a,

b,c)
Bilateral inguinal lymph nodes were enlarged, largest one was 2*2 cm in size. Lymph nodes were non-tender and firm in consistency. Rapid plasma regain test was 1: 32 and Treponema Pallidum Hemagglutination Assay titre was 1: 160. HIV status of patient and Gram stain from lesion were negative. Herpes simplex Virus antibodies IgG and IgM were negative. Patient denied history of any topical application. History of single, heterosexual, unprotected, unpaid sexual exposure 4 weeks before with unknown partner was present. According to NACO guidelines, a single dose of Injection Benzathine penicillin 2.4 MU was given which resulted in complete disappearance of lesion. (Figure 2)

Discussion
Syphilis is known as a great imitator in dermatological field. Though chancre is the classical presentation of primary syphilis, it can also present as balanitis in some cases. SBF, a rare presentation of primary syphilis, was first described in Budapest by a dermatologist, Eugene Follmann and hence given this name. 4 Audry and Chatellier published the case of erosive balanitis without chancre for the first time. It was associated with inguinal lymphadenopathy and serology positive for syphilis. 5 Follmann suggested that erosive balanitis can be a manifestation of primary syphilis in 1931 for the first time. In 1970 Degos considered SBF as a possible manifestation of so called 'syphiliome diffus primaire 'which means a dark reddish coloured diffuse induration of glans in a stage before or associated with chancre. 4 To best of our knowledge, less than 100 cases of SBF are reported till date where an erosive balanitis was only mucocutaneous lesion or balanitis preceded, accompanied or appeared later than chancre. 6 In 1975, Lejman and Starzycki published a patient whose balanitis was preceded by the appearance of syphilitic chancre. Probable explanation was, active penetration of Treponema pallidum through the epidermis with an hematogenous origin, and intraepidermal proliferation of this would lead to a massive accumulation of Treponema pallidum bacteria.
(analogous to condyloma lata). 7 Babu et al reported two cases of SBF in two homosexual patients, one with HIV-positive serology. 1  Pathophysiological mechanism behind the occurrence of balanitis as a manifestation of primary syphilis is still not defined clearly. Some authors have hypothesized role of Fuso-spirilli, associated with the spirochetes in clinical presentation as balanitis, while some authors noted that widespread Primary Syphiloma clinically appearing as dark red coloured and scaly lesion, localized around the chancre can involve whole of the glans penis and clinically present as balanitis. 4,9 Diagnosis of SBF is difficult even by experienced dermatologist taking into consideration that serology might be negative in early stages of disease. Differential diagnosis of SBF should always be considered in patient of balanitis or balanoposthitis. 5,9 Multiple, superficial and painful erosions which resembles more herpetic than syphilis should raise suspicion. 10 To conclude the treating dermatologist should consider a differential of SBF in cases of Balanitis and Balanoposthitis after ruling out other causes like candida albicans, herpes progenitalis.