The lesion of Condylomata Acuminata popularly known as venereal warts are lesions which are generally diagnosed based on their warty appearance. The mode of treatment range from application of podophyllin to surgical excision by cauterization. A case of unusual presentation of giant Condylomata in a 26 year old, single, nulliparous, retroviral disease positive woman is presented and the literature reviewed. She presented with 18 months history of rapidly progressive vulval swelling and associated itching, contact bleeding, malodorous vaginal discharge and difficulty in walking. She had previously been treated with podophyllin without success. The growth measured 40×30 cm and was successfully excised with no evidence of malignancy.
Keywords: Giant genital warts, human papilloma virus, retroviral disease positive
Condylomata Acuminata are commonly transmitted through sexual intercourse or where there is labio-scrotal contact.  They are hyperplastic, pedunculated or sessile growth which appear red or pink, forming soft exuberant masses strangulated at their bases.  They are caused by the low serotype of human papilloma virus (HPV).  HPV was identified with the development of molecular biology techniques as the virus responsible for condyloma acuminata.
Giant lesions could develop in immune suppressive state such as HIV and HTLV infections, debilitating illness or in pregnancy.
Reports from other of parts of Nigeria (Enugu), gave an incidence of 2.7 per 1000 women. 
Treatment options could either be medical by the use of podophyllin, 5 fluorouracil or by surgical excision. In 20-30% of women that are not immunocompromised however, the growth may spontaneously resolve within three months. ,
We present a case of 26 year old HIV positive single lady with a late presentation of giant condyloma acuminata from low-resource setting that was successfully treated with surgical excision.
A 26 year old nulliparous, presented to the gynaecology clinic on 20 th June 2011 with an 18 months history of progressive vulval swelling, associated itching, contact bleeding and malodorous vaginal discharge. The swelling was so huge that she had difficulty in walking [Figure 1]. She was a known retroviral disease on highly active anti-retroviral drugs (zidovudine, lamuvidine and nevirapine) over the last 12 months. She was seen earlier at a peripheral hospital where she was placed on podophyllin without improvement.
Examination revealed a young woman, mildly pale, pulse rate of 96 beats/minute and blood pressure of 100/70 mmHg. She had a huge florid vulval growth with malodorous vaginal discharge. The growth had covered the introitus, measuring about 40×30 cm.
An assessment of giant vulval warts in a known retro-viral disease positive patient was made. The patient’s haemoglobin was 9.2 g/dl; liver function test, urea, electrolytes and creatinine were within normal limits. Her CD4 count was 199 cells/ul. Biopsy of the lesion confirmed condylomata acuminata.
She was admitted, transfused with two units of blood, counselled and prepared for simple vulvectomy.
Intraoperative findings were huge vulval warty growths measuring about 40×30 cm completely covering the whole vulva from the mons pubis up to the anal verge and obliterating the vaginal introitus with malodorous discharge. Both inner thighs were free of warty growths. The cervix was free of warts.
Simple vulvectomy was carried out and the vulva skin wound was closed primarily using nylon 1. She was commenced on intravenous ceftrixone, metronidazole and intramuscular pentazocine. She made a remarkable recovery and was discharged 10 days later. Further follow-up visit at the gynaecology clinic revealed a satisfactory healed vulva and no evidence of further growth; the histology result did not show evidence of malignancy.
Giant Condyloma acuminata was first described by Buschke and Loewestein in 1925.  This condition is described as large exophytic cauliflower lesion affecting the anogenital mucosal surface, and is caused by human papilloma virus (HPV).  It has a benign appearance and rarely metastasizes. Several studies have shown that Condylomata expands by expansion rather than by infiltration. , They are almost always associated with infection with low risk HPV 6 and 11.  Often, the giant condyloma acuminata have rich blood supply and mild trauma on the surface may lead to severe bleeding that may be unresponsive to the routine methods of achieving haemostasis such pressure, ligation or electric coagulation.  The growth is more rapid in individuals with immunosuppression such as HIV, HTLV and also tend to grow rapidly in pregnancy. , Our patient is a HIV patient diagnosed two years prior to presentation, which accelerated the growth of this lesion.
Giant condylomata are not usually seen nowadays in developed nations, but such cases are still seen in the under-resourced countries like Nigeria. This is because most patients do not present early for treatment to the hospital. Our patient was initially seen when the lesion was small at a peripheral clinic, but failed to continue treatment with the prescribed podophyllin. She only presented to us when the swelling became so huge that she was unable to walk properly [Figure 1].
Condyloma acuminata can be treated with medical therapy or surgical intervention. Medical therapy with Podophyllin salts, Imiquimod,  Sinecatechins  and Five-flourouracil  have all been used with varied results. Podophyllin is still considered one of the best medical therapies. The reported effect of podophyllin is to incite mitotic activity in the prickle cell layers of the lesion and to arrest mitotic activity at the same time.  Size of the growth is the major impediment to medical treatment.
Surgical treatment in the form of simple excision with a tumour free margin of 1.5 cm with either scalpel or laser is considered optimal treatment for giant condylomas.  Other surgical options include carbon dioxide laser therapy, electro surgery and cryotherapy.  This patient was counselled for simple vulvectomy which she had and was discharged 10 days after treatment [Figure 2]. Although this patient had a successful outcome, the lesson here is for patient to be properly counselled, so that they can present to hospital early to be offered optimal treatment.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]