Unexplained Giant Genital Enlargement: Is It Due to Inverse Psoriasis?

Figure 1. A healthy 54-year-old man previously presented to vascular surgeons with a 4-year history of swelling of the penis and scrotum was scheduled for ultrasound evaluation in the angiology office. At presentation, there was a giant enlargement of the penis and scrotum, without swelling of the legs (A). The penile ultrasound was negative for vascular abnormalities and/or thrombotic complications (B). A diagnosis of chronic lymphatic disease was suspected; thus, a lymphoscintigraphy was performed (C). This test was normal, showing a good visualization of major lymphatics. The patient had a history of psoriasis, with a documented previous event of flexural psoriasis, as shown in (D) (axillary fossa) and (E) (left and right gluteus and intergluteal cleft), also involving his genitals with secondary infection 4 years before. Since that infection, his genitals progressively increased in size, and despite medical treatment and different surgical evaluation, the patient’s symptoms did not resolve, with marked disability related to walking and sexual activity. The diagnostic work-up for filariasis was performed as soon as the genital enlargement started, with negative results (direct detection in the blood, antigen detection and molecular diagnosis by PCR). The patient reported that, before experiencing penis enlargement, an acute phase of psoriasis occurred with signs of infection, as diagnosed by the family practitioner, and because of that, empirical antibiotic treatment was started. Taking into account the negative results of the test for filariasis, and the absence of vascular obstruction (as shown by the Doppler evaluation) as well as lymphatic obstruction (as shown by the lymphoscintigraphy), the role of inverse psoriasis in generating this process was postulated.