The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Circinate Balanitis
A B

A
37-year-old man presented to the emergency department with Ana Pulido-Perez, M.D.
a 7-day history of genital lesions. He also had weight loss (approximately Ricardo Suarez-Fernandez,
4 kg), fatigue, and back pain but no gastrointestinal symptoms. Two M.D., Ph.D.
months before presentation, he had had dysuria and urethral discharge, both of Hospital General Universitario
which resolved spontaneously. He took no medications on a regular basis, and his Gregorio Maranon
medical history was unremarkable. Physical examination revealed erythematous, Madrid, Spain
ana.pulido@salud.madrid.org
well-demarcated annular plaques on the glans penis and meatal inflammation
(Panels A and B). He also had conjunctival injection in both eyes. The patient had
a positive test result for infection with the human immunodeficiency virus (HIV),
with a viral load of 15,000 copies per milliliter. His CD4 T-cell count was 172 per
microliter. A test for rheumatoid factor was negative, and a test for HLA-B27 was
positive. A serum sample was obtained to evaluate the patient for infection with
hepatitis B virus, hepatitis C virus, and syphilis; the test results were negative.
Infection with Chlamydia trachomatis was detected on nucleic acid amplification
testing with a sample from a urethral swab. A single oral dose of 1 g of azithro-
mycin was administered, and antiretroviral therapy was started. During the next
month, the circinate balanitis persisted. Topical tacrolimus 0.1% was administered,
and the patient had complete remission within the next 10 days.
DOI: 10.1056/NEJMicm1603913
Copyright 2017 Massachusetts Medical Society.

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