Diagnostic uncertainty in a patient with severe hidradenitis suppurativa revealing Buschke-Löwenstein tumor

Buschke-Löwenstein tumor (BLT), also known as giant condyloma acuminatum, is a rare human papillomavirus-associated lesion characterized by locally aggressive growth with the potential for malignant transformation. Diagnosis may be particularly challenging when BLT arises in the setting of severe chronic inflammatory disease. We present a 44-year-old man with severe hidradenitis suppurativa, well-controlled HIV infection, recurrent gluteal abscesses, and chronic sacral osteomyelitis who presented with worsening perineal pain and chronic drainage. Although imaging demonstrated extensive infiltrative soft-tissue disease suspicious for neoplasm with superimposed infection, the patient's severe chronic inflammatory disease, recurrent abscesses, and chronic osteomyelitis created substantial diagnostic uncertainty. After the patient did not improve with broad-spectrum antimicrobial therapy, open biopsy of a large fungating perianal lesion established the diagnosis of BLT. This case highlights the diagnostic uncertainty that may arise when BLT coexists with severe hidradenitis suppurativa, emphasizing the importance of early tissue biopsy when clinical features are atypical or progressive.