Rohit Agrawal, MD1, Bashar M. Attar, MD, PhD2, Hemant Mutneja, MD1, Muhammad Majeed, MD1, Tejinder Randhawa, DO1, Yazan Abu Omar, MD2, Oscar Rivas Chicas, MD1
1John H. Stroger, Jr. Hospital of Cook County, Chicago, IL; 2Cook County Health and Hospital Systems, Chicago, IL
Introduction: Rectal pain and hematochezia are common symptoms of anorectal pathology. Sexually transmitted infections such as gonorrhea, chlamydia and syphilis are often implicated as infectious etiologies of such symptoms in men who have sex with men. We report a case of young male who presented with rectal pain, hematochezia and weight loss and was concomitantly diagnosed with syphilitic proctitis and HIV.
Case Description/Methods: A 35-year-old bisexual male presented with a 9 months history of rectal pain, hematochezia and involuntary 30 pounds weight loss. Initial laboratory tests revealed normocytic anemia with a hemoglobin of 9.2 gm/dl, ferritin of 81.1 ng/ml, a positive HIV test with CD4 count of 50 cells/microL. Colonoscopy demonstrated large, semi-circumferential ulcers around 10 cm from the anal verge(Figure 1). Biopsy of the ulcerated lesions revealed chronic active colitis with cryptitis, crypt abscess and destruction. Numerous spirochetes were identified on Warthin-Starry and Steiner stains in the ulcerated mucosa and random biopsies of colon (Figure 2). Enzyme immunoassay (EIA) and rapid plasma reagin (RPR) for syphilis were positive with a RPR titer of 1:256. He was treated with benzathine penicillin 2.4 million units intramuscularly once a week for 3 weeks for syphilits proctitis along with anti-retroviral medications. He had resolvement of symptoms on subsequent follow up visit at 6 months with a repeat RPR of 1:64 suggesting an adequate serological response.
Discussion: Anorectal syphilis can either present as a chancer in primary infection or proctocolitis as a manifestation of secondary infection. Establishing a diagnosis often requires endoscopy for visualization of colonic inflammation, histopathology for documentation of spirochetes and serological test such as EIA and RPR to identify Treponema palladium. The histopathological features of syphilitic proctitis can mimic that of inflammatory bowel disease in which case the microbiological stains such as Warthin-Starry and Steiner aid in diagnosis. As proctocolitis is a manifestation of secondary syphilis, treatment includes Penicillin G benzathine 2.4 million units IM once. With the rise in the MSM population, cases of syphilis are more frequently being encountered and therefore syphilitic proctitis should be a common differential in such patients presenting with lower gastrointestinal symptoms.
Citation: Rohit Agrawal, MD; Bashar M. Attar, MD, PhD; Hemant Mutneja, MD; Muhammad Majeed, MD; Tejinder Randhawa, DO; Yazan Abu Omar, MD; Oscar Rivas Chicas, MD. P0142 - A CASE OF SYPHILITIC PROCTITIS IN A NEWLY DIAGNOSED PATIENT WITH HIV. Program No. P0142. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.