University of Central Florida College of Medicine Orlando, FL
Irene T. Riestra Guiance, MD, Ernesto Robalino Gonzaga, MD, Richard Henriquez, MD, Steven M. Char, MD, Wojciech Blonski, MD; University of Central Florida College of Medicine, Orlando, FL
Introduction: Proctosigmoiditis is usually caused by gonorrhea, herpes simplex, syphilis, and less commonly by lymphogranuloma venereum (LGV) which can pose diagnostic difficulties as it is often not included in a differential. Presumptive diagnosis of LGV may be made based on symptoms such as tenesmus and constipation, especially in HIV infected males as more than 70% of proctitis patients have coinfection with HIV. If left untreated, strictures and lymphorrhoids can occur. Clinical, endoscopic and histopathological findings are nonspecific and can mimic malignancy or IBD, thus necessitating a high index of suspicion.
Methods: A 55 year-old homosexual male with a medical history of well-controlled HIV presented with 1 month history of brick-like painful stool, anorexia, rectal bleeding and inguinal lymphadenopathy. Positron emission tomography searching for underlying lymphoma demonstrated multiple hypermetabolic lymph nodes in the mesorectal, inguinal and inferior mesenteric stations for which biopsy was negative for malignancy. Computer tomography (CT) showed rectosigmoid colon wall thickening. Colonoscopy found granular, friable mucosa with large deep ulcerations from the anal verge to 20 cm. Biopsies revealed acute inflammation with erosion and granulation tissue and were negative for CMV, HSV I/II and Treponema pallidum. Testing for underlying IBD was unremarkable. Blood test for LGV serology, and anal swabs for Chlamydia trachomatis were positive for serotypes L and D-K. Flexible sigmoidoscopy after 21 days of treatment with doxycycline showed resolving distal proctitis below 8 cm from the anal verge. Discussion: Chlamydial serotypes D-K cause mild proctitis and up to two thirds of patients are asymptomatic. Serotypes L1-L3 are more invasive and the clinical course typically has three stages. The first is usually an unnoticed painless pustule or erosion 3-30 days after sexual intercourse. The second results 3-6 months after exposure with tender inguinal or femoral lymphadenopathy, anal pain with purulent, bloody or mucous discharge. The third stage is chronic inflammation associated with tissue destruction, stricture and fistula formation that can mimic Crohn’s disease. Although LGV is rare, there have been clusters of outbreaks of the disease primarily in men who practice anal intercourse. It is critical to keep such a diagnosis on the differential as the symptoms and imaging findings can mimic malignancy, IBD and other infections leading to unnecessary and costly work ups.
Figure A: Computer tomography of the abdomen and pelvis with contrast showed marked thickening and stranding surrounding the rectum and downstream sigmoid colon with a 14.6x12.5mm lymph node. Figure B: PET scan demonstrating marked thickening and stranding surrounding the rectum and downstream thickened colon with accompanying intense uptake. Figure C: Rectum with large ulcers and inflammation. Figure D: Rectosigmoid junction with friable mucosa, ulceration and mucosal erosion. Figure E: Rectum with diffuse inflammation and ulceration
Disclosures: Irene Riestra Guiance indicated no relevant financial relationships. Ernesto Robalino Gonzaga indicated no relevant financial relationships. Richard Henriquez indicated no relevant financial relationships. Steven Char indicated no relevant financial relationships. Wojciech Blonski indicated no relevant financial relationships.