Sara Kamionkowski, DO, Abdulfatah Issak, MD, Jaclyn Jacobs, MD, Claire Zhang, MD, Nisheet Waghray, MD; MetroHealth Medical Center, Cleveland, OH
Introduction: Intestinal spirochetosis (IS) has been reported as a rare cause of diarrhea and abdominal pain with the prevalence of IS varying worldwide. We report a case of a patient with previously known IBS-D diagnosed with IS on colonic biopsies.
Methods: A 33-year-old male presented to gastroenterology clinic with chronic diarrhea for ten years. He reported four to ten daily episodes of watery diarrhea accompanied by peri-umbilical abdominal pain. Review of systems were negative otherwise. Initial laboratory work-up including gliadin IgA and IgG antibodies, stool culture, giardia, cryptosporidium, syphilis IgG/IgM, CRP, and ESR were normal. A trial of amitriptyline 25 mg QHS, as needed loperamide 2 mg and dicyclomine 20 mg with increased fiber supplementation was unsuccessful prompting colonoscopic evaluation, which revealed normal mucosa. Hematoxylin and eosin (H&E) stain of the random colonic biopsy specimens revealed dense, fingerlike basophilic bands on the epithelial surface of the large intestine (Figure 1). A diagnosis of intestinal spirochetosis was confirmed by Steiner silver stain (Figure 2). He was prescribed metronidazole 500 mg TID for ten days with resolution of his symptoms and remained asymptomatic in follow up nine months later. Discussion: Colonic spirochetes have a lower prevalence of 0.2% to 3.2% in developed countries, but a higher prevalence has been seen in Eastern Asian regions. Prevalence is higher among those with gastrointestinal complaints and among men who have sex with men (28% to 62.5%). Certain species of spirochetes have been found to be associated with symptomatic disease. Those with Brachyspira pilosicoli are more likely to have gastrointestinal symptoms whereas those colonized with B. aalborgi may be asymptomatic. Intestinal spirochetes are diagnosed on histopathology with H&E stain and confirmed with immunohistochemistry using Steiner or Dieterle silver stain. Mucosal findings on colonoscopy are non-specific or normal. IS is also reported to be associated with irritable bowel syndrome (IBS) and hyperplastic/adenomatous polyps. It is thought that spirochete colonization can lead to destruction of the microvilli, which is speculated to lead to symptomatic IS; however, the pathophysiology for symptomatic colonic disease is unknown. It is important to consider spirochetes as a cause of diarrhea in those who carry concurrent diagnosis of unrevealing chronic diarrhea and IBS-D. Treatment with metronidazole should be considered in symptomatic patients.
Figure 1: H&E stain of colonic biopsy
Figure 2: Steiner Silver stain of colonic biopsy
Disclosures: Sara Kamionkowski indicated no relevant financial relationships. Abdulfatah Issak indicated no relevant financial relationships. Jaclyn Jacobs indicated no relevant financial relationships. Claire Zhang indicated no relevant financial relationships. Nisheet Waghray indicated no relevant financial relationships.