University of Connecticut Health Center Farmington, CT, United States
Sriya Bhumi, MD, MBA1, Courtenay Ryan-Fisher, MBBCh2, Corey Saraceni, MD1, Lisa Rossi, MD3 1University of Connecticut Health Center, Farmington, CT; 2University of Connecticut, Farmington, CT; 3Saint Francis Hospital, Hartford, CT
Introduction: Intestinal spirochetosis (IS) is a disease caused by the non-treponemal spirochetes Brachyspiraceace. Presentation varies based on the extent of spirochete invasion and many patients are asymptomatic or present with diarrhea. We report a rare case of IS causing severe rectal inflammation and obstructive signs in a patient with human immunodeficiency virus (HIV).
Case Description/Methods: A 38-year-old male with HIV (CD4 count 698 and undetectable viral load) presented to clinic with one month of diffuse abdominal pain and constipation with associated 20-pound weight loss. He denied hematochezia or fevers. He reported receptive anal intercourse two months prior. His only medications were antiretroviral therapy. Labs were unremarkable including normal CBC. Colonoscopy revealed a 20mm ulcerated rectal mass and severe inflammation with narrowing of the lumen, as well as localized inflammation in the cecum. Cecal and rectal biopsies both showed chronic active colitis (Figure 1) and immunohistochemical stains were positive for spirochetes (Figures 2, 3). Biopsies were negative for CMV/HSV. Rapid plasma reagin and Treponema pallidum particle agglutination assay returned negative, ruling out syphilitic proctitis. Our patient was treated with metronidazole for 14 days with symptom resolution on follow-up.
Discussion: This case of intestinal spirochetosis (IS) is unique in its presentation. Currently, there is no literature that associates IS with constipation or significant luminal narrowing. Typical colonoscopy findings in IS include polypoid lesions, erythema, or normal mucosa. IS is diagnosed by hematoxylin-eosin stain of biopsied tissue revealing spirochetes attached to the luminal surface of colorectal epithelium. Further confirmation is obtained with Warthin-Starry silver stains. IS is seen in increasing prevalence in men who have sex with men and those with HIV, supporting a route of sexual transmission, and the importance of a thorough sexual history in patients presenting with rectal symptoms. Malignant pictures including syphilitic proctitis must be ruled out in a timely fashion. Treatment is with a spirochete antibiotic, such as metronidazole. There is currently no data stating a need for stool studies or repeat colonoscopy to confirm eradication of spirochetes. This case highlights the need for a high clinical suspicion of intestinal spirochetosis regardless of symptomology when local involvement of the rectum is present in patients with risk factors such as HIV or men who have sex with men.
Figure: Figure 1: Rectal mass. Chronic active colitis with epithelial denudation of the surface (*), intraepithelial neutrophils consistent with active colitis (red arrows), and features of chronicity (expanded lamina propria caused by a chronic inflammatory infiltrate, basal lymphoplasmacytosis, and architectural distortion). Figure 2: Cecum immunohistochemistry for spirochetes. Numerous organisms on the surface of the colon, appearing as “false brush border”. Figure 3: Rectal mass immunohistochemistry for spirochetes showing the “spiral” shape of the organisms.
Sriya Bhumi indicated no relevant financial relationships.
Courtenay Ryan-Fisher indicated no relevant financial relationships.
Corey Saraceni indicated no relevant financial relationships.
Lisa Rossi indicated no relevant financial relationships.
Sriya Bhumi, MD, MBA1, Courtenay Ryan-Fisher, MBBCh2, Corey Saraceni, MD1, Lisa Rossi, MD3. P2270 - Intestinal Spirochetosis: A Cause of Partial Colonic Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.