P0227 - “Brush Border” on a Colonic Polyp: An Unusual Diagnosis in the Immunocompetent Patient

Grace Hopp, DO, MBA¹, Tamneet Basra, MD², Dhruv Mehta, MD³, Apeksha Agarwal, MD^2
1University of Texas Health Science Center San Antonio, San Antonio, TX; ²UT Health San Antonio, San Antonio, TX; ³University of Texas Health Science Center at San Antonio, San Antonio, TX

Introduction: Human intestinal spirochetosis (IS) usually presents as a profuse watery diarrheal illness accompanied by vague abdominal pain in the immunocompromised host. We present a rare case of IS in an immunocompetent patient with the initial chief compliant of rectal bleeding.

Case Description/Methods: A 37 year-old male with well compensated alcoholic cirrhosis presented with symptoms of rectal bleeding. A colonoscopy demonstrated non-bleeding internal and external hemorrhoids and diverticulosis throughout the sigmoid colon. There was a 4 mm sessile polyp in the ascending colon that was removed via cold snare. Initial histology of the polyp revealed tubular adenoma and a filamentous “brush border” overlying the epithelium. A Warthin Starry stain confirmed the presence of spirochetes attached to the luminal surface and confirmed the diagnosis of intestinal spirochetes (IS).








Shortly after his colonoscopy, our patient had negative HIV and Syphilis screening tests. On further inquiry, he reported diarrhea. Due to these symptoms, he was prescribed a course of Metronidazole. After completion of his antibiotic course, his symptoms resolved.

Discussion: is a high incidence of IS in immunocompromised patients. Symptoms are more common in children and immunocompromised hosts and include watery diarrhea, abdominal pain, flatulence, or the presence of fecal blood.









Endoscopic evaluation alone cannot make the diagnosis. Interestingly, in a review of 15 patients with IS completed by Alsaigh et al, 4 patients had a “polypoid” lesions similar to our patient’s. Diagnosis is made on the histological appearance of the biopsy and require a diffuse blue fringe along the border of the epithelial layer on H&E staining. Warthin-Starry staining is then used to confirm the diagnosis by highlighting the fixed spirochetes, as seen in our image.









The clinical significance in immunocompetent patients is not well understood. Generally it is felt that if intestinal spirochetosis is found in a symptomatic immunocompetent patient, this patient should be treated as ours was. This case highlights the importance for endoscopists and pathologists to recognize IS and treat, if symptomatic.


Figure: The diffuse brush border of the epithelial layer on H&E staining (left). Warthy-Starry staining highlights the fixed spirochetes (right).


Disclosures:
Grace Hopp indicated no relevant financial relationships.
Tamneet Basra indicated no relevant financial relationships.
Dhruv Mehta indicated no relevant financial relationships.
Apeksha Agarwal indicated no relevant financial relationships.


Grace Hopp, DO, MBA¹, Tamneet Basra, MD², Dhruv Mehta, MD³, Apeksha Agarwal, MD². P0227 - “Brush Border” on a Colonic Polyp: An Unusual Diagnosis in the Immunocompetent Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.