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Syphilitic Proctitis
Image of the Month Syphilitic Proctitis MELISSA TEITELMAN,* JOANNE A. P. WILSON,* and CYNTHIA D. GUY‡ *Department of Medicine, Division of Gastroenterology, and ‡Department of Pathology, Duke University Medical Center, Durham, North Carolina
A
46-year-old human immunodeficiency virus–positive man with a normal CD4 count presented with lower abdominal pain, constipation, and occasional hematochezia. A computed tomography scan of the abdomen revealed circumferential thickening of the rectal wall with numerous perirectal lymph nodes causing concern for rectal carcinoma. On rectal endoscopic ultrasound, the lesions appeared to be T3 node–positive. There were multiple large lymph nodes in his mesorectum. Physical examination was unremarkable. Abdominal and rectal examination were normal, there was no palpable lymphadenopathy. At colonoscopy, there were discrete ulcerations with surrounding erythema in the rectum (Figure A), but no mass was seen. The biopsies revealed ulcerated rectal mucosa with densely cellular plasma cell–rich granulation tissue and prominent proliferative capillary endothelial cells (Figure B). Special stains for acid-fast bacilli and fungal organisms were negative. Immunohistochemical stains for cytomegalovirus, Epstein– Barr virus, and human herpes virus-8 were negative. Keratin stain showed no evidence of carcinoma. Immunohistochemical stains for a malignant hematopoietic process (CD20, CD3, CD138, and and light chain restriction) were negative. Warthin–Starry silver stain of the colonic biopsy specimens confirmed spirochetosis (Figure C). On further questioning, the patient recalled recent receptive unprotected anal intercourse. Subsequent rapid plasma reagin and fluorescent trepenomal antibody-absorption were reactive. After treatment for primary syphilis, a follow-up flexible sigmoidoscopy revealed healing ulcers.
Syphilis remains an important public health problem in the United States. The Centers for Disease Control instituted a national plan to eliminate syphilis. As a result, the rate of primary and secondary syphilis declined 89.7% between 1990 and 2000, but then began to increase between 2000 and 2005. The rates of primary and secondary syphilis have increased in the South, urban areas, and among human immunodeficiency virus–positive homosexual men.1,2 When syphilis affects the gastrointestinal tract, it usually affects the proximal small bowel and stomach. Less commonly, gastrointestinal infiltration also can be seen in the more distal small bowel and colon, as was seen in this patient. Patients may complain of hematochezia, urgency, diarrhea, or constipation. The presentation of syphilis also has been shown to mimic lymphoma or carcinoma, as was seen in this patient. At endoscopy, the findings vary from ulcerated lesions to erythema to normal mucosa. Histologically, chronic inflammation often is seen with infiltration of plasma cells and lymphocytes. Anorectal primary syphilis is easily overlooked because it often causes mild symptoms and clinicians may fail to examine extragenital sites for chancres.3,4 Syphilis is a relatively easy infectious disease to treat but remains a public health problem. Clinicians should have a low index of suspicion to evaluate a patient with unexplained gastrointestinal symptoms for possible syphilis, especially if that patient falls into a high-risk group. References 1. Division of STD Prevention. The national plan to eliminate syphilis from the United States. Atlanta, GA: National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention; 2006. 2. MMWR Morb Mortal Wkly Rep 2006;55:269 –273. 3. Quinn TC, Corey L, Chaffee RG, et al. The etiology of anorectal infections in homosexual men. Am J Med 1981;71:395– 405. 4. Surawicz CM, Goodell SE, Quinn TC, et al. Spectrum of rectal biopsy abnormalities in homosexual men with intestinal symptoms. Gastroenterology 1986;91:651– 659.
© 2008 by the AGA Institute
1542-3565/08/$34.00 doi:10.1016/j.cgh.2007.12.031 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:xxvi
A
46-year-old human immunodeficiency virus–positive man with a normal CD4 count presented with lower abdominal pain, constipation, and occasional hematochezia. A computed tomography scan of the abdomen revealed circumferential thickening of the rectal wall with numerous perirectal lymph nodes causing concern for rectal carcinoma. On rectal endoscopic ultrasound, the lesions appeared to be T3 node–positive. There were multiple large lymph nodes in his mesorectum. Physical examination was unremarkable. Abdominal and rectal examination were normal, there was no palpable lymphadenopathy. At colonoscopy, there were discrete ulcerations with surrounding erythema in the rectum (Figure A), but no mass was seen. The biopsies revealed ulcerated rectal mucosa with densely cellular plasma cell–rich granulation tissue and prominent proliferative capillary endothelial cells (Figure B). Special stains for acid-fast bacilli and fungal organisms were negative. Immunohistochemical stains for cytomegalovirus, Epstein– Barr virus, and human herpes virus-8 were negative. Keratin stain showed no evidence of carcinoma. Immunohistochemical stains for a malignant hematopoietic process (CD20, CD3, CD138, and and light chain restriction) were negative. Warthin–Starry silver stain of the colonic biopsy specimens confirmed spirochetosis (Figure C). On further questioning, the patient recalled recent receptive unprotected anal intercourse. Subsequent rapid plasma reagin and fluorescent trepenomal antibody-absorption were reactive. After treatment for primary syphilis, a follow-up flexible sigmoidoscopy revealed healing ulcers.
Syphilis remains an important public health problem in the United States. The Centers for Disease Control instituted a national plan to eliminate syphilis. As a result, the rate of primary and secondary syphilis declined 89.7% between 1990 and 2000, but then began to increase between 2000 and 2005. The rates of primary and secondary syphilis have increased in the South, urban areas, and among human immunodeficiency virus–positive homosexual men.1,2 When syphilis affects the gastrointestinal tract, it usually affects the proximal small bowel and stomach. Less commonly, gastrointestinal infiltration also can be seen in the more distal small bowel and colon, as was seen in this patient. Patients may complain of hematochezia, urgency, diarrhea, or constipation. The presentation of syphilis also has been shown to mimic lymphoma or carcinoma, as was seen in this patient. At endoscopy, the findings vary from ulcerated lesions to erythema to normal mucosa. Histologically, chronic inflammation often is seen with infiltration of plasma cells and lymphocytes. Anorectal primary syphilis is easily overlooked because it often causes mild symptoms and clinicians may fail to examine extragenital sites for chancres.3,4 Syphilis is a relatively easy infectious disease to treat but remains a public health problem. Clinicians should have a low index of suspicion to evaluate a patient with unexplained gastrointestinal symptoms for possible syphilis, especially if that patient falls into a high-risk group. References 1. Division of STD Prevention. The national plan to eliminate syphilis from the United States. Atlanta, GA: National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention; 2006. 2. MMWR Morb Mortal Wkly Rep 2006;55:269 –273. 3. Quinn TC, Corey L, Chaffee RG, et al. The etiology of anorectal infections in homosexual men. Am J Med 1981;71:395– 405. 4. Surawicz CM, Goodell SE, Quinn TC, et al. Spectrum of rectal biopsy abnormalities in homosexual men with intestinal symptoms. Gastroenterology 1986;91:651– 659.
© 2008 by the AGA Institute
1542-3565/08/$34.00 doi:10.1016/j.cgh.2007.12.031 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:xxvi