Medical College of Georgia Philadelphia, PA, United States
Michael Coles, MD1, Ahmad Alkaddour, MD2, Pooja Mude, MD1, John Erikson Yap, MD3 1Medical College of Georgia, Augusta, GA; 2Augusta University-Medical College of Georgia, Augusta, GA; 3Medical College of Georgia at Augusta University, Augusta, GA
Introduction: Syphilis is a sexually transmitted infection spread via the spirochetal organism Treponema Pallidum. Since the start of the 21st century rates of syphilis in MSM are increasing, especially with HIV co-infection. The increasing prevalence of syphilis infections warrants a diagnostic consideration in cases of undifferentiated proctitis.
Case Description/Methods: A 25-year-old male with a past medical history of Human-Immunodeficiency Virus on HAART presented to the ED with back and abdominal pain. His vital signs were within normal limits. Lab work was significant for elevated PT (14.7 seconds), ALT 141 U/L, alkaline phosphatase 236 U/L. Right upper quadrant abdominal tenderness and a new non-tender diffuse maculopapular rash with palmar sparing was appreciated on exam. Abdominal CT with contrast was concerning for proctitis (Figure 1A). However, malignancy could not be excluded. Subsequent colonoscopy revealed patchy erythema and inflammation proximal to the dentate line (Figure 1B). Gonorrhea and chlamydia and anal swabs returned negative. Pathology reports of rectal biopsies indicated colorectal mucosa with focally active proctitis with positive spirochete stain result and negative CMV, HSV 1 and 2 immunohistochemical stains. An RPR titer was elevated at 1:64 consistent with secondary syphilis and underwent treatment with benzathine penicillin G 2.4 million units Intramuscularly once with an oral course of doxycycline and ultimately discharged home.
Discussion: Anorectal manifestations of primary and secondary syphilis may present with symptoms of change in bowel habits, tenesmus, pruritus, anal discharge or defecatory urgency- symptoms shared by all benign anorectal pathologies and some malignancies. Endoscopic findings are also non-specific and include proctitis, masses or ulcers. Our patient’s findings were isolated to patchy erythema. In addition to proctitis, hepatitis with elevated levels of alkaline phosphatase disproportionate to bilirubin and LFTS may also be present, as was the case in our patient. Hepatic manifestation is likely a result of contiguous portal venous drainage from the rectum. The non-specific nature of both gross and symptomatic disease manifestations has likely resulted missed diagnoses. Furthermore, a detailed patient investigation addressing sexual practices and preferences may be overlooked during history taking. A missed diagnosis delays patient treatment, exacerbating disease burden and augments the risk of further transmission.
Figure: FIgure 1A: CT Abdomen Pelvis with contrast in the coronoal view demonstrating asymmetric thickening and inflammation of the rectum with prominent peri-rectal lymph nodes indicated by red arrows.
Figure 1B: Patchy erythema and inflammation noted past the dentate line within the rectum noted on colonoscopy.
Disclosures: Michael Coles indicated no relevant financial relationships. Ahmad Alkaddour indicated no relevant financial relationships. Pooja Mude indicated no relevant financial relationships. John Erikson Yap indicated no relevant financial relationships.
Michael Coles, MD1, Ahmad Alkaddour, MD2, Pooja Mude, MD1, John Erikson Yap, MD3. P0433 - A Case of Proctitis With a Twist, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.