A0143 - The Great Mimicker Gets Caught! A Rare Case of Syphilis in the Gastrointestinal Tract

Dema Shamoon, MD, Sarahi Herrera-Gonzalez, MD, Theodore DaCosta, MD, DO, Yatinder Bains, MD
Saint Michael's Medical Center, New York Medical College, Newark, NJ

Introduction: Syphilis is a sexually transmitted disease that impacts a vast number of organ systems and may present in different clinical settings. It can mimic various diseases leading to misdiagnosis and incorrect treatment. It is important to properly diagnose syphilis in special populations that are at high risk of contraction.

Case Description/Methods: A 49-year-old transgender female with diabetes mellitus and hyperlipidemia presented to the emergency department with dull abdominal pain in the left upper and lower quadrants for 2 days. She had non-bloody, nonbilious emesis, 10-pound weight loss over 1 month, and constipation for 2 weeks. Laboratory results showed a cholestatic pattern with elevated CA 19-9 and equivocal AMA (Table 1). Computed tomography (CT) of the abdomen and pelvis showed hepatic steatosis, normal caliber of the biliary system, rectal wall thickening, multiple enlarged perirectal adenopathy, and mild inflammatory infiltration around the rectum suggesting superimposed proctitis (Images G,H,I). Magnetic resonance cholangiopancreatography was normal. First colonoscopy showed possible rectal mass or severe proctitis with near complete obstruction unable to be traversed (Images A,B,C). Initial pathology said possible lymphoma or a rare type of colitis (Image E). Patient was empirically started on ceftriaxone and doxycycline. A second colonoscopy, 4 days later, was successfully completed and inflammation improved (Image D). Chlamydia and gonorrhea were negative, RPR weakly positive, and FTA was positive. Special stains requested were positive for Treponema pallidum and negative for HH8 confirming the diagnosis of syphilitic proctitis and highly suggestive syphilitic hepatitis (Image F). Prior to discharge, liver function tests (LFTs) were significantly reduced. The patient received 1-month course of doxycycline.

Discussion: Syphilis is the cause of sexually transmitted proctitis in only 1% of men that have sex with men and transgender females. Few cases of syphilitic proctitis imitating rectal malignancy have been reported. Syphilitic hepatitis presents with intrahepatic cholestatic pattern with normal biliary tract imaging. AMA may be positive prior to treatment. Diagnosis requires abnormal LFTs, serological evidence of syphilis, exclusion of other diseases and normalization of LFTs after treatment. Tissue diagnosis is not required. Syphilis commonly mimics severe pathologies and requires exclusion as well as confirmation of spirochetes for high risk populations with special staining.




Disclosures:


Dema Shamoon, MD, Sarahi Herrera-Gonzalez, MD, Theodore DaCosta, MD, DO, Yatinder Bains, MD. A0143 - The Great Mimicker Gets Caught! A Rare Case of Syphilis in the Gastrointestinal Tract, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.