Atypical Presentation of Rectal Bleeding: Unveiling Severe Proctosigmoiditis and Concurrent HIV, Syphilis, Gonorrhea, and Chlamydia Infections

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Proctitis is defined as inflammation involving the distal rectum. The presenting symptoms can be non-specific, thus takes a careful history and diagnostic work-up for diagnosis and management. We present a case of a 30-year-old man presenting for hematochezia and rectal pain initially attributed to hemorrhoids; however, diagnostic work-up led to diagnosis of infectious proctitis. Case Description/Methods: A 30-year-old previously healthy man presented to the emergency department with a 2-month history of painful rectal bleeding, initially attributed to hemorrhoids on outpatient work up. The severity of his pain led to fear of defecation, food aversion, and a 30-pound weight loss. Despite laxatives, topical creams, and Sitz baths, he found no relief. Upon assessment, he exhibited diaphoresis and tachycardia. Initial hemoglobin levels revealed a significant drop from his baseline of 13 g/dL to 7.5 g/dL. A rectal examination elicited pain and identified a small external hemorrhoid. Colonoscopy was performed for further evaluation and revealed multiple ulcerated, violaceous, and erythematous plaques from the anal verge to 20 cm and multiple perianal condylomas. Rectal biopsies were taken, revealing severe active proctitis. Due to suspicion of sexually transmitted infections, infectious work up was completed showing positive for HIV (CD4 count: 553, viral load: 85,000), syphilis, along with positive gonorrhea and chlamydia lymphogranuloma venereum. On further history, he reported multiple sexual partners, including men and women that was previously denied. Infectious disease consultation led to initiation of antiretroviral therapy and treatment for syphilis, gonorrhea, and chlamydia. A month after admission, the viral load was undetectable, and hemoglobin levels had risen to 11 g/dL. Patients rectal bleeding had resolved, however continues to report significant rectal pain 1 month after diagnosis. Discussion: As seen in this case, the diagnosis of proctitis can often be delayed and can result in significant patient distress. Our patient's endoscopic findings were consistent with long standing LGV, characterized by diffuse granulomatous lesions. As with our patient, co-infection can often be seen in concomitant HIV. Thus, patients with suspicion of infectious proctitis should have a detailed infectious work up to ensure complete treatment. This emphasizes the importance of a thorough history to guide diagnostic work up for prompt diagnosis and treatment (see Figure 1).

Volume

119

Issue

10

First Page

S1934

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