1555 Intestinal Spirochetosis: A Call to Unravel the “Spiral” of Undetermined Significance

Abstract

INTRODUCTION: Intestinal Spirochetosis (IS) is a rare incidental finding on routine biopsies of the colon, thought to be a commensal organism more prevalent among those with HIV, immunocompromised, or those in developing countries. Anecdotally, it does not seem to be widely known among practicing gastroenterologists, and in those who have encountered it, their management has varied widely. The classic histologic finding is a fringe-like attachment of densely packed filamentous spirochetes on the surface epithelium of the large intestine. Identification can be done with H&E staining, but confirmation requires Warthin-Starry staining. Although clinical presentation varies, often patients are asymptomatic and have an endoscopically normal appearance. CASE DESCRIPTION/METHODS: In this case report, we present a 37 year old otherwise healthy homosexual female with intermittent hematochezia and RLQ pain and a family history remarkable for polyps in her sister (36), and father who was diagnosed with colon cancer in his 50s. Colonoscopy was remarkable for punctate ulcers on her IC valve and cecum, with biopsy findings of “chronic inflammation and architectural distortion” suspicious for Crohn's. She was started on Apriso BID, and on second read, the pathologist stated, ‘of note, we also identify organisms morphologically consistent with intestinal spirochetosis (Brachyspira), confirmed with a Warthin Starry stain, with an appropriately positive control. Intestinal spirochetosis usually is an incidental finding and the organisms are generally not considered pathogenic'. Consideration was given to treat the patient with a course of Flagyl, however, the patient was no longer symptomatic and on repeat colonoscopy the ulcers had resolved. Biopsies taken of the involved area again demonstrated Spirochetosis. DISCUSSION: While often regarded as a clinically insignificant finding, not enough is known about IS to make firm conclusions about the relevance of this organism. IS has been associated with IBS in a general population in Sweden1, and a retrospective case-control study in Japan demonstrated a strong association between IS and Sessile Serrated Adenomas/Polyps2. This case sheds light on the fact there is a lack of awareness and understanding of this organism among all involved sub-specialties. Further studies on this potentially pathogenic organism need to be carried out.