2037 Intestinal Spirochetosis: An Unexpected Cause of Massive Gastrointestinal Bleed

Abstract

INTRODUCTION: Human intestinal spirochetosis (HIS) is a condition characterized by the presence of spirochetal microorganisms attached to the apical cell membrane of the colorectal epithelium leading to chronic diarrhea. The invasive form of this disease is more often seen in HIV patients or homosexual individuals. Here, we present a rare case of HIS presenting as lower gastrointestinal (GI) bleed and abdominal pain in the absence of diarrhea. CASE DESCRIPTION/METHODS: A thirty-year-old male with a history of peptic ulcer disease (PUD) and HIV (CD4 >250) presented to the emergency department with a two-days duration of severe, generalized abdominal pain and bleeding per rectum. On presentation, the patient was hypotensive (mean arterial pressure < 65) and tachycardic (heart rate 120). Physical examination revealed generalized abdominal tenderness with normal bowel sounds but no rebound tenderness or guarding. Labs were significant for anemia (Hemoglobin 6.5 g/dl; baseline >14 g/dl). The rest of his labs including serum chemistry, white blood cells, amylase, lipase levels, were within normal limits. Due to the patient’s significant history of PUD and concern for rapid GI bleed, aggressive fluid resuscitation and proton pump inhibitor infusion were initiated. He also received two units of packed red blood cells with good toleration. CT scan of the abdomen/pelvis did not reveal any acute intraabdominal pathology. Despite the achievement of hemodynamic stability, the patient continued to have bright red blood per rectum. Extensive infectious workup (including blood cultures and stool tests such as stool culture, ova, and parasites) were negative. Esophagogastroduodenoscopy was performed and revealed well healed PUD without any signs of bleeding. Colonoscopy, however, revealed pan-colonic ulcers, most pronounced in the descending colon. Histopathology revealed spirochetal microorganisms attached all the way from the ascending colon to the rectum consistent with invasive HIS. Metronidazole was initiated with significant clinical improvement and he was subsequently discharged home with appropriate outpatient follow up. DISCUSSION: Most cases of HIS are asymptomatic and often diagnosed during screening/surveillance colonoscopy. Thus, data regarding symptomatic patients is scant. The few cases describing affected patients generally associate infection with chronic watery diarrhea, acute appendicitis or intermittent hematochezia. Metronidazole is an effective treatment of choice in symptomatic patients.