A Curious Case of Severe Proctitis

Abstract

Question: A 40-year-old man with well controlled human immunodeficiency virus presented to the emergency department with one week of severe rectal pain. He subsequently developed fevers and hematochezia with loose stools, prompting him to seek care. Past sexual history includes anal receptive intercourse and a previous diagnosis of anal human papilloma virus. On presentation, he was febrile to 103.2°F, but otherwise hemodynamically stable. Rectal exam was limited by severe pain, but was notable for mucopurulent discharge, perianal ulcers, and erythema (Figure A). Laboratory testing was significant for leukocytosis with white blood cell count of 12.6 /mm3 and an elevated C-reactive protein of 111 mg/L. A computed tomographic scan of his abdomen with intravenous contrast was performed and showed marked inflammatory changes of the rectum and surrounding soft tissue without abscess or other upstream colonic inflammation and multiple enlarged perirectal and retroperitoneal lymph nodes (Figure B). Extensive testing for multiple infectious diseases, including syphilis, herpes simplex virus, gonorrhea, and chlamydia, was negative. What is the diagnosis? Look on page 528 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Given high index of suspicion, he was placed on our standard precautions for monkeypox rule-out, which includes isolated room, gowns, gloves, eye protection, and N-95 filter. A rectal polymerase chain reaction swab for nonvariola orthopox virus returned positive, confirming a diagnosis of monkeypox virus. This was reported to the State Department of Health for contact tracing. The patient was treated with tecovirimat antiviral therapy under emergency use authorization, as approved by the Center for Disease Control and State Department of Health. He noted symptomatic improvement within a few days and was discharged to complete an oral course of 600 mg tecovirimat twice daily for a total of 14 days. Monkeypox virus is a zoonotic orthopox DNA virus that was previously endemic to Africa.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar In the spring of 2022, cases outside of endemic regions began to rise and a global outbreak began. The presenting symptoms of monkeypox can be nonspecific, including fevers, myalgias, mucosal involvement, and skin lesions, which are vesicular and evolve over days to weeks.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Monkeypox has now been declared a public health emergency, and this case highlights many important considerations for diagnosis and treatment. First, the current monkeypox outbreak is disproportionately affecting men who have sex with men.2Guarner J. del Rio C. Malani P.N. Monkeypox in 2022—what clinicians need to know.JAMA. 2022; 328: 139-140Crossref PubMed Scopus (70) Google Scholar Transmission is thought to occur through to skin-to-skin contact. The lesions typically appear first at the site of inoculation, and thus anal/genital lesions may be more common. In a recent international case series published in the New England Journal of Medicine, 73% of the 528 patients with polymerase chain reaction–diagnosed monkeypox had anogenital ulcerations.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Also noted in that case series, the most common cause of hospitalization was anorectal pain.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar The was true for our patient, who required intravenous pain medication on presentation. Symptomatic treatment with opioids, ibuprofen, topical anesthetics (lidocaine jelly per rectum), and stool softeners provided mild improvement while the patient was admitted. However, starting tecovirimat provided the greatest symptomatic improvement, and the patient was able to be discharged with only ibuprofen and stool softeners for pain control after 2 days of treatment. The World Health Organization believes the true number of monkeypox to be underestimated owing to lack of recognition of this infection that was previously only seen in a few countries.3World Health Organization Multi-country monkeypox outbreak: situation update. June 27, 2022.https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396Google Scholar Thus, a high degree of suspicion must be maintained for the disease, even in patients with isolated anal ulceration or proctitis