Infectious Proctitis: A Case of a Clandestine Cause for Proctitis

Abstract

We present the case of a male patient who described four months of painful defecation, tenesmus, pruritus, hematochezia and mucous per rectum. Initial work-up by the primary care physician (PCP) included negative stool culture and ova and parasite studies. Family history was notable for a first-degree relative with ulcerative colitis. The patient's medical history included adjustment disorder and acne. Social history was notable for sexual intercourse with men, including anal intercourse with inconsistent use of barrier protection. He had recent travel to the United Kingdom (UK) at which time he engaged in unprotected anal intercourse. He had no other systemic symptoms. Rectal exam was notable for visualization of bright red blood, without the presence of external hemorrhoids. Colonoscopy was performed for persistent symptoms, family history of inflammatory bowel disease (IBD), as well as risk for sexually transmitted infections (STIs). Multiple circumferential non-bleeding ulcers were found in the distal rectum and anal canal. Biopsies were negative for p16 protein, P63, CMV and HSV I and II. Pathology revealed ulceration and acute inflammation, with no viral inclusions. Recent rectal, throat and urine culture for gonorrhea and chlamydia were negative, however cultures were not obtained for these organisms via colonoscopy. Referral was made to colorectal surgery. Anoscopy revealed thick yellow drainage from anal crypt with associated ulcer. He was given a clinical diagnosis of infectious proctitis secondary to likely gonorrhea and empirically treated with ceftriaxone and doxycycline, with resolution of symptoms. Maintaining a wide differential is important when patients present with symptoms of proctitis. While IBD is a common etiology, social and clinical context provide information vital to making the correct diagnosis. Importantly, clinical suspicion should guide treatment, even when faced with negative test results. In the case of this patient, his initially negative rectal swabs for STIs likely delayed treatment. Finally, recognition of the current epidemiologic trends in specific patient populations, provides keys to diagnosis. Recent surges in infectious proctitis, including lymphogranuloma venereum (LGV) among men who have sex with men (MSM) in Europe have been documented. Consideration of this relevant data helps point to the correct diagnosis.