Painful Hematochezia in HIV-Positive Male

Abstract

A 37 year old male presented to the emergency room with complaints of sudden onset, progressively worsening painful hematochezia and abdominal cramping for 1 week. The patient had formed stool coated on the outside with fresh blood and clots. He denied similar symptoms in the past, local trauma, fever or diarrhea. His only medication was efavirenz/emtricitabine/tenofovir combination (Atripla) which he started taking for human immunodeficiency virus (HIV) infection in 2007. His CD4 count was 1069/mm3 and he had recently been treated for syphilis. His physical exam was unremarkable except for streaks of fresh blood and pain on rectal examination. His lab parameters were normal. A contrast enhanced CT scan showed mild rectal wall thickening possibly from proctitis or underdistension. Stool cultures were negative for ova and parasites. Urine and culture examinations were negative for Neisseria gonococcus and Chlamydia trachomatis. A flexible sigmoidoscopy showed noncircumferential diffusely erythematous mucosa with bleeding on contact, extending contiguously from 5 cm to 20 cm from the anal verge (Figure 1). Biopsies showed non-specific chronic inflammation in the lamina propria. When questioned, the patient disclosed that he recently had anal receptive intercourse. A rectal swab tested positive for Chlamydia trachomatis Lymphogranuloma venereum (LGV). He was treated with Doxycycline 100 mg BID for 21 days with resolution of symptoms. C. trachomatis is the most commonly reported sexually transmitted infection in the United States and an important cause of proctitis and proctocolitis in men who have sex with men. LGV serovars L1, L2, L3 produce a more aggressive infection manifest by perianal, anal or rectal ulceration with resulting pain and discharge. Since itis an obligate intracellular organism, diagnostic samples should contain cellular material to permit detection. This often necessitates the use of a rectal swab and subsequent microbiological assessment.Figure 1Figure 2