Proctitis in AIDS Patient: A Diagnostic Dilemma

Abstract

Introduction: Syphilitic proctitis is a rare disease. It is, therefore, difficult to diagnose and is occasionally treated inappropriately. We are reporting a case of a 31-year-old male with history of AIDS who presented with abdominal pain of 3 days’ duration accompanied with bright red blood per rectum and tenesmus. He had a whitish, milky discharge with no evidence of bleeding on rectal exam. A 31-year-old male with recent diagnosis of untreated AIDS and syphilis, which was treated 1 year ago, presented with a 1-week history of bright red blood per rectum and a 3-day history of abdominal pain associated with tenesmus and constipation. He had history of anal fissure and he admitted having same-sex sexual behavior. Rectal examination revealed tender whitish papules with milky discharge and no bleeding. Vital signs were unremarkable. Laboratory studies showed microcytic anemia with normal results on complete metabolic panel. RPR was 1:512. The CT scan of the abdomen was unremarkable. Flexible sigmoidoscopy showed erythema and erosion with friable mucosa in the rectum distally, which was consistent with proctitis. A biopsy specimen was obtained. Histological findings of the biopsy showed focal submucosal hemorrhage with disruption of the epithlium without active inflammation. Rod-like organisms is identified on the Warthin-Starry stain. The findings are consistent with spirochetosis. The organisms were seen on the mucosal surface with no invasion of mucosa. The patient was treated with benzathine penicillin 2.4 million units weekly for 3 weeks. At the time of discharge he was clinically stable and symptoms resolved. The incidence of venereal diseases has steadily increased over years. Although physicians are becoming more alert for genital and anal syphilis, it is still incorrectly felt that extragenital involvement, especially rectal syphilis, is uncommon. It is difficult to estimate the size of the homosexual population in the United States but it is probably between 2% and 10% of the population. Syphilis has been termed the great imitator. Symptoms and signs can vary and the differential diagnosis includes nonspecific fissures, ulcers, Crohn’s disease, and cancer. The primary physician or the specialist must always be on the alert for syphilitic proctitis.