Proctitis: Whatʼs the Bottom Line?

Abstract

This is a case of a 45 y/o male with a history of GERD, hemorrhoids and syphilis who presented for 2 months of anal pain, hematochezia and constipation, ultimately diagnosed with proctitis. This is being presented given the unique etiology of proctitis, rare in clinical practice. While findings including endoscopy present similarly to IBD, this diagnosis requires a high degree of suspicion and supportive history. He previously failed fiber, probiotics and stool softeners. He admitted to anal intercourse but denied a family history of colon polyps or cancer. Exam was notable for hemorrhoids, perianal condylomata and anal fissure. Labs were normal and no imaging was performed. Given his symptoms, he underwent diagnostic colonoscopy with good prep to the terminal. Nodular, friable and ulcerated mucosa encompassing 50% of the luminal circumference, extending 10cm proximal to the anus was seen. Pending biopsy results, he was started on empiric rectal mesalamine. Pathology revealed acute cryptitis, chronic inflammation, granulation tissue and reactive changes. Findings were not classic of IBD given inflammation was not circumferential and was more mass like than ulcerative. Biopsy was negative for CMV, HSV 1/2, spirochetes and dysplasia or malignancy using pancytokeratin and p16 immunostains. Serum HIV and syphilis were negative. Given atypical appearance, rectal swab was obtained, revealing C. trachomatis and N. gonorrhoeae RNA. These findings and clinical suspicion led to a diagnosis of Lymphogranuloma venereum proctitis with a 21 days of treatment with doxycycline. This is an uncommon form of infectious proctitis caused by the L1-L3 serovars of Chlamydia trachomatis. Risk factors include men who have sex with men, previous STIs and ulcerative disease. Lymphatic spread occurs after the bacterium passes the epithelial barrier, usually via unprotected anal intercourse. Hemorrhagic proctitis results with anorectal pain, bleeding, tenesmus and constipation. Endoscopically there is rectal inflammation, often mistaken for IBD. Clues include supportive history and failure to improve with IBD therapy. Diagnostic techniques include nucleic acid amplification testing to detect C. trachomatis and the specific serotype. Alternatives include culture and serology. First line therapy is doxycycline with erythromycin preferred in pregnant or breastfeeding women. As with other STIs, sexual partners should be informed, screened and treated if similarly affected.1526_A Figure 1. Endoscopic view from colonoscopy. Evidence of nodular appearing, mass like ulceration of the rectal mucosa, encompassing approximately fifty percent of the luminal circumference.1526_B Figure 2. Histologic slide from rectal biopsy, detailing acute cryptitis with associated reactive changes.1526_C Figure 3. Magnification of histologic slide from rectal biopsy, showing further evidence of chronic inflammation alongside acute cryptitis.