S2266 Crohn’s Disease or Not

Abstract

INTRODUCTION: Lymphogranuloma venereum (LGV) is a sexually transmitted disease due to Chlamydia trachomatis infection. It can present with symptoms and endoscopic features similar to Inflammatory Bowel Disease (IBD). We report a case of LGV proctitis initially diagnosed as Crohn’s disease. CASE DESCRIPTION/METHODS: A 52-year-old man developed rectal bleeding, 8-10 loose stools a day, abdominal pain and a 20 pound weight loss over 6 months. Perianal exam found large verrucous lesions typical for Crohn's disease and rectal exam demonstrated an anorectal stricture. CTE showed rectal wall thickening, with numerous enlarged lymph nodes. Diffuse severe inflammation edema, friability, erosions in distal sigmoid progressing to confluent ulcerations and luminal narrowing in the rectum was found on colonoscopy. Biopsy showed severe active colitis with ulceration, granulation tissue and focal changes of chronicity but without granuloma, dysplasia or viral inclusions. HIV was negative in 1999 and 2005. Prior to starting therapy for Crohn’s disease, the patient confided to having unprotected receptive anal intercourse in the past. HIV testing was positive with a CD4 count of 148 cells/mm. He was started on HIV medications. Serologic panel was positive for Chlamydia trachomatis (LGV) infection. He was treated with doxycycline for 21 days and his symptoms markedly improved. He is well without GI symptoms 6 months after LGV treatment and on maintenance HIV medications. DISCUSSION: LGV is a genital ulcerating disease caused by Chlamydia trachomatis. It is rare in Europe and North America found mostly in HIV-positive men who have sex with men. LGV commonly presents with manifestations similar to inflammatory bowel disease including rectal bleeding, frequent bowel movements, tenesmus and ano-rectal pain. If untreated, patients may develop rectal strictures and fistulae. On endoscopy, erythema, friability and ulceration have been described. On rectal biopsy, inflammation, crypt abscesses, granuloma formation and transmural inflammation are found making it difficult to differentiate from IBD. The diagnosis of LGV depends on clinical presentation and identification of risk factors. Nucleotide amplification test can help make a diagnosis; PCR can help with differentiating specific chlamydia serotypes. A 21 day course of doxycycline 100 mg PO twice daily is the preferred treatment. LGV infection should be considered in the differential diagnosis of inflammatory bowel disease involving the rectum.Figure 1.: CTE showing rectal wall thickening, with numerous enlarged lymph nodes.Figure 2.: Colonoscopy demonstrating diffuse severe rectosigmoid inflammation.Figure 3.: Biopsy showed severe active colitis with ulceration and granulation tissue.