The Great Mimicker: Syphilitic Gastritis and Colitis

Abstract

Introduction: Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum and has been on the rise since the turn of the millennium. Worldwide syphilis affects 45.4 million people, per US CDC data 23872 cases of primary and secondary syphilis were reported between 2014-2015 with the largest increase in reportable STD cases falling in this category (19%). Gastrointestinal involvement is a rare manifestation of secondary and tertiary syphilis. Case presentation: 29 year old male with history of cannabis abuse, GAD, depression and hyperlipidemia was admitted for evaluation of several months of diarrhea and now presenting with nausea and non bloody vomiting. History was positive for patient having unprotected sexual intercourse with an HIV positive partner and a 40lbs weight loss, he also reported possible family history of ulcerative colitis. Vitals signs on admission were stable and physical exam positive for cervical and axillary lymphadenopathy. Labs including a CBC, KFT, LFT and lipase were all within normal, patient tested negative for HIV and Hep C. CT scan of the abdomen showed possible mild colitis and enteritis. Colonoscopy was normal, EGD showed erythema seen on the lesser curvature near the fundus. The whole antrum looked abnormal, there was antral thickening, suspicious raised lesion and mucosa consistent with more edema erosions and swelling from the inflammation, this raised the concern for malignancy. Multiple biopsies were taken from both the colon and stomach. Spirochete immunohistochemical stain demonstrated numerous long, thin, tightly-coiled microorganisms within the epithelium and in the lamina propria of both organs consistant with syphilis. Discussion: Syphilitic gastritis and colitis is rare, gastritis occurs in less than 1% of cases of syphilis. Other organs such as the liver and rectum may be involved. Patients usually present with nonspecific findings like nausea vomiting, weight loss and abdominal pain. On endoscopy the pylorus is the usual site of involvement, with it having ulcers or raised lesion, if left untreated the stomach shrinks and becomes more fibrotic resembling linitis plastic, in regards of the colon it can cause ulcers and possible strictures. Conclusion: Syphiltic gastritis and colitis diagnosis require high index of suspicion, this diagnosis should be considered in individuals at high risk for having sexually transmitted disease. Antibiotics are the mainstay of treatment.Figure: Antrum spirochete stain.Figure: colon spirochete stain.