Introduction: Syphilitic proctitis is a rare manifestation of syphilis that can present as proctitis with or without rectal ulcers. This unusual clinical presentation can lead to misdiagnosis and subsequent mistreatment. In this case we discuss a patient with syphilitic proctitis that manifested as an anal fistula.
Case Description/Methods: A 27-year-old male with HIV complaint w/ antivirals, undetectable viral load and adequate CD4 count presented to the office with a chief complaint of anorectal pain, tenesmus and bloody mucus anal discharge, discharge. The patient reported three months of ongoing perianal discomfort and mucus discharge during bowel movements. He was prescribed Nitroglycerine 0.2% compounded with Lidocaine 5% rectal cream and advised warm soaks. He showed minimal improvement in symptoms over 2 weeks and was subsequently prescribed Hydrocortisone 2.5% rectal cream, again with minimal improvement in symptoms. A diagnostic colonoscopy showed presence of a deep anal fissure with active oozing and several small aphthous ulcers in the distal rectum. The mucosa of the distal rectum appeared moderately erythematous and friable. Biopsy of the involved mucosa was negative for granulomas, dysplasia, CMV staining, or chronic inflammation indicating an active acute inflammatory proctocolitis potentially consistent with Ulcerative Colitis. Subsequent MRI showed perirectal lymphadenopathy and grade 2 perianal fistulas further suggesting IBD. Subsequent MRI showed perirectal lymphadenopathy and grade 2 perianal fistulas further suggesting IBD. Upon further questioning the patient noted that he was in a short relationship with a male partner who had active syphilis prior to symptoms. Rapid Plasma Reagin (RPR) and Treponema antibody were positive confirming a diagnosis of syphilis. The patient was treated with penicillin G resulting in resolution of his symptoms.
Discussion: There has been an increased rate of STIs in recent years, with approximately 1/5 American adults diagnosed with an STI in 2018. This increased incidence is especially seen in high-risk populations such as men who have sex with men (MSM), people with multiple sexual partners, and people living with HIV. A strong clinical suspicion of STIs is necessary when treating high risk individuals. As seen in this case, MRI and colonoscopy findings of Syphilitic Proctitis are nonspecific; but it is integral to correctly differentiate it from inflammatory causes such as IBD or malignancy to ensure appropriate patient centered treatment.
Figure: Colonoscopy Images
Disclosures:
Ishan Handa indicated no relevant financial relationships.
Priyanka Chugh indicated no relevant financial relationships.
Ishan Handa, BS1, Priyanka Chugh, MD2. P0817 - A Rare Mimicker of Ulcerative Proctitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
