World Journal of Colorectal Surgery

Transcription

1 World Journal of Colorectal Surgery Volume 3, Issue Article 14 A Case Presentation and Review of Lymphogranuloma Venerum Proctitis Mohammed Bayasi University of Texas Medical Branch, mbayasi@gmail.com Copyright c 2013 The Berkeley Electronic Press. All rights reserved.

2 Bayasi: A Case Presentation and Review of Lymphogranuloma Venerum Proctit 1 A case presentation and review of Lymphogranuloma Venerum Proctitis Mohammed Bayasi, MD and Aakash H. Gajjar, MD. Department of Surgery, Division of Colorectal Surgery. The University of Texas Medical Branch, Galveston, Texas Introduction: Rectal symptoms like pain, bleeding, itching, are common in the men having sex with men (MSM) population and warrants further investigation. Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) caused by serovars L1-L3 of Chlamydia trachomatis. Even though rare in the western world prior to 2003, different outbreaks or clusters of LGV have been reported in Europe, North America and Australia among men who have sex with men (MSM). LGV is one of the common causes of proctitis in MSM, and a delay in diagnosis has been the rule because of the misleading symptomatology of LGV proctitis, the unfamiliarity of the disease to physicians, and the lack of a routine diagnostic test for LGV serovars. We present a case of a patient with LGV proctitis and review a systematic literature search using Pubmed. Case presentation: A 47 year old male who is HIV positive with history of multiple sexual partners presented to the colorectal surgery clinic with complaints of what he thought was an anal fissure stating he was having internal muscle spasms. He reported blood with stool, rectal discharge, anismus, and pain with defecation for 2.5 months. He reports a history of irritable bowel syndrome. No family history of colon/rectal cancer, Ulcerative Colitis, or Crohn s disease. Patient did mention history of Gonorrhea. On exam, he was noted to have a mass at ~4-5cm from the anal verge with rigid proctoscopy performed confirming a mass-like lesion (Figure 1). The patient was taken to the operating room for an exam with biopsies. He was noted to have diffusely inflamed rectal mucosa with purulent drainage, no signs of internal opening to suggest a fistula, and multiple mucosal erosions (Figure 2). Random biopsies were also taken which showed colonic mucosa with ulceration and severe acute and chronic lymphoplasmacytic inflammation. Immunohistochemical stains were negative for CMV, herpes, adenovirus, and spirochetes. A CT scan was performed after the procedure (Figure 3) showing proctitis. He was seen at the infectious diease clinic and anal swab cultures were performed. The patient was empirically treated with doxycycline 100mg po BID for three weeks. He was found to be negative for Neisseria gonorrhea, herpes infection or syphilis. He was later found to be positive for Chlamydia Trachomatis on culture and by immunofluorescent detection with an elevated IgA of 1:128 confirming chronic infection. Patient was seen 3 weeks later, and still had some purulent discharge and occasional bleeding. Rigid proctoscopy was performed revealing some friable mucosa, however, revealing much improvement. He was prescribed an additional 2 weeks of Doxycycline. He was seen 4 weeks later and symptoms had resolved completely. Rigid proctoscopy revealed normal appearing mucosa. Produced by The Berkeley Electronic Press, 2013

3 2 World Journal of Colorectal Surgery Figure 1: Mass-like lesion in the rectum. Figure 2: Small superficial mucosal ulcerations in the rectum. Vol. 3, Iss. 2 [2013], Art. 14

4 Bayasi: A Case Presentation and Review of Lymphogranuloma Venerum Proctit 3 Figure 3: Yellow arrow depicting inflammation of the rectum. Discussion: Sexually transmitted infections are a common cause of proctitis in MSM population, and appropriate testing is imperative (2). The clinical and histologic presentation of LGV proctitis can be similar to the initial manifestations of inflammatory bowel disease (12). LGV should be considered in the differential diagnosis of proctitis in homosexual men and be treated with 100 mg of doxycycline/12 hours for three weeks. On the basis of the present literature review, the CDC's treatment recommendations for LGV remain unchanged (10-11). A high index of clinical suspicion is the mainstay to the early diagnosis of LGV since the clinical presentation remains unspecific (4). Mean time of symptoms of proctitis is 28 days (3). Chlamydia trachomatis was determined by PCR on rectal swab specimens, with a negative result after 21 days of treatment with doxycycline (4). With the assistance of novel molecular diagnostic techniques, more than a thousand cases of Chlamydia trachomatis L2 serovar disease have now been reported in MSM worldwide. Almost all have presented with rectal infection (5). No studies were found to determine whether screening asymptomatic men would reduce transmission or prevent acute infections or complications (6). In a study of 145 MSM, the prevalence of anorectal chlamydia infection was 24% in the study population and was significantly associated with proctitis symptoms. Up to 50% of the anorectal infections were asymptomatic. The most prevalent genotypes were G (39%) and D (37%), followed by J (11%) (1). Treatment prevents rectal strictures, abscess formation, bowel obstruction, bowel perforation and possibly death (9). Produced by The Berkeley Electronic Press, 2013

5 4 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 14 Conclusion: LGV is should be considered in the differential diagnosis of proctitis in men having sex with men (MSM) population, high index of suspicion is key to early diagnosis, early treatment ( 100 mg doxycycline every 12 hours for three weeks) is required to prevent further complications. References: 1-Høie S, Knudsen LS, Gerstoft J. Lymphogranuloma venereum proctitis: a differential diagnose to inflammatory bowel disease. Scand J Gastroenterol Apr;46(4): Epub 2010 Nov 30 2-Davis TW, Goldstone SE. Sexually transmitted infections as a cause of proctitis in men who have sex with men. Dis Colon Rectum Mar;52(3): Vall-Mayans M, Caballero E.Lymphogranuloma venereum: an emerging cause of proctitis in homosexual men in Barcelona. Rev Clin Esp Feb;209(2): Heras E, Llibre JM, Martró E, Casabona J, Martín R, Sirera G.Lymphogranuloma venereum proctocolitis in men with HIV-1 infection. Rev Clin Esp Jul-Aug;209(7):346 5-White JA.Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis Feb;22(1): Nelson HD, Helfand M. Screening for chlamydial infection. Am J Prev Med Apr;20(3 Suppl): Li JH, Cai YM, Yin YP, Hong FC, Shi MQ, Feng TJ, Peng RR, Wang BX, Chen XS. Prevalence of anorectal Chlamydia trachomatis infection and its genotype distribution among men who have sex with men in Shenzhen, China. Jpn J Infect Dis. 2011;64(2): Martin-Iguacel R, Llibre JM, Nielsen H, Heras E, Matas L, Lugo R, Clotet B, Sirera G. Lymphogranuloma venereum proctocolitis: a silent endemic disease in men who have sex with men in industrialised countries. Eur J Clin Microbiol Infect Dis Aug;29(8): Epub 2010 May Richardson D, Goldmeier D.Lymphogranuloma venereum: an emerging cause of proctitis in men who have sex with men. Int J STD AIDS Jan;18(1):11-4; quiz Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines MMWR 2006;55(no. RR-11). 11-Götz H, Nieuwenhuis R, Ossewaarde T, et al. Preliminary report of an outbreak of lymphogranuloma venereum in homosexual men in the Netherlands, with implications for other countries in western Europe. Eurosurveillance Weekly 2004;8(4) 12-Bauwens JE, Lampe MF, Suchland RJ, Wong K, Stamm WE. Infection with Chlamydia trachomatis lymphogranuloma venereum serovar L1 in homosexual men with proctitis: molecular analysis of an unusual case cluster. Clin Infect Dis Mar;20(3):

6 Bayasi: A Case Presentation and Review of Lymphogranuloma Venerum Proctit 5 Produced by The Berkeley Electronic Press, 2013