Anorectal disease in HIV-infected patients

A Rare Case of Herpes Simplex Virus and Cytomegalovirus Dual Infection Inducing Unremitting Ulcerative Colitis

Ulcerative colitis (UC) is a subtype of inflammatory bowel disease that results in inflammation and ulceration in the lining of the large intestine. Patients with UC are frequently prescribed immunosuppressive medications to treat their symptoms, resulting in an increased risk of reactivation of many latent viruses, including herpes simplex virus (HSV) and cytomegalovirus (CMV). However, it is rare for a patient to present with simultaneous reactivation of both viruses. Here, we document the presentation, hospital course, and clinical findings of a UC patient with HSV and CMV dual infection. We also describe treatment strategies and prophylactic measures for managing a dual infection. This is seen through initiating valganciclovir in the outpatient setting following the diagnosis.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

Anorectal pathology amongst HIV infected patients attending the Douala General Hospital: a cross-sectional study

While gastrointestinal disease is common among HIV infected individuals, the prevalence and distribution of ano-rectal pathology has not been well studied in our setting. The objective of this study therefore was to determine the prevalence and determinants of ano-rectal pathology in HIV infected patients attending the Douala General Hospital HIV treatment centre. A hospital-based cross-sectional study was undertaken. We collected socio-demographic, clinical and laboratory data using a structured questionnaire and patients' files. Each study participant had a full physical and ano-rectal examination. We further studied factors associated with having at least one ano-rectal lesion by logistic regression reporting odds ratios (ORs) and their 95% confidence intervals (CI). We included 390 HIV infected patients. The mean age was 41 (SD: 8) years and 48% were men. Median duration since HIV diagnosis was 3 (interquartile range: 2-5) years and median CD4 cell count was 411 (interquartile range: 234-601) cells/mm³. Prevalence of ano-rectal pathology was 22.8% (95% CI: 18.7-27.3). Hemorrhoids and proctitis were most common lesions found; each in 10% of patients. From multivariate logistic regression, factors associated with ano-rectal pathology were CD4 < 350 cells/ml (OR: 2.1, 95% CI: 1.1-4.2), not on highly active antiretroviral therapy (OR: 2.2, 95% CI: 1.1-4.6), inpatient (OR: 2.3, 95% CI: 1.2-4.3), ano-rectal intercourse (OR: 5.0, 95% CI: 1.7-15.1), and more than one sexual partner (OR: 2.4, 95% CI: 1.3-4.2). Ano-rectal pathology is common amongst HIV infected patients. Care givers should actively investigate and treat them as this will improve the quality of life of people living with HIV/AIDS.

Results of surgical treatment on benign anal diseases in Korean HIV-positive patients

Perianal diseases are the most common reasons for surgery in HIV-positive patients. This study aimed to evaluate the outcomes of these surgical procedures in Korean patients, focusing on wound healing and postoperative complications. Retrospective analysis was performed on 72 HIV-positive patients who underwent surgery by a single surgeon for benign anal disease between 1998 and 2011. Of these, 68.1% (49/72) of patients received surgery for condyloma acuminata, 19.4% (14/72) for anal fistulas, 6.9% (5/72) for hemorrhoids, and 5.6% (4/72) for perianal abscesses. Patients with condyloma acuminata received surgical excision with electrical coagulation, and all wounds healed completely within 3 months, though 16.3% (8/49) of these patients experienced recurrence. Twelve of the 49 patients (24.5%) who were treated for condyloma acuminata underwent simultaneous operations for concomitant anal fistulas (n = 6), hemorrhoids (n = 4), and perianal abscesses (n = 2). Overall, 3 postoperative complications developed following a total of 94 procedures, and there was no significant increase in complication rate for patients with a low CD4+ T-cell count ( < 200/µL) compared to those with a higher count. The results demonstrate favorable results following perianal surgery in HIV-positive Korean patients.

Sexually transmitted and anorectal infectious diseases

Sexually transmitted diseases (STDs) are common and they can involve the anus and rectum in both men and women. In this article, the main bacterial and viral STDs that affect the anus and rectum are discussed, including their prevalence, presentation, and treatment.

Anorectal opportunistic diseases in human immunodeficiency virus/acquired immunodeficiency syndrome patients: spectrum of cross-sectional imaging findings

Patients infected with the human immunodeficiency virus, particularly male homosexuals, are prone to develop disorders involving the anorectal and perineal structures. Cross-sectional imaging techniques, such as multidetector computed tomography with multiplanar reformations and magnetic resonance imaging performed with phased-array coils, are increasingly adopted to detect and stage infectious and neoplastic diseases, and to assess posttreatment modifications. Pyogenic perianal sepsis may be usefully investigated with imaging, particularly to assess the presence and topography of abscess collections to allow a correct surgical choice. Rectal inflammatory involvement is frequently detected during intestinal opportunistic infections, such as cytomegalovirus, pseudomembranous, and amebic colitides, including primary and secondary imaging signs consistent with proctocolitis. Anal carcinoma and intestinal lymphoma are increasingly diagnosed; therefore, special attention should be paid to the identification of solid tissue consistent with tumor; furthermore, MRI provides optimal staging and posttreatment follow-up of neoplastic lesions. Knowledge of this varied spectrum of anorectal and perineal opportunistic abnormalities and their imaging appearances should help radiologists to propose appropriate differential diagnoses, suggest correlation with laboratory and microbiological assays or biopsy, and reliably assess therapeutic response.

MRI and CT of anal carcinoma: a pictorial review

BACKGROUND

Squamocellular anal carcinoma is increasingly diagnosed in patients with risk factors.

METHODS

State-of-the-art imaging with magnetic resonance imaging (MRI) using phased-array coils and volumetric multidetector computed tomography (CT) provides detailed visualisation of anal disorders, identification and extent assessment of neoplastic tissue, detection and characterisation of nodal and visceral metastases. MRI has been recommended by the European Society for Medical Oncology (ESMO) as the preferred modality of choice to stage anal cancer, taking into account the maximum tumour diameter, invasion of adjacent structures and regional lymph node involvement.

RESULTS

Cross-sectional imaging techniques allow the identification of coexisting complications, and differentiation from other perineal abnormalities.

CONCLUSION

Cross-sectional imaging is useful for planning radiotherapy, surgical drainage or salvage abdomino-perineal resection. After chemo-radiotherapy, MRI follow-up provides confident reassessment of therapeutic response, persistent or recurrent disease. TEACHING POINTS : • Anal carcinoma is increasingly diagnosed in patients with human immunodeficiency virus (HIV), anoreceptive intercourse, chronic inflammatory bowel disease. • An established association exists with human papillomavirus (HPV) infection and premalignant intra-epithelial dysplasia. • Phased-array MRI is recommended as the preferred imaging modality for regional staging. • Imaging allows detection of infectious complications, planning of radiotherapy or salvage surgery. • Follow-up MRI allows reliable assessment of therapeutic response after chemo-radiotherapy.

Perianal Bowen disease in a child with human immunodeficiency virus

Individuals infected with the human immunodeficiency virus (HIV) are at increased risk for human papillomavirus (HPV)-related cancers of the anogenital region. A majority of these cancers have been reported in adult patients; few reports are available regarding anogenital HPV-associated carcinomas developing in children. We report a case of perianal Bowen disease in an HIV-positive child. An 8-year-old HIV-positive boy with a history of perianal verrucous lesions presented to a clinic in Lesotho because his caregiver noted his lesions were changing in color, texture, and extent. Histologic sections revealed squamous cell carcinoma in situ. Several cases of anogenital condyloma in HIV-positive children have been reported, but very few cases of HPV-associated cancer. Children with vertically transmitted HIV may be uniquely susceptible to persistent infection with strains of HPV acquired perinatally. While the introduction of highly active antiretroviral therapy has resulted in immune restoration, decreased opportunistic infection, and increased life expectancy for children and adults with HIV, it has not affected the incidence of HPV-related cancers in these patients. The increased life expectancy of children with HIV may actually put them at risk for developing an HPV-related anogenital cancer.

Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era

PURPOSE

This study aimed to determine the prevalence of macroscopic anal lesions and associated factors in HIV-infected outpatients during the era of highly active antiretroviral therapy.

METHODS

A randomly selected sample of patients with HIV-infection receiving follow-up care in the infectious diseases department of Bichat University Hospital was invited to participate in a systematic screening program consisting of anal examination with anoscopy and a standardized questionnaire.

RESULTS

Of 516 patients, 473 (92 percent) participated. Overall, 208 patients (44 percent) had at least one anal macroscopic lesion: 108 patients (22.8 percent) had human papilloma (HPV)-related lesions (condyloma with or without dysplasia), 67 (14.2 percent) had hemorrhoidal disease, 50 (10.6 percent) had anal fissures, and 44 (9.3) percent had other anal lesions. Independent significantly associated factors for anal condyloma were history of anal condyloma (OR, 2.09) and median number of episodes of sexual intercourse per month (OR, 1.03) in men who have sex with men; history of genital condyloma (OR, 26.74), and unprotected sexual intercourse (OR, 7.47) in heterosexual men; and CD4 cell count below 200/mm3 (OR, 6.02), receptive anal intercourse (OR, 6.37), and history of anal condyloma (OR, 16.69) in women. Neither sexual behavior nor characteristics related to HIV infection were associated with hemorrhoidal disease or anal fissure.

CONCLUSIONS

Because patients with HIV infections have a high prevalence of unreported anal lesions that may be highly contagious, involve risk of anal neoplasia, or negatively affect quality of life, systematic anal screening should be conducted in the HIV-infected population.

Gastrointestinal opportunistic infections in human immunodeficiency virus disease

Gastrointestinal (GI) opportunistic infections (OIs) are commonly encountered at various stages of human immunodeficiency virus (HIV) disease. In view of the suppressive nature of the virus and the direct contact with the environment, the GI tract is readily accessible and is a common site for clinical expression of HIV. The subject is presented based on information obtained by electronic searches of peer-reviewed articles in medical journals, Cochrane reviews and PubMed sources. The spectrum of GI OIs ranges from oral lesions of Candidiasis, various lesions of viral infections, hepatobiliary lesions, pancreatitis and anorectal lesions. The manifestations of the disease depend on the level of immunosuppression, as determined by the CD4 counts. The advent of highly active antiretroviral therapy has altered the pattern of presentation, resorting mainly to features of antimicrobial-associated colitis and side effects of antiretroviral drugs. The diagnosis of GI OIs in HIV/acquired immunodeficiency syndrome patients is usually straightforward. However, subtle presentations require that the physicians should have a high index of suspicion when given the setting of HIV infection.

Genital and perianal herpes simplex simulating neoplasia in patients with AIDS

Genital and perianal herpetic ulcers are common in HIV-infected patients and chronic mucocutaneous ulcers persisting for more than 1 month are the hallmark of active AIDS status. However, atypical clinical manifestations of herpes simplex virus (HSV) may occur in immunocompromised patients presenting as tumor-like nodules or condylomatous or hypertrophic lesions, rather than a classic ulcer. Such unusual presentations raise the risk of misdiagnosis and a delay in appropriate treatment. Here we describe nine immunocompromised HIV-positive patients with CD 4 count ranging from 14-362/mm(3) (mean 170/mm(3)), with unusual tumoral presentation of anogenital herpes. There were six male and three female patients with AIDS with mean duration of HIV infection of 14 years. All of the patients had history of highly active antiretroviral therapy (HAART), with five patients compliant with the therapy at the time of biopsy. Six patients presented with scrotal or vulvar masses and three with perianal nodules. Five patients had adjacent human papilloma virus (HPV)-related lesions. Prior to excision, herpetic lesion was clinically suspected in only three patients and in the rest of the patients a malignant growth was the main clinical concern. The predominant histopathologic finding was dense dermal plasmacytic infiltration with overlying pseudoepitheliomatous hyperplasia, superficial ulcers and classic herpetic inclusions. Patients with AIDS may experience excessive number and size of both primary and reactivated herpetic lesions. The tumoral presentations discussed here are less common, but are often clinically misdiagnosed. It is important to be aware of these unusual presentations to provide a correct diagnosis and prompt, effective treatment for HSV. Several studies suggest that aggressive treatment of HSV in combination with HAART therapy provides a significant survival benefit. Pathobiology mechanisms of unusual and exaggerated tumor-like inflammatory response are not completely elucidated.

Comparison of perianal diseases in HIV-positive patients during periods before and after protease inhibitors use: what changed in the 21st century

PURPOSE

Highly active antiretroviral therapy has enabled better control over HIV infection. Thus, the immunologic status of such patients has been improving and we believe that changes in their perianal diseases also have been occurring. This study was designed to compare anorectal disease incidence among HIV-positive patients attended in two eras: prehighly active antiretroviral therapy and highly active antiretroviral therapy.

METHODS

We examined 5,660 HIV-positive patients with anorectal diseases, divided into two groups: 1,860 treated during 1989 to 1995 (Group 1), and 3,800 during 1996 to 2005 (Group 2).

RESULTS

In Group 1, the most common diseases were condylomas (24.7 percent), ulcers (21.8 percent), and anal fistulas (19.7 percent). Tumors occurred in 2.5 percent, with Kaposi's sarcoma in 51.1 percent, and squamous-cell carcinoma in 27.6 percent. In Group 2, the most common anorectal lesions were condylomas (75.6 percent), ulcers (17 percent), and fistulas (12.1 percent). The tumor incidence was 1.8 percent, with squamous-cell carcinoma in 59.4 percent and Kaposi's sarcoma in 23.2 percent. Changes in incidence were statistically significant for the increase in condylomas and fissures, and for the decrease in ulcers, fistulas, and Kaposi's sarcoma among Group 2 patients.

CONCLUSION

Anorectal disease incidences have changed in the highly active anti-retroviral therapy era.

Herpes simplex virus colitis complicating ulcerative colitis: A case report and brief review on superinfections

In patients with inflammatory bowel disease herpes simplex virus infection has been described as a major cause of morbidity and mortality, especially in immunocompromised individuals. Here we present the case of a 35-year old woman with an exacerbation of ulcerative colitis caused by herlpes simplex virus infection (HSV-2). The diagnosis was confirmed histologically following subtotal colectomy. After intravenous treatment with aciclovir for 2 weeks postoperative hematochezia stopped. Herpes simplex virus colitis is a rare but potentially fatal complication of immunosuppressive treatment in patients with inflammatory bowel disease. Prompt diagnosis and efficient antiviral therapy are mandatory to improve prognosis.

[Anorectal lesions in HIV-positive patients using highly active antiretroviral therapy]

Anorectal lesions are common in patients with human immunodeficiency virus (HIV). Highly active anti-retroviral therapy (HAART) has little influence on the progression of anal neoplasms. The prevalence of anorectal lesions in 88 HIV-positive patients attended at the infectious diseases service of the University Hospital of Brasília who were using HAART was studied. Sociodemographic data were collected using a pre-prepared questionnaire and then the patients underwent proctological examination. Around 71% of the patients said they practiced anal intercourse. 30.7% were using a protease inhibitor. The prevalence of anorectal lesions was 36.4%, and condyloma acuminata and anal fissure were the most frequent of these. Condyloma acuminata was the most prevalent anorectal lesion and was strongly associated with the use of lopinavir/ritonavir. Screening for anorectal lesions caused by human papillomavirus in HIV/AIDS patients who use protease inhibitors is suggested.

Perineal herpes simplex infection in bedridden geriatric patients

BACKGROUND

Herpes simplex virus (HSV) lesions are prone to reactivation and recurrence in response to various local or systemic triggering factors.

OBJECTIVE

To study the characteristics of five bedridden geriatric patients who presented with herpetic recurrences on the buttocks, gluteal cleft, and perianal region during hospitalization.

METHODS

Data were gathered regarding age, gender, reason for hospitalization, localization of lesions, clinical presentation, previous clinical diagnosis and topical treatments, immune status and immunosuppressant drug intake, as well as prior history of labial or genital herpes. A skin biopsy was taken for histologic examination and immunohistochemical viral identification. Viral culture and viral serology were performed and data regarding antiviral therapy were recorded.

RESULTS

The five patients (three women, two men) were aged >80 years and hospitalized for either severe drug-induced renal insufficiency (one case), severe pneumonia (two cases), or stroke causing restricted mobility (two cases). Numerous well demarcated, painful ulcerations developed in the perianal region of these patients, and one patient also presented with some vesicular lesions. The lesions had been confused with mycotic and/or bacterial infections for 10-14 days. No inguinal lymphadenopathies were present and there was no fever. None of the patients had a previous history of recurrent labial or genital HSV infections or HIV infection. Histology was suggestive of HSV infection in two of five patients. Immunohistochemistry identified HSV type I (three patients) and HSV type II (two patients) infections. Viral culture with immunofluorescence viral identification revealed HSV type I in one of the four patients in whom a swab for viral culture was taken. Serology revealed past HSV infection. All lesions cured gradually after 10-14 days of intravenous acyclovir (aciclovir) treatment.

CONCLUSION

Herpetic lesions of the perineal region represent a rare complication in bedridden geriatric patients in the absence of a previous history of HSV infections at the same site. Common traits of patients with this condition were the presence of numerous ulcerated lesions, prolonged time course, and confinement to bed. The latter probably modifies the skin condition, which triggers viral reactivation and favors cutaneous extension of the infection. Complementary diagnostic methods for viral detection and identification are mandatory.

Immunoreactivity of p16 in anal cytology specimens: histologic correlation

BACKGROUND

Cytology has been proposed as a potential screening tool in the evaluation of squamous anorectal disease in view of the morphologic similarities between anal and cervical squamous lesions. Previous studies have demonstrated that p16 overexpression correlates with the degree of dysplasia in the uterine cervix with promising results. Due to potential diagnostic pitfalls in anal cytology, p16 overexpression in these specimens was studied.

METHODS

Patients with anorectal cytology who underwent follow-up biopsy within 1 year were selected. Forty-three anorectal cytologic specimens from 29 patients were selected. One slide of each case was destained. Avidin-biotin immunocytochemical studies with the monoclonal antibody CINtec p16(INK4a) were performed. The results of the p16 immunostaining were correlated with the histologic findings.

RESULTS

Twenty-eight of the 43 cases demonstrated the presence of squamous cells immunoreactive for p16 in cytology specimens. The p16-positive cells were identified in cases of low-grade squamous intraepithelial lesion (LSIL) (n = 3 cases), high-grade squamous intraepithelial lesion (HSIL) (n = 22 cases), and invasive squamous carcinoma (n = 1 case), and in 2 cases with negative follow-up biopsies. No cell immunoreactive for p16 was found in 15 cases (5 benign cases and 10 cases with either LSIL or HSIL). The sensitivity and specificity of p16 immunoreactivity in the detection of anal intraepithelial neoplasia or carcinoma were 72% and 71%, respectively. The positive and negative predictive values were 93% and 33%, respectively.

CONCLUSIONS

The presence of p16 immunoreactivity is a good predictor of dysplasia in anal specimens. However, the sensitivity and specificity of this marker are not high.

Prévalence des condylomes anaux chez les patients infectés par le VIH

BACKGROUND

In the general HIV-infected population, there are few data on the prevalence and risk factors for anal condyloma, precursor lesions for anal cancer.

METHODS

Screening for perianal and endoanal condyloma with an anoscopy was systematically proposed to 516 consecutive outpatients, followed in a university hospital in Paris. For each point, HIV characteristics and sexual behaviors assessed through semi-directive questionnaire were collected.

FINDINGS

The 473 (92%) examined patients, consisted of 200 homosexual men, 123 heterosexual men, 150 women; 76% were receiving HAART, HIV-RNA was<50 copies/ml in 60%, mean (+/-SD) CD4 cell count were 484 (+/-274)/mm(3). Overall, 108 (23%) pts had histologically-confirmed anal condyloma (36, 15 and 11% of the respective populations), including 51 (47%) pts with only endoanal localisation. Intraepithelial neoplasia of grade I was noted in 59 patients, of grade II in 10 and of grade III in 2 and an invasive endoanal cancer in 1. In multivariate regression analysis, condyloma independent risk factor were history of gonococcia or syphilis (OR=0.54 (0.29-0.99)), and history of previous anal condyloma (OR=2.05 (1.07-3.92) in homosexual men, history of previous penis condyloma (OR=26.8 (2.3-309.6), and unprotected sexual intercourse (OR=7.5 (2.1-26.3)) in heterosexual men and CD4 cell count below 200/mm(3), (OR=8.9 (1.5-51.6)), receptive anal intercourse (OR=6.7 (1.7-25.8)) and history of previous anal condyloma (OR=25.4 (3.4-188.2)) in women.

INTERPRETATION

In the HAART era, systematic screening revealed a high rate of anal condyloma in all HIV positive pts (not only in homosexual men). Anal examination should be proposed systematically to all HIV-infected patients.

Anal intraepithelial neoplasia

Background

Anal intraepithelial neoplasia (AIN) is believed to be a precursor of anal squamous cell cancer and its incidence is rising in high-risk groups, particularly those infected with the human immunodeficiency virus (HIV). The natural history of AIN is unclear and management strategies are lacking.

Methods

This review is based on a literature search (Medline and PubMed) with manual cross-referencing of all articles related to AIN.

Results and conclusions

The aetiology of AIN is intricately linked with human papilloma viruses. The pathological processes involved in the progression of AIN are becoming clearer but the natural history, particularly the rate of progression to invasive cancer, remains unknown. There is no standard management for AIN and this is mainly due to difficulties in both diagnosis and treatment. A variety of treatment options have been tried with varying success. Surgery is associated with significant recurrence, particularly in HIV-positive patients. Non surgical approaches with imiquimod, photodynamic therapy and vaccination are appealing, and further work is required. Long-term follow-up of these patients is essential until the natural history of AIN becomes clearer.

Anorectal cytology as a screening tool for anal squamous lesions: cytologic, anoscopic, and histologic correlation

BACKGROUND

Anorectal cytology has been increasingly used as a screening method for anal squamous lesions, particularly in high-risk, homosexual, patients with human immunodeficiency virus infection. The diagnostic cytologic, anoscopic, and histologic criteria bear some resemblance to the criteria used in cervicovaginal samples with few differences. It is important to recognize these differences because they can lead to an erroneous diagnosis of dysplasia and unnecessary procedures.

METHODS

Seventy-eight anorectal cytology specimens from 51 patients were reviewed blindly. Of the 51 patients, 33 were HIV positive. The cytology specimens consisted of 75 ThinPrep (Cytyc, Boxborough, MA) and 3 conventional Papanicolaou-stained smear specimens. The revised diagnosis was compared with the original diagnosis, corresponding histology specimens, and anoscopic results, when available.

RESULTS

Six specimens were unsatisfactory for review. The revised diagnosis was negative in 15 patients, atypical squamous cells of undetermined significance in 3 patients, low-grade squamous intraepithelial lesions in 24 patients, high-grade squamous intraepithelial lesions in 28 patients, and squamous cell carcinoma (SQC) in 2 patients. Five patients with an original diagnosis of SQC had the diagnosis revised upon review of their specimens. It is noteworthy that these five specimens showed the presence of atypical parakeratotic cells. Thirty-two patients had anoscopic evaluation and 30 patients had histologic correlation. Twenty-seven patients with abnormal anoscopic findings had confirmed abnormal histologic findings. Twenty- five of the 32 (78%) patients had abnormal cytology that correlated with abnormal anoscopic findings.

CONCLUSIONS

Anorectal cytology is an accurate method for screening patients for anal squamous lesions. Atypical parakeratotic cells represent a potential pitfall. Anoscopy is important in confirming the presence of a lesion, but only a biopsy can accurately determine the grade of a lesion.

Management options for symptomatic hemorrhoids

Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.

Nodular perianal herpes simplex with prominent plasma cell infiltration

BACKGROUND

Nodules are exceptional manifestations of herpes simplex virus (HSV) infection in immunocompromised patients. Only two cases of nodular HSV-2 infection of the perianal region have been reported previously.

GOAL

The case of a 46-year-old homosexual man with AIDS presenting with painful perianal nodules resembling squamous cell carcinoma is described.

STUDY DESIGN

This case report presents details of the histologic findings and treatment regimen.

RESULTS

Histologic examination showed the presence of rare multinucleated giant epithelial cells and a dense inflammatory infiltrate composed mostly of plasma cells. Polymerase chain reaction analysis was positive for HSV-2 and negative for HSV-1, cytomegalovirus, Epstein-Barr virus, and human herpesvirus types 6 and 7. After being treated ineffectively with oral acyclovir (4 g/d) for 15 days, the patient was treated with oral valacyclovir (6 g/d), resulting in marked improvement in 10 days and complete resolution after 2 months.

CONCLUSIONS

In immunocompromised patients, HSV-2 infection may present with atypical clinical and histopathological features.

Septic complications after treatment of haemorrhoids

BACKGROUND

Recent reports of serious sepsis following stapled haemorrhoidectomy have raised concerns about the appropriate treatment of haemorrhoidal disease.

METHODS

A Medline search was undertaken for reports of sepsis following the commonly practised conservative and surgical treatments of haemorrhoids.

RESULTS

Published accounts of significant septic complications after injection sclerotherapy, rubber-band ligation, cryotherapy, open and closed haemorrhoidectomy, and stapled haemorrhoidectomy are discussed. This is supplemented by the authors' own experiences of stapled haemorrhoidectomy.

CONCLUSION

Septic complications following both conservative and surgical treatment of haemorrhoids are rare but may be catastrophic. Immunological compromise poses an additional risk for many treatment modalities. The technique of stapled haemorrhoidectomy should be learned diligently to avoid septic complications.

Anal condyloma and HIV-associated anal disease

Although there are a large variety of anal diagnoses associated with the HIV population, anal condyloma and anal ulcerations make up the vast majority. A large percentage of individuals having multiple concurrent pathologies should also be noted. Thus, this article concentrates on anal condyloma, anal ulceration and HIV, making note of other significant issues.

Anal Carcinoma Arising from Condyloma Acuminata

Condyloma acuminata is a common anorectal condition that frequently requires surgical evaluation and treatment. We have noted an increased incidence of anal carcinoma in patients with condyloma acuminata. The purpose of this study is to review the incidence of malignant transformation of condyloma in our recent experience. We conducted a 5-year retrospective review of patients with condyloma acuminata treated at a university medical center that serves as a major referral center for the state. From May 1994 through May 1999 257 patients were treated for anal condyloma. During the same time period 74 patients were diagnosed with squamous cell carcinoma of the anus; nine of these patients also had condyloma acuminata (12.2% of patients with anal carcinoma). All nine were immunosuppressed by illness and/or medication. The extent of carcinoma at diagnosis ranged from stage 0 (carcinoma in situ) to stage IVb. Overall 3.5 per cent of patients with condyloma acuminata also had squamous cell carcinoma of the anus. One patient with stage IVb disease died shortly after initial evaluation. Two patients with advanced disease required extensive surgical intervention and had complex postoperative courses. Malignant transformation of condyloma acuminata may be increasing in incidence. This disease progression can be insidious and may be fatal. Screening of high-risk patients might be of value, and more aggressive early management of condyloma may prevent the development of malignancy.

Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome

PURPOSE

Patients with acquired immunodeficiency syndrome are often in poor general physical condition. Diarrhea and bleeding hemorrhoids frequently contribute to the morbidity, and patients with such problems cause an increasing load on many outpatient clinics.

METHODS

Twenty-two patients (17 males) with acquired immunodeficiency syndrome had injection treatment for bleeding second-degree to fourth-degree hemorrhoids according to standard outpatient clinic routines. Mean follow-up was 24 months.

RESULTS

No complications were recorded. The treatment was successful in all patients, and no hemorrhoidectomy was necessary. Nineteen patients improved after their first injection, whereas 3 patients required two to six weeks repeated treatments to improve. Four subjects with the longer follow-up (4 years) showed an improvement lasting 12 to 18 months and then required one to two treatments per year to stop recurrent bleeding.

CONCLUSIONS

Because of their poor general condition and poor wound healing, a conservative approach is preferable to avoid a formal hemorrhoidectomy in patients with acquired immunodeficiency syndrome. Sclerotherapy seems to be an attractive alternative.

Anorectal manifestations of sexually transmitted infections

Sexually transmitted infections have a wide range of clinical presentations, including involvement of the anal verge, anal canal and rectum. This review focuses on anorectal sexually transmitted infections which may cause diagnostic difficulty when encountered by the coloproctologist. An approach to the diagnosis of a variety of sexually transmitted infections is set out, with a discussion of the role of biopsy and a summary of relevant histopathological findings. The value of early antibiotic treatment is discussed. Problems related to HIV/AIDS are highlighted, as clinical presentation may be atypical in immunosuppressed individuals. Sexually transmitted oncogenic viruses and their role in anal neoplasia are also briefly summarized.

Anorectal lymphoma and AIDS: an outcome analysis

BACKGROUND AND OBJECTIVE

Primary lymphoma of the anus is an extremely rare problem. In patients with the Acquired Immune Deficiency Syndrome (AIDS), there is a marked increase in gastrointestinal non-Hodgkin's lymphomas (NHL). The aim of this study was to evaluate the outcome of patients with anorectal NHL and AIDS.

METHODS

Over an 18-year period, we identified 6 patients with AIDS and primary anorectal NHL. Five were male. All were high-grade B-cell lymphomas and half showed systemic "B" symptoms. Patient's mean CD4 count was 93 (range 8 to 201).

RESULTS

The average life span for those with "B" symptoms was 6.7 months and 16 months for those without symptoms. No benefit was shown from radiation or chemotherapy in those with "B" symptoms. Younger patients and those without systemic constitutional symptoms of lymphoma do better. One patient without "B" symptoms was able to tolerate his radiation and chemotherapy and is disease free at 10 months.

CONCLUSION

Despite traditional non-Hodgkin's lymphoma treatment regimens, our AIDS patients (and those examined in a review of the pertinent literature) with anorectal NHL and "B" symptoms have a poor prognosis. For those without "B" symptoms and who can tolerate the therapy, NHL remission may be obtained.

Viral infections of the gastrointestinal tract

Acute gastroenteritis is common in adults. It can occur in institutional epidemics or epidemics of food-borne illness; in these cases, caliciviruses are the major cause of the condition. When acute gastroenteritis occurs in nonepidemic form, its causes are less clear. It may be due to caliciviruses or to the less common serotypes of childhood gastroenteritis viruses, such as rotavirus, astrovirus, and adenovirus. The pathogenesis of acute viral gastroenteritis is not completely understood. Old evidence suggests that mild villus damage is responsible, but new evidence indicates that active secretion and motility disturbance may be involved in the production of symptoms. Five common viruses can remain latent in gastrointestinal tissues and produce disease many years after initial infection. Two major herpesviruses, cytomegalovirus and herpes simplex virus, cause ulcerative disease of the gastrointestinal tract. This disease occurs in healthy persons but is more common and more severe in immunocompromised patients. Three other viruses--Epstein-Barr virus, human papilloma virus, and human herpesvirus-8--are implicated in benign and malignant proliferative diseases of the gastrointestinal tract. Epstein-Barr virus has been associated with immunoproliferative disease after transplantation and may also cause small-bowel and colonic lymphoma in healthy adults. It causes most AIDS-related lymphomas. Human papillomaviruses cause anorectal condyloma and anal cancer. Human herpesvirus-8 causes gastrointestinal Kaposi sarcoma.