Sexually transmitted infections manifesting as proctitis

Prevalence of Chlamydia infection detected by immunohistochemistry in patients with anorectal ulcer and granulation tissue

Anorectal ulcer with granulation tissue is typically associated with left-sided inflammatory bowel disease or infection. Due to emerging cases of Chlamydia proctitis, we aim to investigate the prevalence of Chlamydia infection using immunohistochemistry (IHC) in anorectal biopsies showing ulcer and granulation tissue. Seventy-seven patients including 60 males and 17 females with mean age of 51 years old were retrospectively identified in surgical pathology archives. Chlamydia IHC was validated with a monoclonal antibody on an index who was positive for Chlamydia by rectal swab nucleic acid amplification test (NAAT), then performed on formalin fixed and paraffin embedded (FFPE) tissue sections. Confirmative molecular test using real-time PCR was performed on DNA extractions of 14 IHC-positive and 14 IHC-negative FFPEs, 18 NAAT-positive, and 5 NAAT-negative cytology specimens. Chlamydia IHC showed strong intracytoplasmic or extracellular sphere morphology in 14 of 77 (18.2 %) FFPEs, including 11 of 60 (18.3 %) males and 3 of 17 (17.6 %) females (age 11-84 years). Eight of 14 (57.1 %) Chlamydia-IHC positive patients had known history of STDs, high-risk behavior, or immunosuppressive conditions. One of 14 (7.1 %) IHC-positive FFEP and 15 of 18 (83.3 %) NAAT-positive cytology cases were confirmed by real-time PCR. Chlamydia inclusions were detected in all 4 randomly selected NAAT and PCR-positive cytology specimens by IHC. Our data suggested that Chlamydia infection is more prevalent than we thought in patients with active proctitis and ulceration. Chlamydia IHC may be performed as a screening test in biopsies to facilitate early detection of this treatable proctitis in high-risk population.

When Bacteria and Viruses Collide: A Tale of Chlamydia trachomatis and Sexually Transmitted Viruses

The global incidence of sexually transmitted infections (STIs) remains high, with the World Health Organization (WHO) estimating that over 1 million people acquire STIs daily. STIs can lead to infertility, pregnancy complications, and cancers. Co-infections with multiple pathogens are prevalent among individuals with an STI and can lead to heightened infectivity and more severe clinical manifestations. Chlamydia trachomatis (CT) is the most reported bacterial STI worldwide in both men and women, and several studies have demonstrated co-infection of CT with viral and other bacterial STIs. CT is a gram-negative bacterium with a unique biphasic developmental cycle including infectious extracellular elementary bodies (EBs) and metabolically active intracellular reticulate bodies (RBs). The intracellular form of this organism, RBs, has evolved mechanisms to persist for long periods within host epithelial cells in a viable but non-cultivable state. The co-infections of CT with the most frequently reported sexually transmitted viruses: human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus (HSV) have been investigated through in vitro and in vivo studies. These research studies have made significant strides in unraveling the intricate interactions between CT, these viral STIs, and their eukaryotic host. In this review, we present an overview of the epidemiology of these co-infections, while specifically delineating the underlying mechanisms by which CT influences the transmission and infection dynamics of HIV and HSV. Furthermore, we explore the intricate relationship between CT and HPV infection, with a particular emphasis on the heightened risk of cervical cancer. By consolidating the current body of knowledge, we provide valuable insights into the complex dynamics and implications of co-infection involving CT and sexually transmitted viruses.

Case series of perianal and pelvic MRI imaging findings in monkeypox

Monkeypox is a viral infection historically rarely seen in humans, but currently the focus of international attention due to a multi-country outbreak outside endemic countries of Central and West Africa, where cases are typically confined. Perianal pain and lesions have recently been recognised as a feature of monkeypox. We present a case series of the imaging findings of patients with monkeypox, including active proctitis, anal canal inflammation, and perianal inflammation. The aim is to increase awareness of perianal and rectal monkeypox MRI imaging features during this current outbreak.

Gastrointestinal tract and viral pathogens

Viral gastroenteritis is the most common viral illness that affects the gastrointestinal (GI) tract, causing inflammation and irritation of the lining of the stomach and intestines. Common signs and symptoms associated with this condition include abdominal pain, diarrhea, and dehydration. The infections commonly involved in viral gastroenteritis are rotavirus, norovirus, and adenovirus, which spread through the fecal-oral and contact routes and cause non-bloody diarrhea. These infections can affect both immunocompetent and immunocompromised individuals. Since the pandemic in 2019, coronavirus gastroenteritis has increased in incidence and prevalence. Morbidity and mortality rates from viral gastroenteritis have declined significantly over the years due to early recognition, treatment with oral rehydration salts, and prompt vaccination. Improved sanitation measures have also played a key role in reducing the transmission of infection. In addition to viral hepatitis causing liver disease, herpes virus, and cytomegalovirus are responsible for ulcerative GI disease. They are associated with bloody diarrhea and commonly occur in im-munocompromised individuals. Hepatitis viruses, Epstein-Barr virus, herpesvirus 8, and human papillomavirus have been involved in benign and malignant diseases. This mini review aims to list different viruses affecting the GI tract. It will cover common symptoms aiding in diagnosis and various important aspects of each viral infection that can aid diagnosis and management. This will help primary care physicians and hospitalists diagnose and treat patients more easily.

Infectious proctitis: what every gastroenterologist needs to know

The incidence of sexually transmitted infections (STI) is rising, especially in high-risk groups, namely people living with human immunodeficiency virus (HIV), men who have sex with men, and people with multiple sexual partners. Additionally, the growing availability and use of pre-exposure prophylaxis to prevent HIV infection appears to be associated with an increased risk of infection by venereal agents. The correct recognition of these infections is crucial, not only for individual patients, but also in terms of public health. Furthermore, a diligent diagnostic assessment is key for an efficient therapeutic approach. Infectious proctitis (IP) predominantly occurs in individuals with a history of receptive anal exposure, being a frequent cause for referral to a gastroenterology specialist. The most frequently identified agents are Neisseria gonorrhoeae, Chlamydia trachomatis, Herpes simplex virus, and Treponema pallidum. This paper aims to provide a practice-oriented and up-to-date review regarding the diagnostic and therapeutic approaches to patients with suspected IP. The authors reviewed the most important issues in terms of clinical history, physical examination, and specific diagnostic and therapeutic methods. It is also highlighted the most important topics regarding vaccination, screening for other STIs and differential diagnosis with inflammatory bowel disease. Identification of high-risk groups, screening of potential STIs, and notification of diagnosed anorectal diseases are extremely important and essential to prevent transmission and other complications.

Hypertrophic Perianal Herpes Mimicking Squamous Cell Cancer: A Case Report and a Review of the Literature

Clinical practice frequently involves the discovery of perineal lesions. The human papillomavirus, molluscum contagiosum, and herpes simplex virus are to blame for the majority of these anogenital lesions. In the majority of cases, these lesions may be identified by their distinctive appearance. It is challenging to make a clinical diagnosis in immunocompromised people since these lesions might be large and have uncommon appearances. Verrucous perianal herpes is a rare type of herpes that resembles squamous cell carcinoma in gross appearance. We present a case of a 71-year-old man on azathioprine, an immunosuppressive drug for autoimmune pancreatitis, who developed a perianal lesion resembling squamous cell carcinoma. Excisional biopsy revealed a benign ulcerative lesion with herpetic inclusions. The patient received antiviral treatment, and the perianal wound completely healed. He developed a similar lesion in the perineum at one year follow up, which was successfully treated with oral and topical antivirals.

Colitis caused by Entamoeba histolytica identified by real-time-PCR and fluorescence in situ hybridization from formalin-fixed, paraffin-embedded tissue

Intestinal amoebiasis in a 35-year-old German patient with a 3 weeks travel history in Indonesia was initially misidentified as non-steroidal anti-inflammatory-drug associated colitis in colonoscopy and histopathological analysis. Furthermore, initial stool examination by microscopy and Entamoeba faecal antigen ELISA did not reveal any protozoan infection. When cessation of non-steroidal anti-inflammatory drug (NSAID) use and mesalazine treatment did not lead to clinical improvement, the patient presented to a specialist for tropical diseases. An intensive reinvestigation including a workup of formalin-fixed, paraffin-embedded colonic biopsies by molecular analysis with real-time PCR and fluorescence in situ hybridization (FISH) proofed the diagnosis of Entamoeba histolytica colitis. Molecular methods including real-time PCR and FISH for the diagnosis of amoebiasis from histopathological samples are rarely used for the diagnosis of E. histolytica infections. Bloody diarrhoea vanished after the onset of metronidazole treatment. In conclusion, the here-presented case demonstrates how modern molecular diagnostics may help to diagnose E. histolytica-associated colitis, even from difficult specimens like paraffin-embedded, formalin-fixed tissue.

Immunohistochemical detection of chlamydia trachomatis in sexually transmitted infectious proctitis

Introduction

Since 2003, a progressive increase in sexually transmitted infections (STI), presented as proctitis, has been described in homosexual men. In 2013 Arnold et al. described microscopic features that enable pathologists to formulate a histological diagnosis of STI related proctitis. The aim of this study is to identify the presence of Chlamydia trachomatis by immunohistochemistry in a group of patients with male to male sexual activity and pathology compatible with STI proctitis.

Methods

Cross-sectional study. The study included 54 patients with risky sexual activity and histopathology compatible with STI-proctitis according to Arnold´s recommendations. The Chlamydia trachomatis identification was carried out retrospectively on paraffin blocks using mouse monoclonal antibodies from Santa Cruz biotechnology.

Results

all patients were young men with male to male sexual activity, 69% were positive for HIV. The most common endoscopic presentation was rectal ulcer (61%). Basal lymphoplasmacytic inflammation and mild crypt distortion were the most common histological findings. The immunohistochemical study identified positivity for Chlamydia trachomatis in 40% (18 of 45 tested) of STI proctitis cases.

Discussion

The epidemiological and endoscopic characteristics of the patients studied are similar to those previously reported. In accordance with Arnold et al., the most common histological findings were (a) mild distortion of the crypts; (b) dense and basal lymphoplasmacytic infiltrate and (c) scarcity of eosinophils. The positivity of chlamydia trachomatis in immunohistochemistry was lower than others studies that used PCR for this purpose. We did not find similar published studies to compare our results.

Conclusions

In summary, 54 cases of patients with STI related proctitis are presented, all of them with distinctive histological characteristics and third of the cases tested positive by IHC for Chlamydia trachomatis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02233-w.

Mitigation of endemic GI-tract pathogen-mediated inflammation through development of multimodal treatment regimen and its impact on SIV acquisition in rhesus macaques

Here, we assessed the efficacy of a short-course multimodal therapy (enrofloxacin, azithromycin, fenbendazole, and paromomycin) to eliminate common macaque endemic pathogens (EPs) and evaluated its impact on gastrointestinal (GI) microbiota, mucosal integrity, and local and systemic inflammation in sixteen clinically healthy macaques. Treatment combined with expanded practices resulted in successful maintenance of rhesus macaques (RM) free of common EPs, with no evidence of overt microbiota diversity loss or dysbiosis and instead resulted in a more defined luminal microbiota across study subjects. Creation of a GI pathogen free (GPF) status resulted in improved colonic mucosal barrier function (histologically, reduced colonic MPO+, and reduced pan-bacterial 16s rRNA in the MLN), reduced local and systemic innate and adaptive inflammation with reduction of colonic Mx1 and pSTAT1, decreased intermediate (CD14+CD16+) and non-classical monocytes (CD14-CD16+), reduced populations of peripheral dendritic cells, Ki-67+ and CD38+ CD4+ T cells, Ki-67+IgG+, and Ki-67+IgD+ B cells indicating lower levels of background inflammation in the distal descending colon, draining mesenteric lymph nodes, and systemically in peripheral blood, spleen, and axillary lymph nodes. A more controlled rate of viral acquisition resulted when untreated and treated macaques were challenged by low dose intrarectal SIVmac239x, with an ~100 fold increase in dose required to infect 50% (AID50) of the animals receiving treatment compared to untreated controls. Reduction in and increased consistency of number of transmitted founder variants resulting from challenge seen in the proof of concept study directly correlated with post-treatment GPF animal's improved barrier function and reduction of key target cell populations (Ki-67+ CD4+T cells) at the site of viral acquisition in the follow up study. These data demonstrate that a therapeutic and operational strategy can successfully eliminate varying background levels of EPs and their associated aberrant immunomodulatory effects within a captive macaque cohort, leading to a more consistent, better defined and reproducible research model.

Proktitis (ohne chronisch-entzündliche Darmerkrankung)

Vermehrter Stuhldrang, Schleim‑/Blutabgänge sowie Läsionen an der Mukosa und ödematöse Veränderungen sind typische Beschwerden von Patienten mit Proktitis. Die Symptomatik und häufig auch die klinische Präsentation der Proktitiden sind nicht selten unspezifisch bzw. ähnlich und bedürfen aufgrund der drohenden Komplikationen mit Lebensqualitätseinschränkung einer guten Anamnese und des Wissens um die vielfältigen Ursachen. Man muss die Differenzialdiagnosen kennen, um sie auch erkennen zu können. Unser Fallbeispiel zeigt die Tücken einer vermeintlich leichten Diagnostik. Im vorliegenden Beitrag werden fast alle Proktitiden außer jener der chronisch-entzündlichen Darmerkrankungen beschrieben.

Ultrasonography in infectious and neoplastic diseases of the bowel and peritoneum

Ultrasonography is not the most cited imaging technique for the evaluation of infectious and neoplastic diseases of the gastrointestinal tract and the peritoneum, but it is often the initial technique used in the initial workup for nonspecific clinical syndromes. Despite its limitations, ultrasonography's strengths enable it to provide meaningful diagnostic information. To discuss the most important ultrasonographic, clinical, and epidemiological findings for infectious disease, we follow a topographical approach: stomach (Anisakis), proximal small bowel (Giardia lamblia, Strongyloides stercoralis, Mycobacterium avium-intracellulare complex, and Cryptosporidium), distal small bowel (Yersinia, Salmonella, and Campylobacter), terminal ileum and cecum (tuberculosis), right colon (Entamoeba histolytica), left colon (Shigella), sigmoid colon and rectum, pancolitis (Clostridium difficile, Cytomegalovirus, and Escherichia coli), and peritoneum. To discuss the ultrasonographic and clinical findings of the most common neoplastic diseases, we follow a nosological approach: polyploid lesions as precursors of tumors, carcinomas, neuroendocrine tumors, hematological tumors, mesenchymal tumors, and metastases. We briefly discuss tumors of the peritoneum and the use of ultrasonography to guide percutaneous biopsy procedures.

First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus

Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.

Proctitis: a glance beyond inflammatory bowel diseases

Proctitis is an inflammation involving the anus and the distal part of the rectum, frequently diagnosed in the context of inflammatory bowel diseases (IBD). Nevertheless, when the standard therapy for IBD is ineffective, it becomes necessary for the clinician to review alternative etiologies, beginning from the broad chapter of infectious causes up to rare causes such as radiation, ischemia, diversion and traumatisms. While it is possible to find infectious proctitides caused by pathogens generally inducing extensive colitis, the growing incidence of both sexually transmitted infections and isolated proctitis reported in the recent years require a lot of attention. The risk appears to be higher in individuals participating in anal intercourse, especially men having sex with men (MSM) or subjects who use sex toys and participate to sex parties, dark rooms and so on. The commonest implicated pathogens are Neysseria gonorrhoeae, Chlamydia trachomatis, Herpes Simplex virus and Treponema pallidum. Herpes and Chlamydia infections mainly occur in HIV-positive MSM patients. Since symptoms and signs are common independently from etiology, performing a differential diagnosis based on clinical manifestations is complicated. Therefore, the diagnosis is supported by the combination of clinical history and physical examination and, secondly, by endoscopic, serologic and microbiologic findings. Particular emphasis should be given to simultaneous infections by multiple organisms. The involvement of experts in infectious diseases and in sexual health is crucial for the diagnostic and therapeutic management. The available therapies, empirically initiated or specific, in many cases are able to guarantee a good prognosis and to prevent relapses.

Inflammatory pseudotumor associated with HSV infection of rectal vascular endothelium in a patient with HIV: a case report and literature review

BACKGROUND

Herpes simplex virus (HSV) typically infects oral or anogenital squamous epithelium and causes blisters and ulcerations. Here we reported an unusual case of HSV induced exuberant rectal inflammatory pseudotumor with vascular endothelial involvement.

CASE PRESENTATIONS

A 52-year old man with HIV presented with abdominal pain, rectal drainage and constipation. Proctoscopy and CT scans revealed an 8 × 5 × 4 cm circumferential, mid-lower rectal mass that was concerning for malignancy. PET-CT showed mild to moderate FDG uptake of the rectal mass. Repeated biopsies showed exuberant lymphoplasmacytic inflammation with rich eosinophils and necrosis in the submucosa and scattered single or multi-nucleated viral inclusions in vascular endothelial cells that were positive for HSV by immunostains. There was no evidence of malignancy on histology or by immunostains. The patient started valacyclovir for three weeks and symptoms resolved after the antiviral therapy. Follow-up CT and sigmoidoscopy with biopsy revealed no rectal mass or drainable collection.

CONCLUSIONS

HSV may present as proctitis with exuberant inflammatory response and mass-like lesion, and damages vascular endothelial cells in patients with HIV. The HSV-associated mass-like lesion can be effectively treated by 3-week valacyclovir.

[Time to diagnosis in paediatric inflammatory bowel disease: Key points for an early diagnosis]

Paediatric inflammatory bowel disease is not very common in Spain. Its onset can be silent and an early diagnosis reduces complications and sequelae related to the disease, and can improve the prognosis. It is advisable to define the different intervals into which the time until the diagnosis is divided, as well as the peculiarities and conditions in order to be able to act on them and, to avoid, as far as possible, the diagnostic delay. The aim of this review is to provide tools to reduce the time to diagnosis.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Herpes Simplex Virus Proctitis Masquerading as Rectal Cancer

Herpes simplex virus (HSV) is the leading cause of proctitis in HIV-infected individuals. However, no cases of rectal masses secondary to HSV infection have been reported to date. Herein, we present the case of a 45-year-old man with HIV infection who developed rectal pain and bleeding, along with dysuria and voiding difficulty. Colonoscopy revealed proctitis and a rectal mass with features concerning for rectal cancer. Histologic sections of the rectal mass biopsy demonstrated colorectal mucosa with viral cytopathic changes, ulceration, granulation tissue, marked inflammatory infiltrate, and fibrinopurulent exudate. Immunohistochemistry for herpes simplex virus-1 was positive in epithelial cells demonstrating a viral cytopathic effect. The patient was treated with valacyclovir for 3 weeks, which led to complete resolution of his symptoms. Follow-up sigmoidoscopy at 6 months did not show any masses. Our case illustrates the importance of considering HSV in the differential diagnosis of rectal masses. We advocate the routine use of viral immunohistochemistry for the evaluation of rectal tumors, especially in patients with clinical manifestations and endoscopic findings consistent with proctitis.

Infectious proctitis: a necessary differential diagnosis in ulcerative colitis

INTRODUCTION

In the last years, there was a rising in the incidence of sexually transmitted infections, including proctitis. Infectious proctitis (IP), mainly caused by agents like Neisseria gonorrhea and Chlamydia trachomatis, is an entity that should be considered when patients with suspected inflammatory bowel disease (IBD) are approached, mainly if they have risk factors such as anal intercourse.

CLINICAL CASES/DISCUSSION

The symptoms of IP, like rectal blood, mucous discharge, and anorectal pain, may appear in other causes of proctitis, like IBD. Therefore, to establish the diagnosis, it is crucial to take a detailed history and perform a physical examination, with the diagnosis being supported by complementary tests such as rectosigmoidoscopy, histology, serology, and culture. Depending on the etiology, treatment of IP is based in antibiotics or antivirals, which may be empirically initiated. Co-infections, mainly those that are sexually transmitted, and HIV should be tested and sexual partners should be treated, accordingly. In this article, the authors report three cases of IP, referent to three different patients, and review the initial approach required in cases where there is a clinical and/or endoscopic suspicion of this pathology.

Rectal syphilitic ulcer

Shyphilis is a chronic infectious disease caused by Treponema Pallidum bacteria. Syphilis is most commonly spread through sexual activity, by direct contact with the inoculation point of the spirochete. It has been demonstrated that the desease is more prevalent in men who have sex with men. In primary syphilis, the chancre appears 2-3 weeks after the initial exposure mostly in genitals, but also in oral cavity, pharynx or anus. Secondary syphilis is a systemic disease. It occurs weeks or months later in about 25% of people with primary syphilis that has not been treated. Although many people who present with secondary syphilis do not report previosly having had the classic chancre of primary syphilis.

Sexually transmitted infections of the lower gastrointestinal tract

The World Health Organization estimates that there is greater than one million new cases of sexually transmitted infections (STIs) every day. In many countries, STIs are at an unprecedented high, including the USA, where nearly 20 million new cases were reported in 2016. Although morbidity associated with STIs is usually seen in the context of genitourinary disease, these pathogens may also affect the gastrointestinal tract and cause anal pain, abdominal pain, or diarrhea. It is important to recognize patterns of injury associated with these pathogens, especially those that may mimic other gastrointestinal diseases, such as idiopathic inflammatory bowel disease (IBD). This review focuses upon STIs of the lower gastrointestinal tract, organized by the most common site of involvement: the anus, rectum, and colon.

Are patients in the IBD clinic at risk of proctitis secondary to sexually transmitted infections?

OBJECTIVE

To gauge the potential risk of sexually transmitted infection (STI) as a cause of proctitis in a cohort of patients with inflammatory bowel disease (IBD) and to gauge whether this cohort could benefit from STI testing in the future.

DESIGN

Patients attending the IBD clinic were given an anonymous questionnaire recording demographics, sexual behaviour, rectal symptoms, history of receptive anal intercourse (RAI), STIs and attitudes towards sexual health screening.

SETTING

A gastroenterology teaching hospital IBD clinic.

PATIENTS

280 consecutive patients attending a teaching hospital IBD clinic over a consecutive 6-week period. All patients had an endoscopic, radiological and/or histological diagnosis of IBD.

RESULTS

280 questionnaires were distributed and 274 analysed (3 incomplete, 2 not returned, 1 no sexual activity). 167 female (median: 46 years, range 17-81 years) and 107 males. Two males disclosed RAI and were used as a control. Of the 167 females, 96% were heterosexual, 2.4% were same-sex partners and 1.2% were bisexual. 14% had a history of RAI-this group had more previous STIs (40%) versus those with no history RAI (5%) (p<0.0001; relative risk (RR) 13.41). Chronic rectal pain was more frequent in women with RAI (RR 2.4; p≤0.03). No difference in rectal discharge (RR 1.75; p=0.72) or bleeding (p=0.3).

CONCLUSIONS

This is the first report of sexual behaviours in a non-genitourinary medicine clinic; giving a unique insight into sexual practices in a cohort of patients with IBD. A past history of STI and RAI can identify risk and we propose testing for those with a history of STI, RAI, men who have sex with men and women aged under 25 years.

Herpes Simplex Proctitis Mimicking Inflammatory Bowel Disease in a Teenaged Male

We report the case of a 17-year-old male who was initially assessed for pain with defecation, bloody rectal discharge, and diarrhea, consistent with proctitis. Though proctitis is most commonly due to inflammatory bowel disease (IBD), infectious etiologies must also be considered, including sexually transmitted causes of infectious proctitis. In discussion of his sexual history, he identified as homosexual and acknowledged engaging in receptive anal intercourse. Rectal biopsies obtained via colonoscopy were culture-positive for herpes simplex virus (HSV), leading to a diagnosis of HSV proctitis and treatment with an appropriate antiviral medication. HSV proctitis is more common in individuals with high-risk sexual practices, including men who have sex with men. While this may be an uncommon diagnosis for pediatricians to make in practice, a high clinical index of suspicion for sexually transmitted infectious proctitis in those with risk factors must be maintained in order to facilitate appropriate testing, treatment, and counseling of affected individuals.

Syphilitic proctitis

Syphilitic proctitis is a rare disease that usually presents as proctitis, ulcer, and neoplasm but lacks pathognomonic clinical symptoms. It is thus difficult to diagnose and may be treated inappropriately. We report a 31-year-old man who had a hard, ulcerated mass that occupied the rectal and sigmoid colon wall and mimicked a tumor. Fortunately, a biopsy of the mass demonstrated Treponema pallidum organisms consistent with syphilitic proctitis. The patient was successfully treated with intravenous benzyl penicillin, resulting in improvement in his proctitis.

Sexual health issues in adolescents and young adults

Adolescence is a time of sexual risk-taking and experimentation but also vulnerability. Young people may present to general physicians with systemic symptoms of sexually transmitted infections (STIs), such as arthritis, hepatitis or rash, but may not necessarily volunteer information about sexual activity. It is important for physicians to ask directly about sexual risks and if appropriate test for STIs and pregnancy. Knowing how to take a sexual history and consent a patient for an HIV test are core medical skills that all physicians should be trained to competently perform. Safeguarding young people is the responsibility of all healthcare professionals who come into contact with them, and young victims of abuse may present with physical symptoms such as abdominal pain or deliberate self-harm. We must all be aware of indicators of both child sexual exploitation and HIV infection and not be afraid to ask potentially awkward questions. If we don't we may miss vital opportunities to prevent or minimise harm to young people.

Managing intractable proctitis and the problematic pouch

Proctitis accounts for a significant proportion of cases of ulcerative colitis (UC), and some patients subsequently develop more extensive disease. However, most patients continue to have limited inflammation, although the changes in the distal colon and rectum can occasionally be severe, and symptoms of increased frequency, rectal bleeding and urgency can be as disabling as they are for patients with more extensive colitis. Furthermore, although symptoms are typically well controlled with standard medications, medically refractory proctitis poses particular problems. Patients generally are not systemically unwell, and there is no added fear of cancer. Therefore, the prospect of colectomy for such limited disease is resisted by patients, physicians and surgeons alike. Unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes. The pathogenesis of such limited, yet intractable inflammation remains unclear, and the differential diagnosis should be carefully reviewed to ensure that local disease, whether it is infectious, vascular, or a result of injury or degeneration, is not overlooked. Ileo-anal pouch formation is the surgery of choice for about 20% of patients with UC who undergo colectomy. In the majority of cases, this surgery results in an acceptable quality of life and freedom from a stoma. However, in a sizeable minority of cases, pouch dysfunction can cause intractable problems. The causes of pouch dysfunction are varied and must all be considered carefully, particularly in refractory cases. Pouchitis is a common issue and is usually transient and easily treated. However, refractory and chronic pouchitis can be challenging. Ischaemia, injury, infection and Crohn's disease can all cause refractory pouch dysfunction. In a minority of cases, there appears to be no apparent organic pathology, and the presumptive diagnosis is that of a functional pouch disorder. Although it is much rarer, neoplastic changes in the pouch must also be considered, and the risk managed appropriately. The management of both intractable proctitis and the problematic pouch is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy. Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient. Clinical trials of new treatments should be supported, and data from the experience with small cohorts of patients should be meticulously collected, critically analysed and widely disseminated.