Background Syphilis infections are increasing globally. Lower gastrointestinal syphilis (LGIS) is a rare manifestation of early syphilis transmitted through anal sexual contact. Misdiagnosis of LGIS as inflammatory bowel disease may result from clinician under-awareness. Methods We searched the literature for articles describing cases of LGIS, and identified additional cases diagnosed within our institution. Data were extracted from the articles and medical records and analyzed to provide a summative account. Results 54 cases of LGIS were identified in 39 articles published between 1958 and 2020. 8 additional cases were diagnosed at our institution between 2011 and 2020, totaling 62 cases. All cases were described in men and transwomen aged 15 to 73 years. 50 (93%) individuals endorsed having sex with men. In 26 cases (52%) individuals were HIV co-infected. LGIS presented most commonly with hematochezia (67%) and anal pain (46%). The most common physical exam findings were rectal mass (38%), lymphadenopathy (31%), and rash (26%). Non-treponemal titers ranged from 1:2-1:1024. Of the 52 cases in which endoscopy was reported, 22 (42%) showed anorectal mass and 18 (35%) showed anorectal ulcer. In 44 cases (75%), histopathology revealed a chronic inflammatory infiltrate with a prominent lymphocyte component (45%) and/or plasma cells (36%). 78% of specimens to which a tissue stain was applied were positive for spirochetes. Conclusions LGIS should be suspected in men and transwomen presenting with a lower gastrointestinal symptom or mucosal abnormality. A sexual history must be elicited and guide testing. Misdiagnosis can delay treatment and threatens patient and public health.
Background In the US, syphilis infections have increased 71% since 2014. Proctitis is a rare manifestation of early syphilis transmitted through anal intercourse. We suspect that its misdiagnosis results from physician under-awareness and thus we present the largest case analysis to date of syphilis proctitis. Methods We searched PubMed and Scopus for articles describing cases of proctitis in which Treponema pallidum was a likely causative pathogen based on serologies, and/or organism-specific staining of anorectal biopsy specimens. Furthermore, we conducted chart review to identify cases of syphilis proctitis diagnosed within our health center from 2011-2019. Pertinent data were extracted from the articles and medical records and analyzed to provide a summative account. Results 53 cases of syphilis proctitis were identified in 38 articles. 7 additional cases were diagnosed at our institution, totaling 60 cases. All cases of syphilis proctitis were described in individuals of male sex assignment at birth. The age at diagnosis ranged from 15 to 73 years (average 39 years). In 48 cases (92%) men endorsed sex with men. In 27 cases (56%) individuals were HIV co-infected. Syphilis proctitis presented most commonly with hematochezia (68%) and anal pain (48%). The most common physical exam findings were rectal mass (38%), lymphadenopathy (33%), and rash (31%). Non-treponemal titers averaged 1:60 (range 1:2-1:1024). Endoscopy was performed in 52 cases and most commonly showed anorectal mass (42%) and anorectal ulcer (35%). In 38 cases (68%), histopathology revealed a chronic lymphoplasmacytic inflammatory infiltrate, and in 14 of these cases (37%), prominent plasma cells were described. In 24 cases (77%), treponema immunohistochemical stain revealed spirochetes. Conclusion Syphilitic proctitis should be suspected in boys and men presenting with lower gastrointestinal symptoms. Histopathology, while suggestive, is not pathognomonic, and serology and specific tissue staining are required to make the diagnosis. Given overlapping symptoms and histology with inflammatory bowel disease, the diagnosis may be delayed resulting in personal and public health consequences. A sexual history should be routinely elicited and further testing for syphilis pursued if exposure is suspected. Disclosures All Authors: No reported disclosures
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