Intestinal Spirochetes Associated With Asymptomatic COVID-19 Infection

Abstract

A 60-year-old, human immunodeficiency virus (HIV)-negative, homosexual male presented to our colorectal clinic with abdominal pain for three weeks followed by persistent watery diarrhea refractory to loperamide. He had no history of recent travel, no known infectious contacts, and his last colonoscopy nine years prior was within normal limits. After one episode of hematochezia, computed tomography of the abdomen/pelvis was performed demonstrating colitis and coronavirus disease 2019 (COVID-19)-related changes to the lung bases. Testing confirmed COVID-19 infection which was self-limited. The initial workup for infectious colitis was negative. Colonoscopy revealed no evidence of gross colitis. Histopathology demonstrated microscopic colitis with spirochete colonization of the intestinal epithelium. A course of metronidazole led to the resolution of the patient's symptoms.Intestinal spirochetosis has been described as a rare source of colitis caused by the organism Brachyspira pilosicoli in an immunocompromised population (HIV-positive, organ transplant). It is associated with abdominal pain and refractory diarrhea. This report details the unique case of intestinal spirochetosis in an HIV-negative, COVID-19-positive patient with no other risk factors for immunosuppression. Further review is necessary to establish a true association; however, this case suggests that intestinal spirochetosis should be considered during the workup of chronic diarrhea (more than two weeks) in COVID-19-positive patients.

Factors and presenting symptoms associated with intestinal spirochaetosis in men who have sex with men: A systematic review

“…7,12,14,17,22,27 Furthermore, co-infection with (sexually transmitted) intestinal parasites Giardia duodenalis and Entamoeba histolytica and COVID-19, was associated with intestinal spirochaetosis in MSM. 14,15,26…”

“…The predominant clinical symptom of intestinal spirochaetosis in MSM was diarrhoea and some reported mucus and/or rectal blood or bleeding. 7,[12][13][14][15]17,[20][21][22][23][24][25][26][27] MSM also presented with non-specific gastrointestinal symptoms, abdominal pain, vomiting, constitutional symptoms including night sweats, rash and weakness, rectal symptoms including rectal pain, rectal discharge, flatulence and tenesmus. 7,[12][13][14][15][16][17][21][22][23][24][25][26][27]…”

“…The manuscripts were from Europe (n = 7), North America (n = 5), South America (n = 1) and Australia (n = 2) and included case reports (n = 6), case series (n = 4) and cross-sectional studies (n = 5). 7,[12][13][14][15][16][17][20][21][22][23][24][25][26][27] Altogether there were 188 individual MSM with intestinal spirochaetosis included in this review. We identified both biological and behavioural factors and were able to characterize specific presenting symptoms associated with intestinal spirochaetosis in MSM (Tables 2 and 3).…”

“…Specific sexual behaviours, particularly oro-anal sexual contact (rimming), oro-genital contact, insertion of the fist into the rectum (fisting), condom-less anal sex and receptive anal sex were associated with intestinal spirochaetosis in MSM. 7,13,14,23,26 Having multiple non-regular sexual partners alongside increased number of sexual partners over their life time, was also associated with intestinal spirochaetosis in MSM. 7,13,15,17,26 Frequent antibiotic use was associated with MSM with intestinal spirochaetosis infection.…”

“…7,13,14,23,26 Having multiple non-regular sexual partners alongside increased number of sexual partners over their life time, was also associated with intestinal spirochaetosis in MSM. 7,13,15,17,26 Frequent antibiotic use was associated with MSM with intestinal spirochaetosis infection. 14…”