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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.6 Madrid jun. 2018

http://dx.doi.org/10.17235/reed.2018.5500/2018 

LETTERS TO THE EDITOR

Proctitis and perirectal abscesses: is there anything else to think about?

Alicia Martín-Lagos-Maldonado1  , Myriam-del-Carmen Herrera-Mercader2  , Cristina Lozano-Cejudo3 

1Servicio de Aparato Digestivo. Hospital Campus de la Salud. Granada. Spain

2Servicio de Aparato Digestivo. Hospital Virgen de Altagracia de Manzanares. Ciudad Real. Spain

3Servicio de Radiodiagnóstico. Hospital General Universitario de Ciudad Real. Ciudad Real. Spain

Key words: Proctitis; Chlamydia trachomatis; Lymphogranuloma venereum; Perianal disease

Dear Editor,

Lymphogranuloma venereum (LGV) has emerged as an important cause of proctitis and proctocolitis in men who have sex with other men.

Case report

We present the case of a 49-year-old male with a history of human immunodeficiency virus (HIV) infection under active treatment. He presented with rectal bleeding and tenesmus of a month duration. Colonoscopy identified aphthous ulcers and festering exudate as well as a deep ulcer in the rectum. The biopsy specimens identified active colitis and were negative for malignant cells (Fig. 1A). Perianal magnetic resonance (RMN) revealed a thickening rectum wall with small intramural abscesses, suggestive of Crohn's disease (Fig. 1B). Due to the unclear diagnosis of the endoscopic findings and the clinical context, a second endoscopy was performed to investigate infectious agents. These included the polymerase chain reaction (PCR) test for cytomegalovirus (CMV), herpes simplex virus (HSV), Pallidum trepnema, Gonorrhoeae neisseria, human papillomavirus (HPV), fungus infection and mycobacterium. These were all negative, except for a positive Chamydia trachomatis test. A diagnosis of LGV with perianal involvement and incipient intra and extramural abscesses was confirmed and treatment with doxycycline at 100 mg orally, twice daily for 21 days was initiated. The patient was also recommended to abstain from having sexual relations. The patient had a favorable improvement and a sigmoidoscopic revision eight weeks later reported the complete absence of lesions.

Fig. 1 A. Colonoscopy. A deep rectal ulcer of almost 1.5 cm with a significant festering exudate. B. Magnetic resonance axial T2 imaging. An irregular thick rectal wall with deep ulcers that affect the entire wall (red arrow). Furthermore, a hyperintensive focus in the muscularis layer (green arrow) is seen, limiting the diffusion corresponding to the intramural microabscess. 

Discussion

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis. The classical inguinal presentation is now increasingly uncommon in our environment, where LGV has emerged as a leading cause of proctitis and proctocolitis in men who have sex with men 1,2. Its clinical and endoscopic presentation can be confused with an inflammatory bowel disease. Prolonged infection can lead to the development of complications such as perirectal abscesses or stenosis, underlining the need for an early diagnosis and treatment 3,4.

Bibliografía

1. Lee K, Kim J, Hwan D, et al. Chlamydial proctitis in a young man who has sex with men: misdiagnosed as inflammatory bowel disease. Chonnam Med J 2015;51:139-41. DOI: 10.4068/cmj.2015.51.3.139 [ Links ]

2. Fukushima K, Yanagisawa N. Severe proctitis caused by Chlamydia trachomatis Serovars D. Intern Med 2016;55:3231. DOI: 10.2169/internalmedicine.55.7209 [ Links ]

3. Pérez-Sánchez LE, Hernández-Barroso M, Hernández-Hernández G. Rectal inflammatory stenosis secondary to Chlamydia trachomatis: a case report. Rev Esp Enferm Dig 2017;109(9):668-9. DOI: 10.17235/reed.2017. 4917/2017 [ Links ]

4. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2015. MMWR Recomm Rep 2015;64(RR3);1-137 [ Links ]