Pimentel Raquel, Correia Catarina, Estorninho João, Gravito-Soares Elisa, Gravito-Soares Marta, Figueiredo Pedro
Department of Gastroenterology, Hospital and University Center of Coimbra, Coimbra, Portugal.
Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
GE Port J Gastroenterol. 2021 May 6;29(4):267-272. doi: 10.1159/000516011. eCollection 2022 Jul.
-lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) and an uncommon cause of proctitis. The diagnosis requires a high index of clinical suspicion, since the clinical, imaging, endoscopic, and histological findings can mimic multiple benign or malignant conditions like inflammatory bowel disease and rectal neoplasms.
We present the case of a 48-year-old Caucasian male with no significant previous medical history who was admitted due to the suspicion of a rectal neoplasia. He underwent an abdominopelvic computed tomography (CT) scan and pelvic magnetic resonance imaging (MRI) before admission due to complaints of anorectal pain, hematochezia, and constipation over the previous 2 weeks. The examination revealed a circumferential rectal wall thickening, infiltration of the perirectal fat and invasion of the mesorectal fascia, associated with perirectal fat lymphadenopathy. A radiological diagnosis of a rectal malignant neoplasia staged as T4N2MX was stated. Digital rectal examination identified a circumferential rectal tumor. Rectosigmoidoscopy showed an extensive and circumferential ulceration of the rectal mucosa, with elevated geographical borders, exudate, and aphthoid erosions at the proximal limit of the endoscopic mucosal ulceration. Biopsy specimens revealed acute ulcerative proctitis with lymphoplasmocytic inflammatory infiltrate but no evidence of dysplasia or malignancy. A STI screening was positive for HIV-1 (CD4+ 251/mm; = 700-1,100) and , with an elevated IgA-specific antibody titer (52.000; < 5.0), suggesting LGV disease. The diagnosis was confirmed by the identification of DNA on rectal swab. Other infectious causes of acute proctitis were excluded. When faced with these results, the patient ended up mentioning that he had unprotected anal sex with men. He started treatment with doxycycline 100 mg twice a day for 21 days, with a drastic improvement. Rectosigmoidoscopy was repeated and showed clear signs of progressive resolution of the ulcerative proctitis.
LGV-associated proctitis, often undervalued, is a reemerging disease which should always be considered a benign cause of rectal mass, in order to avoid delay in diagnosis and development of complications. Diagnosis becomes more challenging in patients with unknown HIV status. A detailed clinical history, including sexual behaviors, is a vital step to achieve the final diagnosis.
性病性淋巴肉芽肿（LGV）是一种性传播感染（STI），是直肠炎的罕见病因。由于临床、影像学、内镜及组织学表现可模仿多种良性或恶性疾病，如炎症性肠病和直肠肿瘤，因此诊断需要高度的临床怀疑指数。
我们报告一例48岁白种男性，既往无重大病史，因怀疑直肠肿瘤入院。因过去2周出现肛门直肠疼痛、便血和便秘，入院前接受了腹部盆腔计算机断层扫描（CT）和盆腔磁共振成像（MRI）检查。检查发现直肠壁环形增厚、直肠周围脂肪浸润及直肠系膜筋膜侵犯，并伴有直肠周围脂肪淋巴结肿大。影像学诊断为直肠恶性肿瘤，分期为T4N2MX。直肠指检发现直肠环形肿物。直肠乙状结肠镜检查显示直肠黏膜广泛环形溃疡，边界呈地图样隆起，有渗出物，在内镜黏膜溃疡近端边界处有阿弗他样糜烂。活检标本显示急性溃疡性直肠炎伴淋巴细胞和浆细胞炎性浸润，但无发育异常或恶性证据。性传播感染筛查显示HIV-1阳性（CD4+ 251/mm；正常范围=700-1,100），且沙眼衣原体IgA特异性抗体滴度升高（52,000；正常范围<5,0），提示LGV病。通过直肠拭子检测到沙眼衣原体DNA确诊。排除了急性直肠炎的其他感染原因。面对这些结果，患者最终提及与男性有过无保护肛交。开始每日2次口服多西环素100mg，共21天，病情显著改善。复查直肠乙状结肠镜检查显示溃疡性直肠炎有逐渐好转的明显迹象。
LGV相关直肠炎常被低估，是一种重新出现且应始终被视为直肠肿物良性病因的疾病，以避免诊断延迟和并发症的发生。对于HIV状态不明的患者，诊断更具挑战性。详细的临床病史，包括性行为，对于最终诊断至关重要。
