26 y/o M no PMH presents to the ED with c/o 1 month rectal pain and bleeding. Has been having sharp rectal pain worsened with moving bowels for about 4 weeks. Occasionally passes streaks of bright red blood or a thin purulent discharge. Feels like he has had low-grade fevers at home. Pain occasionally is felt in lower part of his abdomen. Reports that stools are mildly loose.
ROS: Negative aside from above
PMH: None
PSH: None
Meds: None
All: NKDA
SH: No toxic habits, has 1 male sexual partner
Vitals – T 100.4F, HR 88, RR 12, BP 128/77
PE negative except for:
– Mild lower abdominal tenderness without rebound or guarding
– B/l tender inguinal LAD
– Pain with DRE, small amount of bright red blood and purulent mucous on glove
For all the marbles, answer these questions:
What is your differential diagnosis? What would your workup entail? How would you treat your suspected diagnoses?
James Hassel
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Ddx: Sounds like proctitis, caused by syphillis, gonorrhea, chlamydia, or herpes, which this pt is at risk for if he is an MSM, especially the anal-receptive partner and does not use condoms. The inguinal lymphadenopathy points more towards syphilis as the cause of proctitis. You should look for perianal chondyloma lata. The differential also includes anal fissure, anorectal abscess or fistula, or if this patient has HIV/AIDS, he is susceptible to many anorectal opportunistic infections (shigella, salmonella, CMV, crypto, giardia). Also, he may be severely constipated which can cause the abdominal pain, and with straining can lead to fissures/bleeding and even rectal prolapse causing his symptoms (recently saw a case of that at Janus General). I’d also be suspicious of IBD / Crohns.
Workup: Labs with CBC, blood cultures, UA (with GC/chlamydia), RPR/treponemal antibody, VBG/shock, and HIV test . Given the concern for IBD I’d also get a CT scan to look for abscesses and fistulas.
Treatment: for syphilis proctitis– penicillin G IM, or doxy 100mg po bid x 14d. Of course, don’t forget about pain control, stool softener, sitz baths.
Fun fact: if it is rectal prolapse, grab a packet of sugar and dump it on the prolapsed rectum, mix with some sterile lube, and watch for 2-3 minutes as the rectum shrinks down and then is easily pushed back inside. Delicious.
Excellent work Kylie. I think the leading diagnosis is proctitis and my differential doesn’t vary all that widely. This patient is in a high risk patient population for anorectal disease associated with pathogens that cause typical STI’s. However, I think the more prevalent organisms are going to be the GC/chlamydia. With out any skin findings, I put syphilis and herpes lower on my differential. I think this patient has chlamydial proctitis caused by the the same serovars that cause lymphogranuloma venereum which might explain the b/l tender LAD and have been known to cause purulent anorectal disease in the MSM patient population. I would add on an anal GC/Chlamydia culture or nucleic acid amplification if the lab has verified it. Just as on the anterior portion of the perinium, where chlamydia goes, gonorrhea is sure to follow and vice versa, meaning co-infection is certainly possible, if not likely. I think this patient requires treatment with Ceftriaxone IM 250mg and a 3 week course of doxycycline 100mg BID given the high risk population, fever, and likely strain of chlamydia involved.
Thanks
Kopping