Acute Proctitis in Patients With Mpox and Syphilis

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Conference Proceeding

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American Journal of Gastroenterology


Introduction: We present a rare case of a patient with acute proctitis who was diagnosed with monkepox and syphilis at the same time. Case Description/Methods: A 29-year-old man with a past medical history of untreated HIV, presented with rectal pain, tenesmus for 3 days, and erythematous pustular lesions on the chest, back, and face. The patient described his rectal pain as a sandpaper, burning type of pain that prevented him from sleeping. He stated that passing gas relieved some of his abdominal discomfort. The patient reported having bloody mucus discharge for the past 3 days. He had no signs of overt or occult gastrointestinal bleeding. Upon presentation to emergency department, normotensive with a blood pressure of 112/76 mm Hg, tachycardic with a pulse of 118 beats per minute, and afebrile. His labs were significant for sodium of 134 (reference range 135-145) mmol/L, random blood glucose of 183 (reference range 60-139) mg/dL, and protein of 8.6 (reference range 6.4-8.3) g/dL. His CT scan of the abdomen and pelvis with intravenous contrast demonstrated rectal wall thickening, perirectal fat stranding and a few mildly enlarged perirectal lymph nodes that suggested acute proctitis (Figure 1). Rectal exam and flexible sigmoidoscopy were deferred due to patient’s excruciating pain. Visual anus inspection revealed purulent discharge. The patient was empirically started on ceftriaxone and doxycycline to cover Chlamydia trachomatis and Neisseria gonorrhea given his recent history of multiple man sexual partners. His CD4 absolute count came back as 437 (433-1722 reference range) mil/L. Ova and parasite antigen screen, stool culture, cyclospora, isospora, and microsporidia stains were negative. Nucleic acid amplification testing for Chlamydia trachomatis and Neisseria gonorrhea from the rectal swab had returned negative. Rapid plasma reagin came back reactive with a titer of 1: 128. Syphilis total antibody was reactive as well. The patient received penicillin g benzathine injection 2.4 million units. Mpox (Orthopoxvirus) DNA was detected by PCR. He was started on tecovirimat 600 mg twice daily for 14 days. His rectal pain resolved 7 days after presentation. The patient continued to improve and denied having fever, chills, melena, hematochezia, or red blood per rectum. Discussion: Prompt identification as well as a high index of suspicion are necessary for proper diagnosis and management of mpox and syphilis in immunocompromised patients with acute proctitis





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American College of Gastroenterology Annual Scientific Meeting, October 20-25, 2023, Vancouver, Canada

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