Sexual history: its importance in averting detrimental misdiagnosis and delayed diagnosis

Abstract

Two cases where the sexual history proved important in reaching the diagnosis are presented. Case 1 concerns a 37-year-old HIV positive homosexual man, who presented with symptoms of rectal pain associated with bleeding. He was unsuccessfully treated for Crohn disease. A subsequent review of his sexual history led to investigations for venereal infections. A final diagnosis of proctitis secondary to lymphogranuloma venereum was made. The patient was successfully treated with doxycycline and spared an unnecessary colectomy. Case 2 concerns a 22-year-old Caucasian woman under investigation for possible lymphoma. However, the doctor carrying out the biopsy experienced a needle stick injury and the ensuing investigations revealed the patient’s HIV positive status and thus the explanation for her hitherto undiagnosed lymphadenopathy. A prior review of her sexual history could have hastened the diagnosis and prevented the need for invasive tests.

BACKGROUND

The omission of a patient’s sexual history is often the norm in primary and secondary care. Indeed, for a significant proportion of the time it is not pertinent to the case. However, when relevant, it is usually not taken for different reasons. We present two cases where the patient’s sexual history ultimately led to an accurate diagnosis and avoided unnecessary intervention. Firstly, lymphogranuloma venereum (LGV) is often misdiagnosed as inflammatory bowel disease and many patients, frequently with concomitant HIV infection, have wrongly been treated with immunosuppressive drugs such as prednisolone, cyclosporine and mycophenolate mofetil. Furthermore, transmission of HIV and other infections through anorectal ulcerations is an important complication of delayed diagnosis and management. The case demonstrates how a thorough history, including a sexual history, saved a patient from an unnecessary colectomy for assumed Crohn disease. The second case highlights that lymphadenopathy in a young British Caucasian woman is as likely to be an HIV infection as it is a primary malignancy, and how a comprehensive history, including a sexual history, could obviate the need for extensive investigations.

CASE PRESENTATION

Case 1

A 37-year-old HIV positive homosexual Caucasian man presented to his general practitioner with symptoms of rectal pain associated with bleeding and diarrhoea in 2008. A subsequent sexual history revealed that the patient had been in a relationship for 15 years with a male partner. He had had 10 sexual partners in the previous 6-month period and practiced receptive anal intercourse.

Case 2

A 22-year-old Caucasian woman had been under investigation in 2008 for palpable lymphadenopathy in her axillary tail and weight loss. A sexual history was subsequently obtained that showed she had been sexually active since the age of 16 and had been employed on an international cruise ship, with sexual partners from high-risk countries.

INVESTIGATIONS

Case 1

Colonoscopy demonstrated an extensively ulcerated rectum and sections of rectal biopsies confirmed patchy marked inflammation (fig 1). Being patchy in nature, Crohn disease was suspected. MRI revealed enlarged lymph nodes in the pelvis, with a thickened wall of rectum and sigmoid.

Figure 1.

Histopathology: low power (×40) view of rectal mucosa showing a non-specific active chronic proctitis.

A rectal swab for strand displacement amplification (SDA) LGV-specific DNA was positive. Furthermore, serology for Chlamydia trachomatis IgG was 1024 ng/ml, IgM <8 ng/ml, IgA <8 ng/ml, indicating previous exposure to occulogenital classical C trachomatis (serovars D–K).

Case 2

The patient was initially investigated by the breast team. An ultrasound of the left axilla showed evidence of large lymph nodes measuring up to 4 cm with a very thick cortex. Multiple core biopsies were taken from her axillary nodes. However the doctor carrying out the biopsy on the patient experienced a needle stick injury and the ensuing investigations revealed the patient’s HIV positive status and thus the cause of her lymphadenopathy.

TREATMENT

Case 1

The patient was initially given mesalazine suppositories for presumed Crohn disease, which had no effect. Following a review of his sexual history, a final diagnosis of proctitis secondary to LGV was made. The patient was successfully treated with doxycycline, 200 mg twice a day for 6 weeks.

OUTCOME AND FOLLOW-UP

Case 1

The considerable rectal blood loss diminished after about a fortnight of doxycycline and had stopped completely after a month of antibiotics. The rectal SDA LGV-specific DNA test was repeated after the course of doxycycline and it was negative.

DISCUSSION

Many doctors usually find it difficult to take a sexual history, even when the presenting problem is of a sexual nature. The patient and the doctor can be embarrassed and uncomfortable.¹ The cases discussed in the present report reveal that omission of sexual history can lead to misdiagnosis (case 1) and delayed diagnosis (case 2).

LGV is a sexually transmitted infection that is caused by C trachomatis serovars L1, L2 and L3,² which invade and destroy lymphatic tissue.³ Proctitis due to LGV is more common in women and in men who practice receptive anal intercourse, via direct inoculation.² LGV, though endemic in some tropical countries, is uncommon in the UK.⁴ Patients present with rectal pain and bleeding, and frequently with marked constitutional symptoms (pyrexia and weight loss).²

LGV cases have increased across Europe and the UK in recent months,⁴ and it is important that awareness is increased among doctors to whom such cases may present. The patient in case 1 had consulted his general practitioner and a gastroenterologist. The colorectal surgeon, following a sexual history, thought it relevant for the patient to be reviewed by genitourinary medicine. It was then that a further review of the sexual history and subsequent microbiological investigations led to the diagnosis of LGV. Consequently, the patient was spared an unnecessary colectomy and immunosuppressive treatment, which would have been detrimental to his HIV management.

The classical presentation of LGV is with genital ulceration and associated painful inguinal lymphadenopathy that may suppurate and rupture (bubo).⁴ By the end of 2005, 292 cases of LGV in men who have sex with men were reported to the UK Health Protection Agency.³ From October 2004 to the end of April 2007, 492 cases of LGV had been diagnosed in the UK.⁵ Cases are focused in mainly white gay men with high levels of HIV (74%) and hepatitis C (14%) infection.⁵ Untreated infection can cause lymphatic obstruction and fibrosis leading to genital elephantiasis and, in rectal infections, strictures and fistulae can ensue.^2,4

The needle stick injury in case 2 led to the diagnosis of HIV in a young Caucasian British woman under investigation for undiagnosed lymphadenopathy. The subsequent review of her sexual history revealed that HIV infection would have been high on the differential if it had been included in her medical history months before, and would have obviated the needed for extensive investigations. She was also found to be Chlamydia positive and with a degree of cervical intraepithelial neoplasia.

Doctors often ignore the sexual history for reasons such as embarrassment, feeling ill prepared, or not realising the importance to the presenting complaint.⁶ It has been proposed that barriers to improved sexual healthcare can be overcome by primary care doctors proactively and routinely addressing sexual health. Routine assessment of sexual health will also improve preventative care, such as immunisation against hepatitis B in high-risk individuals, counselling on high-risk behaviour and treating Human papillomavirus early before invasive disease.⁶

A simple, routinely used and non-judgemental algorithm to obtain a sexual history can be useful in overcoming any difficulties (fig 2).

Figure 2.

A simple non-judgemental algorithm to obtain a basic sexual history.

LGV is an increasing infection in the UK and other countries and doctors should be more aware. As ulcerations increase the transmission rate of HIV and other sexually transmitted infections, it is important that LGV be diagnosed and treated promptly. Lymphadenopathy in any patient, regardless of demographics, should have HIV infection as a differential diagnosis. A sexual history is important in reducing the delay of important diagnosis and consequently prevents the use of treatment, which can have a negative outcome.

LEARNING POINTS

• Doctors often ignore the sexual history for reasons such as embarrassment, feeling ill prepared, or not realising the importance to the presenting complaint.

• Lymphogranuloma venereum (LGV) is an increasing infection in the UK and other countries and doctors should be more aware.

• Lymphadenopathy in any patient, regardless of demographics, should have HIV infection as a differential diagnosis.

• A simple, routinely used and non-judgemental approach to the sexual history can be useful in overcoming any difficulties.