A 47-year-old Caucasian male with an 11-year history of human immunodeficiency virus (HIV) presented with new-onset hematochezia (blood in stool), constipation, and rectal pain with defecation for 1 month. He denied any abdominal pain, diarrhea, fever, rash, weight loss, recent travel, new medications, or illnesses. His HIV was well controlled on once-daily elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide, with a CD4 count of 843 cells/μl and an undetectable HIV viral load (VL). He had no history of HIV opportunistic infections but had been diagnosed with late latent syphilis 4 years prior to presentation, for which he was treated with intramuscular benzathine penicillin G. His medical history also included hyperlipidemia, depression, and posttraumatic stress disorder (PTSD), and he regularly took rosuvastatin and paroxetine. He denied any prior surgeries or family history of colon cancer. He was sexually active with men to include receptive anal intercourse. He was referred to the general surgery clinic for his symptoms; his initial vital signs revealed no fever or weight loss, and his exam was notable for a well-nourished male with a small anal fissure. He was prescribed stool softeners and diltiazem rectal cream. The patient’s symptoms persisted for 3 months, and after presenting again to the clinic, his labs revealed a white blood cell count (WBC) of 11,000/μl (normal range, 4,500 to 11,000/μl), a hemoglobin level of 12 g/dl (normal range, 13.5 to 17 g/dl), erythrocyte sedimentation rate (ESR) of 110 mm/h (normal range, 0 to 15 mm/h), and C-reactive protein (CRP) of 18.8 mg/liter (normal range, below 3 mg/liter). A rapid plasma reagin test (RPR) 3 months prior to initial presentation was negative. A colonoscopy revealed no masses or gross abnormalities. Random colonic biopsies were taken, and representative histopathology slides are shown in Fig. 1. He experienced spontaneous symptom resolution without treatment prior to his referral to the Infectious Diseases Service.
FIG 1.
Hematoxylin and eosin stain of colonic mucosa, with arrows highlighting organisms resulting in a thickening or accentuation of the brush border (top) (magnification, ×400) and in a darkened appearance on a Warthin-Starry stain (bottom) (magnification, ×400).
For answer and discussion, see https://doi.org/10.1128/JCM.00401-20 in this issue.