Squamous Intraepithelial Lesion of the Anus in a Man With HIV Infection

Susan C. Ball, MD, MPH

Disclosures

AIDS Read. 2004;14(9) 

In This Article

Introduction

Terry is a 37-year-old gay white man who complained of painful hemorrhoids. Terry cuts hair for a living and is on his feet most of the time. He has been HIV-positive for 10 years. He has never had an opportunistic infection; his viral load has been undetectable since he began antiretroviral therapy in 1996. His lowest CD4+ cell count was 310/µL. Terry's current CD4+ cell count is 670/µL, and he is receiving efavirenz, didanosine, and tenofovir. He has tolerated his medications fairly well over the years, and his adherence has been excellent. Terry was treated for primary syphilis in 1999 and again in 2002. He denies a history of herpes simplex. He has had 2 steady boyfriends since you have known him but is not currently in a relationship. He "almost always" practices safer sex.

Terry had no findings other than a small internal and small external hemorrhoid on a digital rectal examination. Guaiac testing for occult blood in the stool was negative. You considered doing a rectal Papanicolaou (PAP) smear but were not sure how to go about it. You prescribed some rectal suppositories with hydrocortisone and stool softeners.

Terry called 2 weeks later to ask whether his hemorrhoids could be removed, because they were really bothering him; sometimes after defecation, he noted spots of blood on the toilet tissue. You referred him to a colorectal surgeon, whose practice is made up largely of gay men. The surgeon agreed to see Terry that week.

One month later, Terry called to say that the surgeon had told him that a rectal PAP smear revealed a high-grade squamous intraepithelial lesion (SIL) in his anus, which required treatment. Terry said he felt very confused by what the surgeon was telling him. He thought PAP tests were for women. The surgeon had told him the lesion was probably caused by human papillomavirus (HPV) and was associated with genital warts. Terry claimed he had never had a wart in his life, much less a wart in his anus. Worst of all, the surgeon had told Terry that his high-grade lesion put him at risk for anal cancer, in the same way women with abnormal PAP tests were at risk for cervical cancer. You asked Terry to see you to discuss this situation and try to clarify what he has been told.

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