Lymphogranuloma Venereum Proctitis Can Mimic IBD

By Will Boggs MD

June 12, 2019

NEW YORK (Reuters Health) - Lymphogranuloma venereum proctitis can be mistaken for inflammatory bowel disease (IBD), especially in men who have sex with men (MSM) and others who engage in unprotected anoreceptive sexual intercourse, researchers from Italy report.

"Rectal symptoms and signs of lymphogranuloma venereum (LGV) proctitis may be similar to those caused by several other etiological factors (infections, hemorrhoids, diverticular disease, inflammatory bowel disease, neoplasia, etc.)," Dr. Andrea Filippini from Universita degli Studi di Bologna Scuola di Medicina e Chirurgia, in Bologna, told Reuters Health by email.

"Remarkably, a high percentage of LGV patients with symptomatic proctitis reports long-lasting examination, misdiagnosis, and even invasive diagnostic or therapeutic procedures (endoscopy with biopsy execution and/or radical surgery) in the suspicion of IBD before the Chlamydia-positive rectal swab," he said.

LGV, a sexually transmitted disease caused by Chlamydia trachomatis serovars L1-L3, typically presents as genital ulceration and/or painful erythematous inguinal lymphadenopathy. When the rectum is the site of primary inoculation (as happens among MSM and women who practice anoreceptive sexual intercourse), muco-hemorrhagic proctitis, usually without inguinal lymphadenopathy, can occur.

More commonly, though, LGV proctitis presents as a nonspecific proctitis with abdominal discomfort, anal pain, diarrhea or constipation, and blood, mucus and pus discharge - symptoms that can mimic IBD and other conditions. Endoscopic findings and histological features can also mimic IBD.

Dr. Filippini's team report their experience with 11 patients affected by LGV who underwent endoscopy with or without endoscopic biopsy for the suspicion of IBD before having a Chlamydia-positive rectal swab. All 11 patients were MSM, and seven were HIV-positive.

Tenesmus, the feeling of needing to pass stools even when the bowels are already empty, and anal discharge were the most common presenting symptoms, seen in nine patients. Eight patients had hematic and mucosal secretions, and five presented with an anal external ulceration.

Most patients (8/11, 72%) had been treated for IBD after a rectal biopsy suggestive of IBD for periods ranging from one to 37 months with no or only minimal improvement of symptoms after previous treatments.

Two patients had undergone proctological surgery for a diagnosis of perianal Crohn's disease before their Chlamydia-positive rectal swab.

All 11 patients achieved a complete recovery within weeks after treatment with minocycline 100 mg twice daily for 21 days, the researchers report in Crohn's and Colitis 360, online May 10.

"A high index of suspicion is necessary to carry out the proper exams for a correct diagnosis," Dr. Filippini said. "Physicians should carefully collect information about the patient’s sexual risk behavior and should be aware that both HIV-negative and HIV-positive MSM, as well as heterosexuals who practice anal intercourse, complaining about unspecific anorectal symptoms, should be tested for LGV and even treated presumptively."

Dr. Itsik Levy from the Sackler Medical School, Tel Aviv University, in Israel, who recently reported on 16 patients diagnosed with a colorectal sexually transmitted disease (STD) after being misdiagnosed with IBD, told Reuters Health by email, "In the past, LGV was described mainly as a urogenital disease causing genital ulcers and inguinal lymph node enlargement. Since 2003 the disease has changed its face and started to cause an invasive proctocolitis among MSM, starting in the Netherlands but soon after that has spread all over Europe. In the last couple of years the serotype that causes IBD-like disease has spread also to Israel and in a recent report we describe the same findings."

"When somebody comes with symptoms that may resemble IBD, especially proctocolitis or rectal symptoms, include in the history taking also sexual history and send an HIV test along with PCR for STDs," said Dr. Levy, who was not involved in the new work.

"Every proctitis/colitis occurring in a sexually active MSM should raise the suspicion of LGV," he said. "Now, in Israel, in every MSM who presents with colorectal symptoms (diarrhea, constipation, pain, blood in the stools, etc.), we send a specimen for a NAAT (nucleic-acid-amplification test) and if positive to chlamydia we are sending to subtyping with a sequencing technique (MLST) and if we diagnose LGV we treat appropriately."

He added that urine testing for STDs is not adequate for identifying STDs in anal or pharyngeal locations. "In sexually active people, you should test for STDs in all three locations," he said.

A rectal swab for NAATs is the most sensitive method for identifying Chlamydia, although commercial assays are not able to differentiate L from non-L serovars, Dr. Filippini and colleagues note.

LGV identification requires Chlamydia trachomatis-molecular genotyping, they add. An elevation of anti-Chlamydia IgG and IgA can suggest the diagnosis of LGV in appropriate settings where advanced testing is unavailable.


Crohns Colitis 360 2019.