The Great Imitator Imitates Again
November 15, 2022 2 minutes read
By Carol A. Kemper, MD, FACP
Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center
SOURCE: Chang H, Tang TY, Kuo CF. Syphilitic pancolitis: A case report with literature review. Int J STD AIDS 2022;33:618-621.
With the nationwide increase in syphilis cases, we are seeing some interesting and unusual manifestations of syphilis — including a case of syphilitic gumma or osteomyelitis in the wrist and several cases of neurosyphilis and/or ocular syphilis with posterior uveitis. A recent case of severe secondary syphilis masqueraded as “long COVID” with three months of fatigue, lymphadenopathy, sore throat, headache, and progressive hair loss. Interestingly, an initial rapid plasma reagin (RPR) was negative (possibly from prozone effect). The subsequent development of rash and a skin biopsy with immunohistochemical staining confirmed the diagnosis, and a repeat RPR was 1:256. The authors described an unusual case of pancolitis caused by secondary syphilis in a 64-year-old man with recent unprotected receptive anal intercourse two months earlier. He presented with one month of diarrhea, tenesmus, and weight loss. Stool studies were unremarkable, and an initial HIV test was negative. Colonoscopy revealed extensive pancolitis with mucosal ulcerations with mucous coating from the cecum to the rectum; the terminal ileum was spared. Histopathology of cecal and rectal biopsies showed chronic active inflammation with lymphoplasmacytic infiltrate with cryptitis and crypt abscesses. Immunohistochemical staining was positive for Treponema pallidum spirochetes. An RPR titer was 1:4. He converted his HIV testing on subsequent studies.
This case report serves as a reminder that even though pancolitis from secondary syphilis is rare, syphilitic proctitis is a not-uncommon manifestation of syphilis — and that syphilis can present as almost anything — even long COVID. Syphilitic proctitis may present similarly to other STDs or enteritis, with painful defecation, rectal bleeding, and diarrhea — but at least clinicians might be more likely to screen for STDs. A syphilitic pancolitis could fool somebody, and the pathology easily could be mistaken for inflammatory bowel disease — unless immunohistochemical staining or T. pallidum PCR is performed. A sexual history and RPR screening are important parts of the workup of “enterocolitis” or proctocolitis.
This case report serves as a reminder that even though pancolitis from secondary syphilis is rare, syphilitic proctitis is a not-uncommon manifestation of syphilis — and that syphilis can present as almost anything — even long COVID.
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