TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

CURRICULUM BASED CLINICAL REVIEW Sexually transmitted infections manifesting as proctitis

Chris A Lamb,1,2 Elizabeth Iris Mary Lamb,1,3 John C Mansfield,4 K Nathan Sankar5

1Institute of Cellular Medicine, ABSTRACT sustained annual increase in the incidence Newcastle University, Newcastle There is a rising incidence of several sexually of sexually transmitted infections (STIs) upon Tyne, UK 1 2Department of transmitted infections (STIs), many of which can over the past decade. Several STIs Gastroenterology, Newcastle present with proctitis. Causative organisms including gonorrhoea, chlamydia, upon Tyne Hospitals NHS include , Chlamydia and herpes virus can manifest with symp- Foundation Trust, Newcastle trachomatis, virus, Treponema toms and endoscopic features of proctitis. upon Tyne, UK 3Northern Deanery General pallidum (syphilis), Giardia lamblia (giardiasis) This article outlines these diagnoses and Practice Vocational Training and Entamoeba histolytica (amoebiasis). This suggests key clinical features or important Scheme, Northern Deanery, paper outlines important clinical discriminators diagnostic tests that may aid earlier diag- North East Strategic Health and key investigations to distinguish these Authority, Newcastle upon Tyne, nosis and appropriate treatment. UK organisms from non-infective pathology that 4Institute of Genetic Medicine, include inflammatory bowel disease, solitary Newcastle University, Newcastle rectal syndrome and Behçet’s syndrome. GONORRHOEA upon Tyne, UK Caused by Neisseria gonorrhoeae, gonor- 5Department of Genitourinary Management of these infections is described Medicine, Newcastle Primary and suggestions are made for successful rhoea is transmitted by direct contact of Care Trust, Newcroft Centre, gastroenterology clinical consultation when an mucosal surfaces, and so proctitis is com- Newcastle upon Tyne Hospitals STI is suspected. monest in men or women participating in Trust, Newcastle upon Tyne, UK receptive anal intercourse, although in Correspondence to women it can occur due to transmucosal Dr Christopher Andrew Lamb, INTRODUCTION spread of infected genital fluid. Symptoms Institute of Cellular Medicine, Patients presenting to secondary care of proctitis are non-discriminatory includ- The Medical School, Newcastle with symptoms of diarrhoea and rectal ing lower abdominal pain, diarrhoea, University, William Leech

Building, Framlington Place, may be found to have features rectal bleeding and tenesmus; however, it http://fg.bmj.com/ Newcastle upon Tyne NE2 4HH, consistent with inflammatory bowel may be associated with an anorectal puru- UK; [email protected] disease (IBD) on endoscopic or radio- lent discharge. Diagnostic suspicion Received 26 October 2012 logical investigation. The main differen- should be raised in the presence of ureth- Revised 26 October 2012 tial diagnoses of infectious colitis, ral discharge and/or pharyngeal Accepted 29 October 2012 ischaemic colitis and non-steroidal anti- infection.2

inflammatory drug enteropathy are well Anogenital samples should be sent for on September 25, 2021 by guest. Protected copyright. understood and widely covered in the lit- immediate Gram stain, in which the pres- erature. However, there are several less ence of Gram-negative diplococci are sug- commonly encountered causes of intes- gestive of a diagnosis with a sensitivity of tinal that may not respond 90–95%2 (although the specificity of this to, or be made worse by, immunosup- test may be lower than 60%).3 Nucleic pressant therapy intended for Crohn’s acid amplification tests (NAAT, eg, PCR), disease or . Competency although not yet licensed for this anatom- 2.c. of the 2010 Gastroenterology cur- ical site2 are more sensitive than culture riculum (box 1) stipulates that UK trai- and based on available evidence should nees must have an appreciation of the be used for diagnosis. In addition, ano- range of potential aetiologies and the genital and pharyngeal swabs in the investigative process of differential causes appropriate transport medium (as advised To cite: Lamb CA, Lamb EIM, of intestinal inflammation, in order to by the local microbiologist) should also Mansfield JC, et al. Frontline guide appropriate and successful thera- be sent for culture in order to determine Gastroenterology 2013, 4, peutic intervention. In the UK and many antibiotic sensitivities. A high proportion 32–40. other western countries there has been a of patients with confirmed gonococcal

32 Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

trachomatis by NAAT and genotyping. Testing for Box 1 Gastroenterology curriculum 2010 other STIs including HIV (which is particularly asso- ciated with LGV), hepatitis B and C, syphilis and gon- Competency 2.c. Intestinal disorders: Inflammatory and infective conditions orrhoea should also be undertaken in confirmed ▸ Recognises the range of important inflammatory conditions of the intestine other than inflammatory bowel disease cases. Current European guidance on the management ▸ Knows the range of potential aetiologies including infection of LGV recommends doxycyline 100 mg twice a day ▸ Knows the means of investigation of infectious diseases for 21 days first line, or erythromycin 500 mg four times a day for 21 days.4 Symptoms should abate within 7–14 days. Patients should be advised to infection will also have chlamydia, and so involvement abstain from sexual contact until completion of of genitourinary medicine (GUM) specialists and therapy, and sexual partners within the preceding testing for co-infection must be undertaken in con- 3 months should be notified and screened for infec- firmed cases. tion. A test of cure should be performed at least Treatment of rectal gonorrhoea without available 4 weeks following completion of therapy. antibiotic sensitivities should be with ceftriaxone 500 mg intramuscularly once, alongside azithromycin CHLAMYDIA 1 g orally once.2 Gonorrhoea is becoming increasingly Caused by C trachomatis serovars D–K, transmission resistant to cefalosporins and so repeat testing is advis- of chlamydia is similar to that of N gonorrhoeae. able following treatment to ensure eradication and to Routine screening using NAAT in GUM clinics detects prevent further resistance development. Azithromycin rectal chlamydia in approximately 10% of MSM and co-treatment with ceftriaxone may improve eradica- 5% of women. Over 50% of chlamydial infection in tion of gonorrhoea and aims to slow the development MSM is rectal without urethral infection. of further cephalosporin resistance. Approximately 70% of rectal chlamydial infections are asymptomatic; however, mild symptoms of diar- rhoea and anal discharge may occur. Occasionally There are several serovars of Chlamydia trachomatis. these symptoms can be as severe as LGV or gonor- Serovars D–K may lead to superficial rectal mucosal rhoea. Microscopy of anal discharge may show the infection (see below); however, serovars L1, L2 and presence of neutrophils but unlike gonorrhoea, chla- L3 may lead to deeper invasive infection that can mydia cannot be diagnosed by immediate Gram stain. affect submucosal tissue and lymphatics, thereby Endoscopy may show a ‘cobblestone’ appearance due allowing spread to lymph nodes. These invasive sero- to the infiltration of underlying lymphoid follicles. vars are responsible for lymphogranuloma venereum Although not licensed for extragenital sites, NAAT has (LGV), also known as lymphogranuloma inguinale, been shown to be sensitive and specific and should be lymphopatia venereum and Durand–Nicolas–Favre’s requested to diagnose rectal chlamydial infection. disease.4 Previously uncommon in western popula- Aptima combo 2 (Hologic Gen-Probe) is a transcription-

tions, there have been several outbreaks of this condi- mediated assay that has the advantage of detecting both http://fg.bmj.com/ tion in Europe and North America within the past N gonorrhoeae and Ctrachomatis.When requesting decade. Although LGV affects men and women, the NAAT for C trachomatis in the presence of proctitis, majority of cases occurs in men who have sex with genotyping for LGV should be requested as this is not men (MSM). The commonest presentation of the con- usually carried out on routine specimens. dition is proctitis, usually within several weeks of Rectal chlamydia is best treated with doxycycline sexual contact, with symptoms including proctalgia, 100 mg twice a day for 1 week. (In cases of proctitis on September 25, 2021 by guest. Protected copyright. rectal bleeding and mucopurulent anal discharge. in which LGV is a possibility a 3-week course of Endoscopic features may mimic IBD proctitis with the doxycycline can be started pending the test results. additional finding of purulent exudate. Advanced If LGV is excluded, the treatment can be stopped after infection may lead to perianal , fistula forma- 1 week.) An alternative is azithromycin 1 g as a single tion and anorectal stricturing. LGV may also exhibit dose but up to 20% treatment failure has been extra-intestinal manifestations including reactive arth- observed and therefore a test of cure with repeat ritis and hepatitis. NAAT after 6 weeks is recommended. Discriminating factors from IBD include urethral or vaginal mucopurulent discharge, and painful inguinal HERPES SIMPLEX VIRUS and femoral lymphadenopathy may be present that Caused by either herpes simplex virus (HSV) type 1 can progress to abscess formation. Low-grade pyrexia or type 2, primary herpes simplex infection may be and rigors may also be discriminating signs. asymptomatic, but 40% of men and 70% of women GUM or infectious disease specialists should be con- will develop systemic features that include , sulted in suspected or confirmed cases of LGV.A diag- headaches and muscle pains. HSV ascends peripheral nosis requires mucosal sampling using anogenital sensory nerves then lies dormant in sensory or auto- swabs and the detection of L1, L2 or L3 biovar C nomic ganglia where it can later reactivate. Recurrent

Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 33 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

HSV occurs in approximately 60% of those infected It should be appreciated that anogenital ulcers asso- with type 1 HSV and 90% in type 2 HSV. Proctitis is ciated with both HSV and syphilis lead to a 1.5 to usually associated with anal intercourse and diagnostic sevenfold increase in HIV transmission due to the suspicion should be raised in the presence of perianal associated mucosal barrier breach, and so HIV testing vesicles or painful oral/anogenital ulceration. should be undertaken. PCR on rectal , or exudate from a lesion is 3 the current ideal diagnostic modality for rectal HSV. SYPHILIS Recommended treatment for acute infection is 5 days Caused by the spirochete Treponema pallidum, the of either aciclovir 200 mg five times a day, aciclovir incidence of syphilis both in men and women has 400 mg three times a day, valaciclovir 500 mg twice a steadily risen in recent years, especially so in MSM.6 5 day, or famciclovir 125 mg twice a day. For recurrent Primary syphilis presents within 3 months of exposure HSV,aciclovir may be given four times a day for up to (on average within 2–3 weeks), with a painless solitary 1 year; however, only 20% of patients will see a sub- ulcer (, see figure 1) and regional lymphaden- sequent reduction in disease recurrence. opathy that may affect the genitalia, mouth or rectum. http://fg.bmj.com/ on September 25, 2021 by guest. Protected copyright.

Figure 1 Solitary syphilitic chancre affecting (a) male and (b) female external genitalia. A chancre is the archetypal feature of primary syphilis. These ulcers are classically anogenital, solitary, indurated and painless; however, in atypical cases they may be multiple and painful, and can occur at extra-anogenital sites.

34 Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

These ulcers are typically indurated with a clean base neurological or cardiovascular sequelae. These include and discharge serous fluid. If unidentified, primary dementia, paresis, seizures, aortitis or aneurysms. disease can progress to secondary syphilis typically in Tertiary syphilis may also feature gumma, which are 6–12 weeks (but up to 2 years) later, in which bacter- granulomatous nodules or ulcers of the gastrointes- aemia leads to multisystem disease that may include tinal tract or buttocks. peripheral neuropathy, maculopapular (typically Early infection up to 2 years after acquisition without palmoplantar, see figure 2), hepatitis, glomeruloneph- any manifestations of primary or secondary stages is ritis, meningitis or anterior uveitis. Secondary syphilis described as early latent syphilis. Primary, secondary and can also manifest with oral ulceration (typically with a early latent stages of syphilis are infectious, whereas the snail tract distribution), proctitis and condylomata later stages of tertiary syphilis are largely non-infectious. lata, which are -like commonly perianal Emphasis should therefore be placed on diagnosing and or genital in anatomical origin. Covered in a greyish treating primary, secondary and early latent syphilis exudate, condylomata lata are highly infectious. promptly so as to avoid later complications. Tertiary syphilis, which may occur several years fol- A diagnosis of syphilis can be made by dark ground lowing primary or secondary disease, can have major microscopy or PCR of ulcer exudate, condylomata http://fg.bmj.com/ on September 25, 2021 by guest. Protected copyright.

Figure 2 Palmoplantar rash in secondary syphilis. The skin eruption associated with secondary syphilis characteristically has a palmoplantar distribution, is pink or dark red and not pruritic.

Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 35 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from lata exudate or rectal . It may be 12 weeks IMPORTANT NON-INFECTIOUS DIFFERENTIAL from infection until antibodies become detectable DIAGNOSES OF STI-INDUCED PROCTITIS within serum, and so a repeat blood sample 3 months While certain genital, oral or systemic features may following last sexual risk may be required. When a suggest an STI cause of proctitis, it is important to be diagnosis is suspected or confirmed, GUM or infec- aware that there are other less commonly encountered tious disease specialists should be consulted. Contact non-infectious causes of proctitis that may display tracing and screening is necessary, as between 40–60% similar characteristics. These include Behçet’s syn- of contactable sexual partners may be infected.6 drome and solitary rectal ulcer syndrome (SRUS). First-line treatment of primary and secondary syphilis is ideally with intramuscular benzyl benzathine penicillin Behçet’s syndrome 2.4 million units once. This form of penicillin is slowly Classically presenting with orogenital ulceration due hydrolysed to benzylpenicillin giving sustained release, to an underlying , Behçet’s syndrome can and is advantageous as it ensures bioavailability and can also affect any part of the gastrointestinal tract.8 It be supervised. Alternatively, intramuscular procaine may present with perianal ulceration, fistulation, seg- penicillin 600 000 units a day for 10–14 days can be mental colitis and abdominal pain. Extra-intestinal given. Second-line therapy is with doxycycline 100 mg manifestations including arthritis, anterior uveitis twice a day for 14 days. For tertiary syphilis prolonged and nodosum may lead to a misdiagnosis of courses of the above therapies may be required. Crohn’s disease. This is further compounded by the possibility of granulomata being found on biopsy. The OTHER SEXUALLY TRANSMITTED PATHOGENS prevalence of Behçets syndrome is greatest in the THAT MAY CAUSE PROCTITIS middle east, far east and the Mediterranean basin and Giardia lamblia (giardiasis) and Entamoeba histolytica is highest in Turkey at 8–42 per 1000 people. Within (amoebiasis) may also be inoculated by sexual Behçet’s populations the prevalence of gastrointestinal contact.37Spread by the faecal oral route, sexual involvement varies, being highest at approximately transmission is most commonly seen in MSM. 30% in Japan. Thrombophlebitis of the legs is fre- quently observed and may be a subtle differentiating Giardiasis feature between IBD and Behçet’s syndrome. In giardiasis, protozoa adhere and replicate on the brush Endoscopically ulcers may appear well demarcated border of the duodenum and jejunum, feeding on the and ‘punched out’, sometimes without surrounding mucous secretions of the intestine. In some cases procti- colitis. Histological examination of intestinal biopsies tis is evident. Classically patients will experience may reveal a lymphocytic infiltration, classically with foul-smelling steatorrhoea around 2–3 weeks following vasculitis of small vessels; however, histology may be infection. Diagnosis is by direct microscopy of faeces indistinguishable from IBD. A diagnosis of Behçet’s that may reveal trophozoites (the motile active feeding syndrome is consequently made clinically and is stage of the protozoan life cycle) in liquid faeces. dependent on the presence of recurrent oral ulcer-

Oocysts may be seen in either liquid or solid faeces; ation plus two of recurrent genital ulceration, eye http://fg.bmj.com/ however, they may be excreted in a cyclical manner, and lesions (uveitis or retinal vasculitis), skin lesions so repeated stool tests or in some cases duodenal biopsy (, pseudofolliculitis, papulopustular or aspirate may be required to confirm the diagnosis. lesions, or acneform nodules in post-adolescent Faecal antigen detection kits may also aid diagnosis. patients), or a positive pathergy test at 24–48 h Treatment of giardiasis is with metronidazole 400 mg (a sterile skin prick test that may lead to pustule or three times a day for 5 days. formation; however, this test is often nega- on September 25, 2021 by guest. Protected copyright. tive).9 Treatment options for intestinal manifestations Amoebiasis of Behçet’s syndrome include 5-aminosalicylic acid, Diarrhoea caused by amoebiasis ensues 2–4 weeks sulfasalazine, or azathioprine. may be following the ingestion of cysts, when trophozoites beneficial in some patients. breach the mucosa causing an inflammatory infiltrate and subsequent proctocolitis. Diarrhoea, which can be Solitary rectal ulcer syndrome bloody, may persist for several weeks. Diagnosis of Commonly, SRUS presents with rectal bleeding, the E histolytica trophozoites or cysts is usually possible on passage of mucous and regularly a sensation of incom- microscopic examination of stool specimens. Treatment plete evacuation.10 The condition is often associated is with metronidazole 800 mg three times a day or tin- with rectal prolapse. Despite nomenclature, SRUS dazole 2 g once a day for 5–8 days, coupled with diloxa- may present with erythema of the rectal mucosa, nide furoate 500 mg three times a day for 10 days to polypoid inflammation or multiple rather than single optimise eradication. Stool samples should be analysed ulcers. Consequently, a misdiagnosis of IBD or malig- at monthly intervals for 3 months following therapy as a nancy may be made. Biopsy is therefore essential to test of cure, and further treatment should be provided if exclude rectal adenocarcinoma, and histological fea- persistent amoebiasis is identified. tures of thickened mucosa and smooth muscle

36 Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from extension from the muscularis into the lamina propria are characteristic of SRUS. In comparison to IBD, an Box 2 Common or key discriminating features from inflammatory infiltrate is not a prominent finding on Crohn's disease or ulcerative colitis histology. Diagnosis is often possible on the basis of history and endoscopic examination; however, defe- Gonorrhoea ▸ Purulent urethral discharge cating proctography and ultrasonography can be ▸ Pharyngeal infection useful aids to diagnosis. Common findings on defecat- ▸ Gram-negative diploccoci on Gram stain of anogenital swabs ing proctography include internal or external rectal ▸ Chlamydia co-infection common Lymphogranuloma venereum prolapse, often with incomplete rectal evacuation. ▸ Mucopurulent anal, urethral or vaginal discharge Endoanal ultrasound classically reveals a thickened ▸ Painful inguinal or femoral lymphadenopathy possibly with associated internal anal sphincter, and may show contraction or abscess formation ▸ Low-grade fever and pyrexia failure of relaxation of the puborectalis muscle on ▸ C trachomatis biovar L1, L2 or L3 identification on nucleic acid amplification straining. Treatment options have variable results and test and genotyping must be considered on an individual basis. These Chlamydia ▸ Proctitis symptoms usually mild (often asymptomatic) include biofeedback therapy to modify defecation ▸ Neutrophils may be seen on microscopy of anal discharge behaviour, and surgical intervention including abdom- ▸ Gonorrhoea co-infection common inal rectopexy. Herpes simplex virus ▸ Malaise, headaches and myalgia ▸ Perianal vesicles or ulcers ▸ Painful genital ulceration FURTHER CONSIDERATIONS WHEN MANAGING ▸ HSV type 1 or 2 identification on PCR PROCTITIS CAUSED BY A SEXUALLY ▸ Syphilis TRANSMITTED PATHOGEN ▸ Painless rectal or orogenital chancre (primary disease) ▸ Snail tract oral ulceration Patients diagnosed in the gastroenterology clinic with ▸ Condylomata lata an STI should be seen by an expert in sexual heath ▸ Associated neurological, cognitive and vascular co-morbidities (secondary and associated infections, when clear information and tertiary disease) ▸ Gastrointestinal or glutaeal gummatous ulceration or nodules regarding their diagnosis should be provided to Behçet's syndrome patients and their sexual contacts. Partner notification ▸ Punched-out oral ulceration and screening should be undertaken (partners in pre- ▸ Proctocolonic ulcers may not have surrounding proctocolitis. ▸ Lower limb thrombophlebitis ceding 3 months for primary syphilis, chlamydia, ▸ Genital ulceration LGV, or rectal gonorrhoea, and 2 years for secondary ▸ Eye and skin lesions common or latent syphilis), and this may help to identify sexual ▸ Positive pathergy test Solitary rectal ulcer syndrome networks with a high risk of future transmission. ▸ Rectal prolapse Empirical treatment for partners may be recom- ▸ Smooth muscle extension from muscularis into lamina propria and relative mended until negative results of investigations are absence of inflammatory infiltrate on histology available. With respect to HSV, patients should be given advice on transmission risks and sharing infor- BEST OF FIVE QUESTIONS mation with partners. Co-infection with other sexu- http://fg.bmj.com/ Question 1 ally transmitted pathogens is common and so full A 23-year-old man presented with an 8-week history sexual health screening including HIV, hepatitis B and of bloody diarrhoea, severe anorectal pain and low- C is advisable. grade pyrexia. On further questioning he also com- plained of malaise, myalgia and arthralgia. He admit-

CONCLUSION ted to unprotected receptive anal sexual intercourse on September 25, 2021 by guest. Protected copyright. When evaluating a patient with either new-onset with two male partners in the preceding 6 months. disease, proctitis that has not responded to standard Perianal and rectal examination revealed two fluctu- treatments for Crohn’s disease or ulcerative colitis, or ant, tender areas of induration adjacent to the anal in the presence of atypical clinical or laboratory fea- verge suggestive of . An urgent flexible sig- tures, there are several differential diagnoses outlined moidoscopy revealed inflamed, friable rectal mucosa by this paper that must be considered. Box 2 describes common or key discriminating features of these condi- tions with respect to Crohn’s disease and ulcerative Box 3 Risk factors associated with sexually trans- colitis. Box 3 outlines risk factors for STIs that should mitted infections11 be considered by clinicians, and box 4 advises on taking a sexual history in the gastroenterology clinic. ▸ Younger age (less than 25 years at highest risk) Sexual health experts should be consulted in cases of ▸ People from or who have visited countries with higher rates of STI ▸ Men who have sex with men confirmed or suspected STI, when further screening ▸ Frequent partner change or multiple concurrent partners for co-infection including HIV, hepatitis B and C ▸ Early onset sexual activity should then be undertaken, along with tests of cure ▸ Previous STI or previous contact with STI ▸ Alcohol or substance misuse and partner identification as appropriate.

Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 37 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

had been investigated for possible Crohn’s disease after Box 4 Components of and tips for taking a sexual presenting with several perianal and anal verge ulcers. 12 history in the gastrointestinal clinic These had resolved spontaneously and no formal diag- nosis had been made. On further questioning he admit- Components ted to a 4-week history of perianal swelling and several ▸ Symptoms: Duration, association with genital or bladder symptoms, presence and colour of discharge oral ulcers with a snail track distribution on inspection. ▸ Partners: Last sexual intercourse, partner gender, establish number of part- Perianal inspection is demonstrated in figure 3. ners within preceding 3–6 months, partner symptoms, type of sexual inter- What is the most likely causative organism: course (oral, vaginal or anal) — ▸ Contraception: Specifically the use of condoms A HSV ▸ History of STI: Previous diagnoses and treatment of STI or partner diagnoses/ B—T pallidum treatment — ▸ C N gonorrhoea Foreign travel: Travel to areas of high incidence — ▸ Social history: Including alcohol and drug misuse D C trachomatis ▸ For women: Last menstrual period E—Human papilloma virus Tips ▸ Speaking to the patient alone may allow them to speak more openly about their symptoms and allow you to ask more detailed questions, as can utilis- ing a sexual history proforma, used in many GUM clinics ▸ Seek permission and explain why you are asking personal questions ▸ Only ask what you need to know, avoid needlessly intrusive questions Question 3 A 40-year-old male patient of Turkish origin presented to ophthalmology as an emergency with acute painless reduced visual acuity in both eyes. Further questioning with several large ulcers and spontaneous bleeding. revealed a several year history of intermittent diar- Rectal swabs sent for NAAT and genotyping revealed rhoea, recurrent oral and penile ulceration, with oro- the presence of C trachomatis genotype L1. genital scarring evident on examination. He also Which of the following is the most appropriate complained of painful red nodules on the extensor treatment regimen: aspects of both forearms. One year previously he had — A Doxycycline 100 mg twice a day for 7 days been diagnosed with anterior uveitis requiring pro- — B Erythromycin 250 mg four times a day for 21 days longed steroid use. Slit lamp retinal examination — C Olfloxacin 400 mg a day for 7 days revealed multiple intraretinal haemorrhages, soft exu- — D Erythromycin 500 mg twice a day for 7 days dates and macular oedema in both eyes. — E Doxycycline 100 mg twice a day for 21 days What is the most likely diagnosis: A—Crohn’s disease Question 2 B— A 32-year-old man presents with a 6-week history of C—Behçet’s syndrome diarrhoea, anorectal pain and maculopapular rash affect- D— ing the trunk, hands and feet. Two years previously he E—Multiple sclerosis http://fg.bmj.com/ on September 25, 2021 by guest. Protected copyright.

Figure 3 Perianal inspection (question 2).

38 Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

be required. The correct answer is therefore doxycy- line 100 mg twice a day for 21 days.

Answer 2: B The depicted flat-topped, papillomatous perianal lesions are typical of condylomata lata, a feature of sec- ondary syphilis caused by T pallidum. The described oral ulceration and macular rash with a palmoplantar distribution are also typical of secondary syphilis. The previous perianal ulcers are likely to have represented multiple primary syphilitic , as although these are classically singular, multiple lesions may be seen. Figure 4 Gram stain of swab exudate (question 4).

Answer 3: C The ocular findings are consistent with retinal vascu- litis that can be confirmed by fluorescein angiography. Question 4 The painful nodules on his forearms are suggestive of A 32-year-old woman presented to the endoscopy erythema nodosum, and these diagnoses associated department for flexible sigmoidoscopy with a with previous anterior uveitis, recurrent orogenital 1-month history of diarrhoea and abdominal pain. ulceration and gastrointestinal symptoms are consist- Two months previously she had been treated in ent with Behçet’s syndrome. The highest prevalence primary care for chlamydia infection following a posi- of Behçet’s syndrome is in Turkey. Tuberculosis, sar- tive urine NAAT. Symptoms of dysuria and urethral coidosis and Crohn’s disease are among the differen- discharge had continued despite 7 days doxycycline tial diagnoses; however, recurrent genital ulceration 100 mg twice a day. Endoscopy revealed mildly ery- would be uncommon and is more typically a finding thematous mucosa and loss of normal vascular pattern of Behçet’s syndrome. Orogenital ulceration is not a in the rectum associated with a purulent discharge. feature of multiple sclerosis. Anal and urethral swabs were obtained and the result- ant Gram stain is shown in figure 4. What is the most likely causative organism: A—C trachomatis

B—HSV http://fg.bmj.com/ C—Human papilloma virus D—T pallidum E—N gonorrhoea on September 25, 2021 by guest. Protected copyright.

ANSWERS Answer 1: E The symptoms described and positive testing for C trachomatis serovar L1 are diagnostic of LGV. While a 7-day course of doxycycline 100 mg twice a day, olfloxacin 400 mg a day or erythromycin 500 mg twice a day would be appropriate to treat uncompli- cated serovar D–K C trachomatis, LGV caused by invasive serovar L1, 2, or 3 requires 21 days of Figure 5 Gram stain of swab exudate (answer 4). Arrows therapy, and while erythromycin would be appropri- point towards neutrophils containing intracellular Gram-negative ate, a higher dose of 500 mg four times a day would diplococci.

Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274 39 TRAINING MATTERS Frontline Gastroenterol: first published as 10.1136/flgastro-2012-100274 on 5 December 2012. Downloaded from

Answer 4: E 2 Bignell C, Fitzgerald M. UK national guideline for the The Gram stain reveals numerous neutrophils, many management of gonorrhoea in adults, 2011. Int J STD AIDS with intracellular Gram-negative diplococci (arrows in 2011;22:541–7. figure 5) consistent with N gonorrhoea infection. 3 McMillan A, van Voorst Vader PC, de Vries HJ. The 2007 Co-infection with gonorrhoea is commonly associated European Guideline (International Union against Sexually with chlamydia, and gonorrhoea would not have Transmitted Infections/World Health Organization) on the management of proctitis, proctocolitis and enteritis caused by responded to the previous course of doxycycline, ’ sexually transmissible pathogens. Int J STD AIDS hence the patient s ongoing symptoms. Rectal infec- 2007;18:514–20. tion with gonorrhoea can occur due to the transmuco- 4 de Vries HJ, Morre SA, White JA, et al. European guideline sal spread of infected urethral discharge. Appropriate for the management of lymphogranuloma venereum, 2010. Int therapy for gonorrhoea proctitis includes ceftriaxone J STD AIDS 2010;21:533–6. 500 mg intramuscularly once, plus oral azithromycin 5 Patel R, Alderson S, Geretti A, et al. European guideline for 1 g once. the management of genital herpes, 2010. Int J STD AIDS 2011;22:1–10. Contributors CAL devised the concept for the 6 French P,Gomberg M, Janier M, et al. IUSTI: 2008 European manuscript, which was subsequently developed by guidelines on the management of syphilis. Int J STD AIDS CAL and EIML. Initial drafting was undertaken by 2009;20:300–9. CAL, all authors contributed to subsequent drafts. 7 Shelton AA. Sexually transmitted parasitic diseases. Clin Colon KNS supplied the colour images used in this paper. Rectal Surg 2004;17:231–4. ’ Patient consent Obtained. 8 Yazici H, Fresko I, Yurdakul S. Behcet s syndrome: disease manifestations, management, and advances in treatment. Nat Funding None. Clin Pract Rheumatol 2007;3:148–55. ’ Competing interests None. 9 International Study Group for Behcet s Disease. Criteria for diagnosis of Behcet’s disease. Lancet 1990;335: Provenance and peer review Not commissioned; 1078–80. internally peer reviewed. 10 Vaizey CJ, van den Bogaerde JB, Emmanuel AV, et al. Solitary rectal ulcer syndrome. Br J Surg 1998;85:1617–23. REFERENCES 11 Clutterbuck DJ, Flowers P,Barber T, et al. UK national 1 Health Protection Agency. New data show sexually transmitted guideline on safer sex advice. Int J STD AIDS 2012;23:381–8. infection diagnoses on the rise in England. HPA Press release, 12 French P.BASHH 2006 National Guidelines—consultations 31st May 2012. http://www.hpa.org.uk/NewsCentre/ requiring sexual history-taking. Int J STD AIDS NationalPressReleases/2012PressReleases/ 2007;18:17–22. 120531newrisingSTInumbersreleased/ (accessed 15 Oct 2012). http://fg.bmj.com/ on September 25, 2021 by guest. Protected copyright.

40 Lamb CA, et al. Frontline Gastroenterology 2013;4:32–40. doi:10.1136/flgastro-2012-100274