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  Table of Contents    
CASE REPORT  
Year : 2017  |  Volume : 60  |  Issue : 2  |  Page : 259-261
Chlamydia trachomatis proctitis masquerading as carcinoma rectum: First case report from India


1 Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
3 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication19-Jun-2017
 

   Abstract 

While proctitis is caused both by infectious and noninfectious causes, infectious causes are acquired typically sexually. Chlamydia trachomatis, which is the most frequent bacterial pathogen causing sexually transmitted infections worldwide, is one of the causative agents of proctitis. We report a case history of a bisexual male who presented to us with rectal bleeding. The colonoscopy showed a nodular ulcerated lesion in the rectum suggestive of rectal malignancy, but biopsies from rectal mass did not reveal malignancy. A rectal biopsy was positive for C. trachomatis by polymerase chain reaction assay, and a diagnosis of C. trachomatis proctitis was made. Considering the invasive anorectal disease and patient's sexual history, he was treated with prolonged doxycycline therapy as per Centres for Disease Control and Prevention's treatment recommendation for lymphogranuloma venereum. A high index of clinical suspicion along with appropriate microbiological testing can clinch the diagnosis of C. trachomatis infection.

Keywords: Bisexual, Chlamydia trachomatis, hematochezia, inflammatory bowel disease, lymphogranuloma venereum, proctitis

How to cite this article:
Dhawan B, Makharia GK, Juyal D, Sebastian S, Bhatia R, Khanna N. Chlamydia trachomatis proctitis masquerading as carcinoma rectum: First case report from India. Indian J Pathol Microbiol 2017;60:259-61

How to cite this URL:
Dhawan B, Makharia GK, Juyal D, Sebastian S, Bhatia R, Khanna N. Chlamydia trachomatis proctitis masquerading as carcinoma rectum: First case report from India. Indian J Pathol Microbiol [serial online] 2017 [cited 2020 Feb 24];60:259-61. Available from: http://www.ijpmonline.org/text.asp?2017/60/2/259/208375



   Introduction Top


Proctitis is caused by both infectious and noninfectious causes. Most of the infectious pathogens leading to proctitis are acquired through sexual transmission. Chlamydia trachomatis is the most frequent bacterial pathogen causing sexually transmitted infections (STIs) worldwide [1] and has been identified as one of the causative agents of proctitis in the early 1980s.[2]

Nineteen serovars of C. trachomatis have been identified causing different types of infections. Serovars A-C cause ocular, serovars D-K cause anogenital infections, and L-serovars (L1–L3) cause lymphogranuloma venereum (LGV).[3] The gastrointestinal manifestations of STI, though common, are often not recognized and can manifest with nonspecific symptoms and hence pose diagnostic difficulties. There is growing evidence that unprotected anal intercourse among men who have sex with men (MSM) is on the rise, increasing the prevalence of C. trachomatis proctitis in the parts of Africa, South America, and Southeast Asia.[3] However, C. trachomatis proctitis has not been reported from India till date. The atypical clinical presentation, the unawareness of physicians and patients in this regard, and the nonavailability of molecular diagnostic methods in routine practice may have contributed to it's underdiagnosis.

We report a case history of a patient who was referred to us for the evaluation of mass in the rectum and was diagnosed as having C. trachomatis proctitis.


   Case Report Top


A 38-year-old male had been having hematochezia, pain in the rectum, mucoid discharge from the rectum, and tenesmus for the past 6 months. Rectal examination confirmed bleeding and mucoid discharge. He underwent a histological examination of the rectal biopsies at two occasions before being referred to us. At both occasions, there were no malignant cells in the biopsies. When he reached us, we repeated the colonoscopic examination which showed discrete areas of hypertrophied nodular mucosa in the rectum with a solitary, large ulceroproliferative mass-like lesion in the rectum suggestive of a malignant lesion [Figure 1]. There was the presence of hemorrhoids and rest of the colon was normal. The biopsies obtained for histological examination revealed ulcerated and fragmented colonic mucosa with granulation tissue formation. Lamina propria showed edema and chronic inflammation [Figure 2]. There was no granuloma, viral inclusion bodies, dysplasia, or malignant cells. On the second occasion, rectal biopsies were also sent for microbiological studies. The rectal biopsy then showed the presence of C. trachomatis by in-house polymerase chain reaction (PCR) assay targeting the cryptic plasmid of C. trachomatis[Figure 3].[4] Biopsy samples were also subjected to Ziehl–Neelsen stain for acid-fast bacilli, PCR for Cytomegalovirus and Mycobacterium tuberculosis, and all of them were found to be negative. A diagnosis of C. trachomatis proctitis was made, and the patient was referred to the sexually transmitted disease clinic. Sexual history revealed that he was a bisexual man and had multiple casual partners. He was engaged in unprotected peno-anal insertive and receptive sex with his male partners and penovaginal intercourse with his female partners.
Figure 1: Colonoscopic findings showing erythema and large ulceroproliferative lesion in rectal mucosa

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Figure 2: (a) colonic mucosa with focal crypt branching (arrow) and lamina propria fibrosis, (b) areas of mucosal ulceration and underlying inflammatory granulation tissue is noted. (c and d) Biopsy fragments showing focal mucosal viliform transformation and crypt branching (arrows) (H and E, ×100)

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Figure 3: Polymerase chain reaction for cryptic plasmid. Lane 1: 100 bp DNA ladder; Lane 2: Positive control; Lane 3 and 5: Clinical sample – negative; Lane 4: Clinical sample (rectal biopsy) – positive

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On examination, the patient did not have any anogenital ulceration or inguinal lymphadenopathy. A full sexual health screen was performed. He was nonreactive for Venereal Disease Research Laboratories, seronegative for HIV, hepatitis B surface antigen, anti-hepatitis C virus, and anti-herpes simplex virus-1, 2 antibodies. Rectal and urethral swabs were collected and subjected to culture for Neisseria gonorrhoeae, Ureaplasma spp., and Mycoplasma hominis and PCR assays for C. trachomatis. A multiplex PCR targeting the urease gene of Ureaplasma spp. and the 16S rRNA of M. hominis was performed, as well as a PCR was also performed to detect M. genitalium targeting the 140 kDa adhesion gene. Both rectal and urethral swabs for C. trachomatis, PCR tested positive. To characterize C. trachomatis strain, a PCR assay targeting the omp A gene was performed as described previously [5] but was found to be negative and thus could not be analyzed by sequencing. We tried contact tracing of the patient, but he denied giving any information of his sexual partners.

Patient was treated with a 21-day course of oral doxycycline 100 mg twice daily with significant improvement in symptoms. The treatment course was repeated, and the patient was counseled for safe sexual practices and advised for regular follow-ups.


   Discussion Top


The index case illustrates invasive anorectal proctitis due to C. trachomatis infection presenting as rectal bleeding and rectal mass mimicking carcinoma rectum. Clinical, endoscopic, and histopathological findings in Chlamydia proctitis are nonspecific, and they may mimic malignancy or Crohn's disease.[6],[7] In severe rectal lesions, endoscopic images can mimic rectal carcinoma or lymphoma. There are no pathognomonic features of Chlamydia proctitis, and this is why clinical suspicion coupled with microbiological identification and molecular typing is crucial.

C. trachomatis PCR is now the standard diagnostic test for both genital and extragenital infections and has emerged as a promising technique that is sensitive and convenient. Specialized laboratories can further amplify sequences in the major outer membrane protein and reliably distinguish among LGV serotypes from other C. trachomatis serotypes. Studies have shown that genotyping of C. trachomatis is clinically important as the treatment modalities may vary.[8] LGV serotypes cause an anorectal syndrome characterized by severe proctitis with tenesmus, pain, bloody discharge, and constipation caused by local edema. If left untreated, it can lead to irreversible anal strictures and lymphorrhoids. In contrast, Chlamydia serovars D-K (non-LGV serovars) remain confined to genital and anal mucosa and generally cause only symptomatic infections.[8] It is generally advised to give antibiotic regimens for a longer duration for LGV serovars, compared to the shorter duration for anogenital infections caused by non-LGV Chlamydia serovars.[9]

In the present case, we were unable to determine the C. trachomatis genotype. Although the patient's samples were positive on the multicopy plasmid target in the initial assay used for the detection of C. trachomatis, they were negative on the single-copy omp A gene target required for sequencing. This was probably due to the lower copy numbers of omp A gene in the samples.

According to a multicenter case–control study from the UK, a presumptive clinical diagnosis of LGV can be made in MSM presenting with tenesmus and constipation.[10] Hence, in the present case, considering the invasive anorectal disease and patient's sexual history, a diagnosis of LGV proctitis could not be ruled out. As recommended by the current guidelines for LGV treatment, our patient was treated with prolonged doxycycline therapy.[9]

HIV coinfection has been reported to be present in >70% of patients with Chlamydia proctitis and is the most important associated risk factor.[3] Moreover, other concomitant STIs are often diagnosed in MSM with LGV. In contrast, in the case reported here, the patient had no other STIs or HIV infection. Nonetheless, the patient was advised regular follow-ups for monitoring of concomitant infections.

This case is a reminder to the gastroenterologists to suspect this emerging disease when compatible symptoms are present, especially in MSM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Bax CJ, Quint KD, Peters RP, Ouburg S, Oostvogel PM, Mutsaers JA, et al. Analyses of multiple-site and concurrent Chlamydia trachomatis serovar infections, and serovar tissue tropism for urogenital versus rectal specimens in male and female patients. Sex Transm Infect 2011;87:503-7.  Back to cited text no. 1
    
2.
Quinn TC, Goodell SE, Mkrtichian E, Schuffler MD, Wang SP, Stamm WE, et al. Chlamydia trachomatis proctitis. N Engl J Med 1981;305:195-200.  Back to cited text no. 2
    
3.
Gallegos M, Bradly D, Jakate S, Keshavarzian A. Lymphogranuloma venereum proctosigmoiditis is a mimicker of inflammatory bowel disease. World J Gastroenterol 2012;18:3317-21.  Back to cited text no. 3
    
4.
Mahony J, Chong S, Jang D, Luinstra K, Faught M, Dalby D, et al. Urine specimens from pregnant and nonpregnant women inhibitory to amplification of Chlamydia trachomatis nucleic acid by PCR, ligase chain reaction, and transcription-mediated amplification: Identification of urinary substances associated with inhibition and removal of inhibitory activity. J Clin Microbiol 1998;36:3122-6.  Back to cited text no. 4
    
5.
Gao X, Chen XS, Yin YP, Zhong MY, Shi MQ, Wei WH, et al. Distribution study of Chlamydia trachomatis serovars among high-risk women in China performed using PCR-restriction fragment length polymorphism genotyping. J Clin Microbiol 2007;45:1185-9.  Back to cited text no. 5
    
6.
Soni S, Srirajaskanthan R, Lucas SB, Alexander S, Wong T, White JA. Lymphogranuloma venereum proctitis masquerading as inflammatory bowel disease in 12 homosexual men. Aliment Pharmacol Ther 2010;32:59-65.  Back to cited text no. 6
    
7.
Patel S, Hay P. Lymphogranuloma venereum and HIV infection: Misdiagnosed as Crohn's disease. BMJ Case Rep 2010;2010. pii: Bcr0220102771.  Back to cited text no. 7
    
8.
de Vries HJ, Smelov V, Middelburg JG, Pleijster J, Speksnijder AG, Morré SA. Delayed microbial cure of lymphogranuloma venereum proctitis with doxycycline treatment. Clin Infect Dis 2009;48:e53-6.  Back to cited text no. 8
    
9.
Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.  Back to cited text no. 9
    
10.
Pallawela SN, Sullivan AK, Macdonald N, French P, White J, Dean G, et al. Clinical predictors of rectal lymphogranuloma venereum infection: Results from a multicentre case-control study in the U.K. Sex Transm Infect 2014;90:269-74.  Back to cited text no. 10
    

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Correspondence Address:
Benu Dhawan
Department of Microbiology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_114_16

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