Lymphogranuloma Venereum of the Rectum: A Rare Diagnosis: 1373

Case Presentation: A 42-year-old homosexual male with limited follow up presented for evaluation of worsening chronic abdominal pain, constipation and weight loss of 15-18 pounds, over the last 6 months. He also noted bright red blood per rectum upon defecation. He reported unprotected ano-receptive sex but stopped a year ago secondary to anal pain and transient fevers after sex. Physical exam was significant for bilateral inguinal lymphadenopathy and an extremely tender smooth circumferential obstructing mass palpated on digital rectal exam. Labs revealed severe iron deficiency anemia with a hemoglobin of 7.8. HIV, hepatitis B and C, Neisseria gonorrhoeae, and syphilis serologies were negative. CT showed severe abnormal thickening and stranding around the rectum with mild proximal dilation of the sigmoid colon. Colonoscopy revealed a circumferential, ulcerated, friable stricture that extended from the anal verge to 10 cm into the rectum. Biopsy results from colonoscopy showed only acute on chronic inflammation. He was subsequently taken to the OR for full thickness biopsy which revealed acute on chronic inflammation with reactive lymphoid follicles. STD testing was significant for Chlamydia trachomatis IgG >1:512, IgM < 1:10 with urine nucleic acid amplification test for gonorrhea and chlamydia being negative. He was discharged with and treated for a presumptive diagnosis of lymphogranuloma venereum (LGV). Discussion: LGV is a rare but increasing diagnosis since 2003, particularly among men who have sex with men (MSM). The reason for the increase is unclear, with some believing that the increase is from better detection. Particularly among MSM, LGV should be on the differential with patients presenting with proctocolitis. LGV proctocolitis can be mistaken for malignancy or inflammatory bowel disease and if left untreated can lead to rectal fistulas and strictures. The increase of LGV is also a public health problem as the ulcerative and inflammatory nature of LGV facilitate transmission and acquisition of other STD. Serology has largely been replaced by direct detection test, though it is useful in high titer antibodies in the appropriate clinical context, typically with microimmunofluorescence titers > 1:256. High suspicion must be taken for this rare diagnosis in the right patient population. It is important to keep LGV on the differential for MSM presenting with colorectal symptoms as its presentation is nonspecific and is often misdiagnosed.Figure 1