Case Presentation: A 28-year-old HIV positive male presented with one week of rectal pain and bloody diarrhea. He was found to have bright red blood in vault on rectal examination. Laboratory studies were concerning for a leukocytosis with left shift, an elevated CRP (>80 mg/dl), and a positive fecal calprotectin. His CT scan demonstrated circumferential wall thickening most prominent at the terminal ileum, cecum, and rectum and was read as “findings non-specific but are most concerning for inflammatory bowel disease (IBD).” With concern for an initial presentation of IBD, a colonoscopy was performed that showed rectal mucosa inflammation and a 4cm rectal ulcer extending to the dentate line. Histopathology analysis was significant for rectal cryptitis and signs of active colitis. At this point, the patient was diagnosed, incorrectly, with IBD. Luckily, a sexual history was obtained prior to initiating treatment and was significant for unprotected anoreceptive intercourse with multiple partners in the weeks preceding symptoms. A rectal swab for chlamydia species was positive, allowing for the correct diagnosis of lymphogranuloma venereum to be made. He was treated with a 21-day course of doxycycline with complete resolution of symptoms on follow up.
Discussion: Lymphogranuloma venereum (LGV) is a chlamydial infection classically described as an affliction of the developing world that has now emerged as a common clinical entity in the Western World, particularly in the HIV+ men who have sex with men (MSM) community. In the west, LGV manifests as proctocolitis, with patients experiencing symptoms of acute inflammatory diarrhea quite similar to IBD. As demonstrated by the presented case, making the diagnosis of LGV can be challenging due to similarities to IBD in presentation, laboratory markers, endoscopic appearances, and histopathological findings. It is therefore not surprising that diagnosis is often delayed, an unnecessary invasive workup pursued, and inappropriate therapies initiated. Simply by obtaining a timely sexual history, clinicians can identify at risk patients, particularly those in the HIV+ MSM community, and order the appropriate workup to reach the correct diagnosis. Diagnosis is confirmed with molecular testing of rectal samples for Chlamydia trachomatis L1-L3 serovars, although subtype verification is not required in the appropriate clinical context. Treatment of LGV is a 21 day course of doxycycline and current guidelines suggest treating empirically if there is a high index of clinical suspicion.
Conclusions: Lymphogranuloma venereum has emerged as a common cause of sexually transmitted proctocolitis across Europe and North America that is often misidentified and mistreated as IBD. Obtaining a thorough sexual history can guide clinicians towards the appropriate workup, diagnosis, and treatment.