Lower Gastrointestinal Syphilis: Case Series and Literature Review

Background Syphilis infections are increasing globally. Lower gastrointestinal syphilis (LGIS) is a rare manifestation of early syphilis transmitted through anal sexual contact. Misdiagnosis of LGIS as inflammatory bowel disease may result from clinician under-awareness. Methods We searched the literature for articles describing cases of LGIS, and identified additional cases diagnosed within our institution. Data were extracted from the articles and medical records and analyzed to provide a summative account. Results 54 cases of LGIS were identified in 39 articles published between 1958 and 2020. 8 additional cases were diagnosed at our institution between 2011 and 2020, totaling 62 cases. All cases were described in men and transwomen aged 15 to 73 years. 50 (93%) individuals endorsed having sex with men. In 26 cases (52%) individuals were HIV co-infected. LGIS presented most commonly with hematochezia (67%) and anal pain (46%). The most common physical exam findings were rectal mass (38%), lymphadenopathy (31%), and rash (26%). Non-treponemal titers ranged from 1:2-1:1024. Of the 52 cases in which endoscopy was reported, 22 (42%) showed anorectal mass and 18 (35%) showed anorectal ulcer. In 44 cases (75%), histopathology revealed a chronic inflammatory infiltrate with a prominent lymphocyte component (45%) and/or plasma cells (36%). 78% of specimens to which a tissue stain was applied were positive for spirochetes. Conclusions LGIS should be suspected in men and transwomen presenting with a lower gastrointestinal symptom or mucosal abnormality. A sexual history must be elicited and guide testing. Misdiagnosis can delay treatment and threatens patient and public health.

Clinical study on the correlation between radiological and intra operative findings in cases of sino nasal polyposis

<p class="abstract"><strong>Background:</strong> Sino nasal polyposis is a common condition often encountered by the otolaryngologists. Though plain radiographs are valuable in the pre-operative evaluation, the CT scan plays a major role in identifying the extent of disease and the anatomic variations accurately for the surgeon. This study evaluates the value of pre-operative CT scans by correlating the scan findings with intra-operative surgical findings.</p><p class="abstract"><strong>Methods:</strong> Total 50 adult patients who attended the ENT department from November 2018 to October 2020 with Sino nasal polyposis were selected for the study. All were subjected to CT scan and underwent Functional Endoscopic Sinus Surgery. The intra-operative findings were compared with the CT scan findings. </p><p class="abstract"><strong>Results:</strong> In our study, the pre-operative CT scan showed single sinus involvement in 20% and multiple sinus involvement in 80% of cases. Mucosal abnormality was reported in 86% and normal in 14% of cases. Osteomeatal obstruction was reported in 44% and normal in 56% of cases. Various anatomical abnormalities were noted in 100% of cases. There was a perfect positive co relation between CT scan findings and intra operative findings with regards to Osteomeatal occlusion and anatomical or mucosal abnormalities. </p><p class="abstract"><strong>Conclusions:</strong> The study done to assess the correlation between pre-operative CT scan findings and intra-operative findings of Sino nasal polyposis cases has shown a perfect positive correlation between the findings. Pre-operative CT scan is an invaluable tool for the surgeon for accurate diagnosis and treatment planning. </p>

Streptococcus bovis Hip and Knee Periprosthetic Joint Infections: A Series of 9 Cases

Introduction: Prosthetic joint infection (PJI) due to Streptococcus bovis group (SBG), specifically S. bovis biotype I (S. gallolyticus), is rare and associated with colorectal carcinoma. Little has been published regarding SBG PJI. We analyzed nine cases of SBG PJI at our institution, the largest series to date.Methods: The medical records of patients diagnosed with SBG PJI between 2000-2017 were reviewed. Patients were followed until death, failure, or loss to follow-up. Mean follow-up was 37 months (range 0.5-74 months).Results: Nine PJI in 8 patients with mean prosthesis age at diagnosis of 8 years (range 4 weeks-17 years) were identified. The median duration between symptom onset and treatment was 38 weeks (range 0.3 weeks-175 weeks). 8/9 had their PJI eradicated with treatment based on acuity of symptoms. Acute PJI (2) was treated with DAIR, and chronic PJI (7) was treated with 2-stage revision arthroplasty. 1 PJI with chronic PJI developed recurrent infection after initial treatment. All patients received post-operative IV antibiotics. 7/8 patients received Ceftriaxone. Three patients received lifelong oral antibiotics. 7/8 patients underwent colonoscopy. 5/7 patients were found to have polyps following PJI diagnosis with one carcinoma and two dysplastic polyps. The two patients without polyps had identifiable gastrointestinal (GI) mucosal abnormality: tooth extraction prior to symptom onset and diverticulosis on chronic anticoagulation.Conclusion: SBG PJI is typically due to hematologic seeding. Colonoscopy should be pursued for patients with SBG PJI. Surgical treatment dictated by infection acuity and 6-week course of Ceftriaxone seems sufficient to control infection.

Definitive therapy of colonic angioectasia by submucosal coagulation

Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel. Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips. Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were destroyed without adverse events. Conclusion Elevation, hot snare resection and coagulation (ESC) of the visible vessel for treating colonic angioectasia appears safe and effective. Larger prospective comparative studies are required to assess its specific role.

Can Immune Checkpoint Inhibitors Induce Microscopic Colitis or a Brand New Entity?

Background Microscopic colitis (MC) has been described as 1 pattern of injury in immune checkpoint inhibitor (ICPI)–induced colitis. The main objective of this study was to characterize ICPI-induced MC by exploring the differences in risk factors, colitis treatments, endoscopic features, and clinical outcomes between cancer and noncancer patients with MC with and without exposure to ICPIs. Methods A retrospective chart review was conducted among patients diagnosed with MC from our institutional pathology database from January 2012 to January 2018. Patients were categorized into MC in cancer patients with or without ICPI exposure and in noncancer patients. Risk factors (use of tobacco and certain medications), colitis treatments (antidiarrheals and immunosuppressants), endoscopic features (with or without mucosal abnormality), and clinical outcomes (diarrhea recurrence, hospitalization, mortality) were collected and compared among the 3 groups. Results Of the 65 eligible patients with MC, 15 cancer patients had exposure to ICPI, 39 cancer patients had no exposure to ICPI, and 11 had no cancer diagnosis. Among the risk factors, proton pump inhibitor was more frequently used in the ICPI-induced MC cohort (P = 0.040). Furthermore, in this population, mucosal abnormality was the most common endoscopic feature compared with normal findings in the non-ICPI-induced MC groups (P = 0.106). Patients with ICPI-induced MC required more treatments with oral and intravenous steroids and nonsteroidal immunosuppressive agents (all P &lt; 0.001) and had a higher rate of hospitalization (P &lt; 0.001). Conclusion This study suggests that despite some similarities between MC with and without exposure to ICPIs, ICPI-induced MC has a more aggressive disease course that requires more potent immunosuppressive treatment regimens and greater need for hospitalization.

Faecaloma in ano

Introduction Faecal concretions or faecalomas (’stone of faeces’) are symptomatic of many well-recognised colorectal conditions. Faecalomas are usually located in the colon or rectum and associated with disorders of colorectal transit. We describe an unusual case of ’faecaloma in ano’ secondary to a chronic fissure in ano. A 67-year-old woman with a 10-year history of chronic constipation and intermittent anal discomfort presented with a painless perianal lump of similar duration. Methods The patient’s case notes were reviewed and a literature search was carried out. Results Examination under anaesthesia, sigmoidoscopy and anoscopy did not reveal any mucosal abnormality or an internal opening or any connection with the perianal lump. The mass was enucleated after incising the skin, leaving behind a cavity completely separate from the anal canal and sphincters. Histology revealed inspissated faecal material with evidence of calcification. Conclusions Chronic fissures may be complicated by sepsis and, rarely, a ’fissure fistula’ may develop. We suspect that this was the underlying pathogenesis of this ’faecaloma in ano’. The term faecaloma in ano befits the clinical picture.