Scientific letter
Sexually transmitted infections as a differential diagnosis of inflammatory bowel disease
Las infecciones de transmisión sexual como diagnóstico diferencial de la enfermedad inflamatoria intestinal
Belén Martínez Benitoa,
, Javier P. Gisberta, Lucio Jesús García Fraile Fraileb, Ana Barrios Blandinob, María Chaparroa
Corresponding author
a Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) y Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
b Servicio de Medicina Interna, Sección de Enfermedades Infecciosas, Hospital Universitario de La Princesa, Instituto de investigación Sanitaria Princesa (IIS-Princesa), Centro de Investigación Biomédica en Red-Enfermedades Infecciosas (CIBEINFEC), Madrid, Spain
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Gisbert, Lucio Jesús García Fraile Fraile, Ana Barrios Blandino, María Chaparro" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Belén" "apellidos" => "Martínez Benito" "email" => array:1 [ 0 => "bemartbe@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Javier P." "apellidos" => "Gisbert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Lucio Jesús" "apellidos" => "García Fraile Fraile" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Barrios Blandino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "María" "apellidos" => "Chaparro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) y Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Sección de Enfermedades Infecciosas, Hospital Universitario de La Princesa, Instituto de investigación Sanitaria Princesa (IIS-Princesa), Centro de Investigación Biomédica en Red-Enfermedades Infecciosas (CIBEINFEC), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Las infecciones de transmisión sexual como diagnóstico diferencial de la enfermedad inflamatoria intestinal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1348 "Ancho" => 1674 "Tamanyo" => 294352 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colonoscopy: a) rectal mucosa with fibrin exudates and superficial ulcerations; b) excavated ulcer with fibrin background and erythematous, raised edges; c) erythematous mucosa, isolated aphthae and deep, fibrin-covered ulcers with mammillated edges; d) several excavated, serpiginous, fibrin-covered ulcers with raised edges.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The increased incidence of inflammatory bowel disease (IBD) and growing awareness of the condition among healthcare professionals have led to an improvement in the diagnosis of these patients. However, it should not be forgotten that other diseases can exhibit manifestations that mimic IBD.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For example, sexually transmitted infections (STIs) can manifest with symptoms and endoscopic and histological findings that overlap with IBD, making differential diagnosis challenging.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The following are two clinical cases of patients diagnosed with ulcerative colitis (UC) who, after failure to respond to treatment for IBD, were eventually diagnosed with an STI.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first case is a 30-year-old male with months of bloody diarrhoea, tenesmus and anal pain. Colonoscopy revealed oedema and erythema in the sigmoid mucosa, and superficial ulcerations and fibrinous exudates in the last 10 cm of the rectal mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). Histological changes suggestive of mildly active UC were observed. The patient was diagnosed with left UC and was treated with oral and topical mesalazine, and subsequently with prednisone, without clinical improvement. HIV infection and late latent syphilis were diagnosed concomitantly. Upon requestioning, the patient reported anal intercourse unprotected by barrier methods. Due to refractoriness to treatment and suspicion of an STI, a repeat colonoscopy was performed, which revealed a 5-cm ulcer, excavated with raised edges, in the rectum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). Biopsy showed mildly active chronic UC lesions, cytomegalovirus infection and positive PCR for <span class="elsevierStyleItalic">Chlamydia trachomatis</span> serotypes L1 to L3. Treatment with valganciclovir and doxycycline for three weeks, three doses of benzathine penicillin and antiretrovirals was administered, and corticosteroids were withdrawn. After this, the patient’s clinical condition rapidly improved. Subsequent proctoscopy showed a scarred area in the rectum, while the rest of the mucosa was normal. Due to the initial extent of involvement, the patient was diagnosed with an STI over an underlying left UC, and treatment with mesalazine was maintained.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The second case is a 53-year-old male who underwent colonoscopy for diarrhoea, incontinence and rectal tenesmus. In this case, involvement was limited to the rectum, with erythematous mucosa with isolated aphthae and, at the inner anal margin, deep ulcers with mammillated edges (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). Histology identified chronic proctitis in association with IBD, with moderate activity. Treatment with rectal mesalazine was started, without clinical improvement. The patient reported unprotected anal intercourse. A repeat colonoscopy was performed and several excavated ulcers with raised edges were seen adjacent to the anal canal (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d). Histology revealed chronic colitis and a positive PCR for <span class="elsevierStyleItalic">C. trachomatis</span> was detected. After a three-week course of doxycycline, the symptoms subsided. Only several scars in relation to the previous ulcers were observed at the follow-up colonoscopy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In both cases, the identification of atypical lesions and refractoriness to treatment led to questioning the diagnosis of IBD. Eventually, microbiological findings confirmed the diagnosis of STI and targeted antimicrobial treatment resolved the condition.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In recent years, the incidence of STI proctocolitis has increased, especially in people who partake in risky sexual practices.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most frequently implicated microorganisms are <span class="elsevierStyleItalic">Neisseria gonorrhoeae, C. trachomatis</span> (serotypes L1 to L3 of which cause lymphogranuloma venereum) and <span class="elsevierStyleItalic">Treponema pallidum</span>, not forgetting the monkeypox virus, which caused a pandemic outbreak in 2022. In these STIs, the endoscopic findings (inflammation or ulcers) and histology (acute inflammation) may overlap with those of UC. Diagnosis is confirmed by PCR and serology (the latter for syphilis).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition, it is recommended to rule out HIV in this population group.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">If a patient diagnosed with IBD exhibits atypical clinical, endoscopic or histological features, or no response to treatment, other diagnoses should be ruled out. A clinical history is required that addresses intestinal and extraintestinal symptoms, travel and sexual behaviour (unprotected passive anal intercourse). Extensive endoscopic and histological evaluation of the lesions is warranted, and microbiological and serological tests may sometimes be necessary to reach a definitive diagnosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">All ethical procedures have been implemented. The privacy rights of the subjects have been respected. Permission has been obtained from the subjects for publication of the (anonymous) information and endoscopy images.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No financial support has been received for the conduct of the research or for the preparation of the article.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors</span><p id="par0050" class="elsevierStylePara elsevierViewall">Belén Martínez Benito: authorship of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">María Chaparro and Javier P. Gisbert: conception of the manuscript, supervision of the drafting of the manuscript, diagnosis and treatment of the patients included.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Other authors: diagnosis and treatment of the patients included.</p><p id="par0065" class="elsevierStylePara elsevierViewall">All authors approved the final version of the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1348 "Ancho" => 1674 "Tamanyo" => 294352 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colonoscopy: a) rectal mucosa with fibrin exudates and superficial ulcerations; b) excavated ulcer with fibrin background and erythematous, raised edges; c) erythematous mucosa, isolated aphthae and deep, fibrin-covered ulcers with mammillated edges; d) several excavated, serpiginous, fibrin-covered ulcers with raised edges.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ECCO topical review on clinicopathological spectrum and differential diagnosis of inflammatory bowel disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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