Syphilis? An Unusual Cause of Surgical Emergency in a Human Immunodeficiency Virus-Infected Man

Below:  Histology slides of a fungating mass consistent with a rarely encountered presentation of Treponema pallidum infection in the anus. (A) A hematoxylin and eosin (H&E)-stained section shows a polypoid lesion composed of hyperplastic squamous epithelium overlying inflamed stroma (20×). (B) Higher power demonstrates a proliferation of blood vessels and dense inflammation (H&E stain, magnification ×100). (C and D) Swollen endothelial cells and thickened vessel walls are characteristic of, but not specific for, syphilis. The surrounding inflammation has a prominent plasma cell component (H&E stain, magnification ×400).

We report on a human immunodeficiency virus-infected man undergoing urgent anorectal surgery, with multi-centimeter fungating masses discovered inside the anus. Initial pathology was inconclusive. After the patient developed a disseminated rash postoperatively determined to be secondary syphilis, the anorectal pathology was reviewed and Treponema pallidum DNA was amplified by polymerase chain reaction from the mass.

A 43-year-old man presented to his human immunodeficiency virus (HIV) primary care provider reporting 2 weeks of worsening rectal pain and red blood in the toilet bowl. Four days after his symptoms started, he was seen by another provider, who visualized external hemorrhoids and prescribed symptomatic treatment. Eleven days later, his rectal pain was so severe that he could not sit in a chair, and he had severe pain with coughing, as well as difficulty voiding urine. He noted milky-pink discharge per rectum, soft formed stools, and no further bleeding. He had received a new diagnosis of HIV 4 months prior, with initial CD4 T-cell count of 567 cells/mL and HIV-1 viral load of 59 000 copies/mL. Other than experiencing symptoms consistent with acute retroviral syndrome approximately 2 years prior, he had no other medical concerns except essential hypertension. He smoked and drank moderately. He reported being sexually active with a single male partner for the last 2 years with last condomless receptive anal intercourse 2 weeks prior. Two months previously, a syphilis immunoglobulin (Ig)G enzyme immunoassay (EIA) test was negative, as were serologic tests for hepatitis A, B, and C. Current medications included amlodipine and Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir), the latter begun 5 weeks previously. On exam, he was afebrile but appeared highly uncomfortable. His abdominal exam was normal and there was no inguinal lymphadenopathy. External rectal exam revealed erythema and induration in an area of 3 × 4 cm from the anal verge onto the right buttock, an external hemorrhoid, and a possible fissure. Rectal exam and anoscopy could not be performed due to pain. Laboratory investigations included normal complete blood count and liver function tests. Plasma HIV-1 viral load was 67 copies/mL. A rectal swab for Chlamydia trachomatisand Neisseria gonorrhoeae was negative by nucleic acid amplification. 

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