梅毒性直腸炎

資料來源：Stephanie V. Sherman, M.D., Editor / August 3, 2023 / n engl j med 389;5 nejm.org

一名 50 歲男子到外科診所就診，有 1 個月長的時間有痛性便血史。 在症狀出現前一個月，他與一位新伴侶進行了無保險套接受性肛交。他報告沒有發燒、體重減輕、皮疹、生殖器病變或腸道習慣變化。 體檢結果正常。 血清學檢測值得注意的是梅毒螺旋體顆粒凝集試驗呈陽性，快速血漿反應素 (RPR) 效價為1:32，人類免疫缺陷病毒檢測呈陰性。直腸拭子所獲得的樣品的衣原體和淋病呈陰性。 隨後的結腸鏡檢查發現直腸遠端有一個直徑 3 厘米的潰瘍，粘膜水腫、脆弱和一些出血（圖 A）。 活檢標本的組織病理學檢查顯示固有層和粘膜下層有組織細胞和淋巴漿細胞浸潤，無肉芽腫或腫瘤，梅毒螺旋體免疫組織化學染色顯示固有層內且有大量螺旋體（圖 B）。 診斷為梅毒性直腸炎。 治療後服用芐青黴素 (benzylpenicillin) 後，患者症狀減輕。 重複 RPR 效價為 1:8，重複結腸鏡檢查顯示直腸潰瘍已消退（圖 C）。

Syphilitic Proctitis

Stephanie V. Sherman, M.D., Editor / August 3, 2023 / n engl j med 389;5 nejm.org

A 50-year-old man presented to the surgery clinic with a 1-month history of painful hematochezia. One month before the onset of his symptoms, he had had condomless receptive anal intercourse with a new partner. He reported no fever, weight loss, rashes, genital lesions, or change in bowel habits. A physical examination was normal. Serologic testing was notable for a positive Treponema pallidum particle agglutination assay, a rapid plasma reagin (RPR) titer of 1:32, and a negative human immunodeficiency virus test. A sample obtained from a rectal swab was negative for chlamydia and gonorrhea. A subsequent colonoscopy identified an ulcer measuring 3 cm in diameter in the distal rectum with edematous, friable mucosa and some bleeding (Panel A). Histopathological examination of a biopsy specimen showed histiocytes and lymphoplasmacytic infiltrates in the lamina propria and submucosa, no granulomas or neoplasia, and numerous spirochetes within the lamina propria on immunohistochemical staining for T. pallidum (Panel B). A diagnosis of syphilitic proctitis was made. After treatment with benzylpenicillin, the patient’s symptoms abated. A repeat RPR titer was 1:8, and a repeat colonoscopy showed resolution of the rectal ulcer (Panel C).

Images in Clinical Medicine Qiya Cai, M.B. Xinling Bi, M.D. Changhai Hospital Shanghai, China