What is the differential diagnosis for patients presenting with proctitis and a history of HIV infection?

Bottom line:  In patients presenting with proctitis and a history of HIV infection, a sexual history of a man who has sex with men suggests a risk for sexually-transmitted infections:   gonorrhea, herpes simplex, chlamydia, and syphilis (in descending order of incidence in this population).  Other infections, such as HSV and lymphogranuloma venerum (LGV) may occur more frequently in this population compared to men who have sex with men but are HIV negative.

Davis BT, Thiim M, Zukerberg LR. Case 2-2006 — A 31-Year-Old, HIV-Positive Man with Rectal Pain. N Engl J Med 2006; 354:284-289.
This case report reviews the process of prioritizing the differential diagnoses based on sexual history and HIV status and discusses the place of empirical therapy and what to do in the case of recurrence.

Bissessor M, et al. The etiology of infectious proctitis in men who have sex with men differs according to HIV status. Sex Transm Dis. 2013 Oct;40(10):768-70. doi: 10.1097/OLQ.0000000000000022.
Case series of 279 men who presented with proctitis (141 HIV+ and 138 HIV-) at a public STI clinic. Incidence of pathogens:

Pathogen Incidence in HIV+ pts Incidence in HIV- pts
Chlamydia 23.4% 21.7% (p=0.7)
Gonorrhea 13.4% 10.8% (p=0.5)
HSV-1 14.2% 6.5% (p=0.04)
HSV-2 22% 12.3% (p=0.03)
LGV 7.8% 0.7% (p=0.004)
multiple infections 17.7% 8.6% (0.017)

 

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About Amy

Clinical Informationist at EUH Branch Library
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