Rectal cancer mimic Dr Rajashri V Patil Sp

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Rectal cancer mimic Dr Rajashri V Patil (Sp. R) Dr Syed Mohammed (Sp. R)

Rectal cancer mimic Dr Rajashri V Patil (Sp. R) Dr Syed Mohammed (Sp. R) Dr James Stephenson (Consultant) Dr Yvette Griffin (Consultant) University Hospitals of Leicester

Clinical Presentation 66 year old retired businessman of homosexual orientation with stable partner Viral

Clinical Presentation 66 year old retired businessman of homosexual orientation with stable partner Viral load count (HIV 1 RNA count) remained stable (<1. 60 log copies/ml) B/G: HIV positive and pulmonary tuberculosis FBC, U&E and carcinoembryonic antigen were normal Presentation: Generalised abdominal pain and constipation Rectal swabs were negative for Neisseria gonorrhoea and chlamydia trachomatis. Examination: generalised abdominal tenderness and empty rectum CT by ED: ? Bowel obstruction or perforation

Contrast enhanced CT abdomen & pelvis • Diffuse mucosal thickening in the rectum with

Contrast enhanced CT abdomen & pelvis • Diffuse mucosal thickening in the rectum with perirectal fat stranding • Multiple enlarged mesorectal lymph nodes • ? Rectal Cancer- advised completion staging chest CT and sigmoidoscopy

Sigmoidoscopy Ulcer Histology: Chronic inflammation Chest CT: No additional findings

Sigmoidoscopy Ulcer Histology: Chronic inflammation Chest CT: No additional findings

MRI • Diffuse rectal wall thickening with diffusion restriction on DWI • Appearances atypical

MRI • Diffuse rectal wall thickening with diffusion restriction on DWI • Appearances atypical for rectal cancer • ? lymphoproliferative disorder or lymphogranuloma venereum

Differentials Rectal malignancy Lymphoproliferative disorder Inflammatory bowel disease Diagnosis Syphilis serology- positive for infection

Differentials Rectal malignancy Lymphoproliferative disorder Inflammatory bowel disease Diagnosis Syphilis serology- positive for infection CSF profile demonstrated treponemal antibody on Treponema pallidum particle agglutination (TPPA) Syphilitic proctitis

Follow-up Treated for syphilis according to the national guidelines Symptomatic improvement Radiological improvement (MRI)

Follow-up Treated for syphilis according to the national guidelines Symptomatic improvement Radiological improvement (MRI)

Discussion Learning points Venereal infection spirochetal bacterium treponema palladium High index of suspicion in

Discussion Learning points Venereal infection spirochetal bacterium treponema palladium High index of suspicion in high risk patients and serological findings play a major role Relatively uncommon in England Differential diagnosis for imaging findings in rectal lesions, particularly in homosexual men with HIV, should include sexually transmitted rectal infections, of which syphilis should be the prime differential diagnosis Can be misdiagnosed clinically and radiologically as rectal cancer or inflammatory bowel diseases.

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