Syphilitic proctitis with profuse rectal bleeding in an HIV-infected patient with preserved CD4 count (case report).

Authors

Mohamad H Mosi, Hisham Alfarra, Chandni Davi, Shaila Saaki, Refat Jayyusi, Logaen Kubaisy, Hayder Yasir

Published in

Medicine. Volume 105. Issue 44. Pages e51230. Oct 30, 2026.

Abstract

Syphilitic proctitis is an uncommon and frequently under-recognized manifestation of Treponema pallidum infection that can closely mimic inflammatory, infectious, or neoplastic rectal disease. We report an unusually severe, hemorrhagic presentation in a patient with human immunodeficiency virus (HIV) and a preserved cluster of differentiation 4 (CD4) count, a setting in which overlapping etiologies often delay the diagnosis.
A heterosexual man in his early 50s with untreated HIV infection and chronic hepatitis B-related cirrhosis (Child-Pugh class B) presented with sudden onset of profuse hematochezia, watery diarrhea, abdominal cramping, and fatigue.
Computed tomography angiography revealed pronounced rectal wall thickening with deep ulceration. Colonoscopy demonstrated an indurated, ulcerated rectal lesion, and biopsy showed dense lymphoplasmacytic inflammation, with spirochetes confirmed by T pallidum immunohistochemistry. Negative cytomegalovirus (CMV) immunohistochemistry, undetectable CMV DNA in plasma and rectal tissue, and a preserved CD4 count (445 cells/µL) made CMV proctitis unlikely. The overall clinical, endoscopic, and histologic findings supported a diagnosis of syphilitic proctitis.
Management included doxycycline 100 mg twice daily for 2 weeks, selected because of the patient's documented penicillin allergy. Antiretroviral therapy with bictegravir/tenofovir alafenamide/emtricitabine was initiated to treat HIV and provide concurrent hepatitis B coverage.
Within 2 weeks, the patient experienced complete resolution of hematochezia and diarrhea. At 3-month follow-up, the CD4 count had risen to 570 cells/µL, HIV RNA was undetectable (<20 copies/mL), and the rapid plasma reagin titer had declined from 1:512 to 1:32.
This case underscores that syphilitic proctitis may manifest with severe ulcerative disease even in patients with relatively preserved immune function. Clinicians should maintain vigilance for syphilis in individuals with HIV who present with rectal bleeding or proctitis to prevent diagnostic delays and ensure timely therapy.

PMID:
43012798
Bibliographic data and abstract were imported from PubMed on 11 Nov 2026.

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