PathologyClues to uncommon and easily overlooked infectious diagnoses affecting the GI tract and distinction from their clinicopathologic mimics
Section snippets
STIs
STIs represent an ever-increasing cause of GI tract inflammation. This discussion is limited to infectious proctitis, because it is predominantly in the rectum that STIs often are mistaken for other conditions, most notably inflammatory bowel disease (IBD). The bacterial pathogens implicated most frequently are Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum.
Proctitis is defined as inflammation involving, although not necessarily restricted to, the rectum.1 Causes of
Chlamydial proctitis
C trachomatis serovars L1, L2, and L3 are the causative agents of lymphogranuloma venereum (LGV), an invasive infection that has tropism for the lymphatic system. Serovars D through K are typically responsible for cases of genital tract infection (urethritis, cervicitis) limited to the mucosal surfaces. An obligate intracellular gram-negative bacterium, this organism replicates inside membrane-bound vacuoles in endothelial and epithelial cells via a process that requires 2 morphologic forms,
Syphilitic proctitis
T pallidum, a gram-negative, motile spirochete, is the causative agent of syphilis. Research on this organism is limited because this metabolically challenged bacterium obtains most necessary macromolecules from its host and cannot survive in vitro for more than a few generations. Despite its slow doubling time (30-33 hours)41 and oxygen and heat sensitivities, T pallidum thrives in the human body, invading and disseminating to a wide variety of tissues.42 Latent or persistent infection in
Gonorrheal proctitis
N gonorrhoeae is a gram-negative diplococcus that grows best at 35°C to 37°C in a medium containing 3% to 5% CO2. This bacterium has fimbriae on its outer surface, which may enhance virulence by facilitating attachment to human epithelial cells and by inhibiting phagocytosis. In addition, the organism inactivates secretory immunoglobulin (Ig) A via an IgA protease, and its outer membrane lipopolysaccharide has endotoxin activity, which plays a role in local and systemic toxicity and
Whipple disease
George Whipple described this multisystemic, malabsorptive disease in 1907.66 Eighty-five years after description of the eponymous disease, the causative organism, Tropheryma whipplei, was identified.67 Whipple disease is a rare condition, with an estimated worldwide incidence of 12 cases annually and a total of approximately 1000 cases reported to date.68, 69 The disease primarily affects middle-aged, white men, with a male-to-female ratio of 8:1.70
Sarcina ventriculi
S ventriculi was first described by Goodsir94 in 1842 in the “cases of chronic disease of the stomach associated with obstinate vomiting of acid, frothy, yeasty matters.” The chronic disease of the stomach in which S ventriculi was first identified was likely gastroparesis or gastric outlet obstruction, because it is in the context of these conditions that most S ventriculi–related illnesses have been reported.95
S ventriculi is a fastidious, anaerobic, gram-positive, sugar-fermenting bacterium.
Giardiasis
Giardia lamblia, also known as G intestinalis or G duodenalis, is a spore-common pathogen worldwide, with an incidence in developing countries of approximately 500,000 cases annually.103 Nearly 20,000 new cases are reported annually in the United States.104 Because ingestion of as few as 10 to 25 cysts can produce the disease in healthy volunteers, Giardia is a common cause of food and water-borne illness and can be transmitted from person to person via the fecal-oral route.105 Wild mammals
Schistosomiasis
Schistosomes are trematode worms known to cause intravascular infestation in humans. Schistosoma hematobium, S mansoni, and S japonicum are species that most commonly infect humans. Schistosomiasis (also known as bilharzia), is endemic to South America, Southeast Asia, and Africa. Africa accounts for 90% of the annual global mortality attributed to schistosomiasis and for 84% of travel-related cases.137 In the United States, the disease is encountered primarily in expatriates from endemic
Cryptosporidiosis
Cryptosporidium is a protozoan parasite that is a common cause of diarrheal illness in the Unites States, with 2.9 cases per 100,000 population reported in 2010.104 C hominis and C parvum are the species most commonly implicated in infections in humans. Cryptosporidium can infect adults and children and immunocompetent as well as immunocompromised individuals. Cattle serve as a reservoir for the parasite, and water-borne outbreaks result from drinking water contaminated by manure.161 Prevalence
Conclusions
Infections affecting the GI tract are numerous, and an all-inclusive review is beyond the scope of this article. In this article we presented an overview of 6 infectious agents that may be misdiagnosed or altogether missed, especially if the clinical scenario is not taken into account at the time of histologic examination. A thorough clinical history that includes travel history, sexual practices, and associated conditions is as important as recognition of the patterns of inflammation
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DISCLOSURE: All authors disclosed no financial relationships relevant to this article.
See CME section; p. 679.