Physical Examination and Workup
The patient's vital signs include a blood pressure of 128/78 mm Hg, a heart rate of 76 beats/min, a respiration rate of 18 breaths/min, and a temperature of 97.8°F (36.6°C). His weight is 168 lb (76.2 kg), and his height is 5 ft 11 in (180.34 cm).
Upon physical examination, he is cooperative and in no distress. No significant lymphadenopathy is noted in the cervical, axillary, or inguinal areas. His abdomen is soft, nontender, and nondistended, with normoactive bowel sounds. The rectal examination reveals mild tenderness, an anal fissure in the eleven o'clock position, and a few external hemorrhoids. No internal hemorrhoids are present.
Laboratory studies show mild anemia, with a hemoglobin level of 10.8 g/dL (reference range, 14-18 g/dL). His white blood cell count is 7100 cells/μL (reference range, 4500-11,000 cells/μL), and his creatinine level is 0.89 mg/dL (reference range, 0.6-1.2 mg/dL). His HIV viral load is undetectable, and his CD4 T-cell count is 275 cells/µL (reference range, 500-1500 cells/μL).
A CT scan shows irregular thickening of the entire rectum, with mesorectal fat stranding and lymphadenopathy. The differential at this point is either an infectious or an inflammatory process with severe proctocolitis or an underlying rectal neoplasm. MRI is subsequently ordered, which confirms an irregular, nodular, polypoidal mass with high T2 signal intensity and multiple subcentimeter lymph nodes in the mesorectal and perirectal fat.
Diagnostic colonoscopy reveals a fungating, infiltrative, and partially obstructing mass in the rectum, approximately 8-12 cm from the anal verge (Figure 1). The rectal mucosa has multiple areas of nonbleeding ulcers, from which biopsies are obtained for histopathology and microbiologic studies.
Because of initial concern for lymphogranuloma venereum (LGV) and syphilis, empiric treatment with oral doxycycline 100 mg every 12 hours is started. The results of a routine workup for common sexually transmitted infections, such as gonorrhea and chlamydia, are negative. The rapid plasma reagin (RPR) titer is 1:4; however, the patient had a titer of 1:16 six months earlier.
Histopathologic sections of the tissue biopsy on hematoxylin and eosin staining show ulcerated colorectal mucosa, abnormal granulation tissue, and epithelial cells with viral nuclear inclusion, as well as an impressive eosinophilic, purulent, and lymphoplasmacytic infiltrate (Figure 2).
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