Aashi
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A 27-year-old homosexual man presents to the emergency department complaining of worsening anal and rectal pain over the past two weeks. There is an occasional rectal discharge containing mucus and blood. He reports feeling the urge to defecate multiple times during the day, but often he is unable to have a bowel movement. For the past three days, he has had high fevers associated with shaking chills, night sweats, arthralgias, and myalgias, all of which started two days ago. He has a temperature of 103.2 F and a heart rate of 115/min. There is marked bilateral inguinal and femoral lymphadenopathy. Digital rectal examination shows marked tenderness and a scant, purulent, blood-tinged discharge. No masses are palpated. The genital examination is within normal limits. His white cell count is 17,500/mm3.. The complement fixation test is strongly positive. Flexible sigmoidoscopy shows ulcerative proctitis with areas of mucosal bleeding and purulent exudates. The rectal biopsy shows crypt abscesses with marked inflammatory cell invasion and granulomas with giant cells within the mucosa. Which of the following is the best treatment for this patient?
(A) Sulfasalazine
(B) Metronidazole
(C) Corticosteroids
(D) Doxycycline
(E) Chemotherapy and/or radiotherapy
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| prathapdoctor
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acute exacerbation of ulcerative colitis, is it not corticosteroids,i will go with C.
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| CocaCola
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C - Steroids are used for acute exacerbation of Inflamm bowel dis
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| Aashi
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Guys try again This q is tricky!
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| nida
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D) Doxycycline
May be infected with Chlamydia trachomatis (L-serotpes)
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| fox
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D doxy
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| Aashi
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Answer:
(D) Doxycycline
Explanation:
This patient has primary anorectal lymphogranuloma venereum (LGV). LGV is a sexually transmitted disease caused by Chlamydia trachomatis.. People who engage in anal intercourse may get a primary anal or rectal infection. Patients with acute LGV infection typically have positive complement fixation tests in high titer. Patients with anorectal infection, as in patients with genital infection, often have inguinal lymphadenopathy and may present with fever, chills, and night sweats, mimicking malignant lymphoma. The presentation of rectal pain with discharge and blood may mimic ulcerative colitis. The biopsy finding of inflammatory cell infiltrates and granulomas with giant cells can closely resemble Crohn's disease, but these patients would have a negative complement fixation test and far less adenopathy. In this patient, sulfasalazine would not be effective, and corticosteroids would be detrimental because he has an infection. Metronidazole provides good coverage of anaerobic bacteria like Clostridium difficile that would cause a pseudomembranous colitis, but it would not be effective against C. trachomatis.. At least three weeks of doxycycline or tetracycline would be the best treatment to clear the infection of C. trachomatis in this patient. Definitive diagnosis can also be with a blood antibody test in high titer or by aspiration of an enlarged lymph node when it shows the organism. Even if you thought this was Crohn's disease, sulfasalazine would not be the best therapy. Mesalamine would be used.
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