*Aneta Obcowska-Hamerska1, Jarosław Basaj2
Sexually transmitted diseases causing anorectal symptoms. Part 2. Viral infections
Choroby przenoszone drogą płciową powodujące objawy proktologiczne. Część 2. Choroby o etiologii wirusowej
1Department of General, Vascular and Oncological. Surgery, Medical University of Warsaw
2Endoscopic Laboratory, Czerniakowski Hospital Sp. z o. o.
Streszczenie
Poza etiologią bakteryjną coraz częściej diagnozowanych STI obecna jest wirusowa, której cechą charakterystyczną są zakażenia latentne.
Bardzo rozpowszechniony, szczególnie w grupie osób z deficytem odporności, wirus HSV poza typowymi pęcherzykami i drobnymi owrzodzeniami wokół odbytu może doprowadzić do zajęcia kanału odbytu i odbytnicy. Każdego chorego należy poddać leczeniu, a równolegle potwierdzić obecność materiału genetycznego HSV oraz oznaczyć typ wirusa.
Cytomegalowirusowe zapalenie odbytnicy najczęściej dotyczy pacjentów z upośledzoną odpowiedzią immunologiczną. Wirus powoduje nadżerki i głębokie owrzodzenia, a u chorych seropozytywnych zmiany krwotoczne. W większości przypadków objawy ustępują samoistnie, ale przy znacznych deficytach odporności może dojść do krwawienia do przewodu pokarmowego i perforacji jelita.
Zakażenie wirusem HPV (Human papilloma virus) jest najszerzej rozpowszechnioną STI, objawiającą się kłykcinami kończystymi. Badanie fizykalne z reguły jest wystarczające do rozpoznania. Metoda terapeutyczna wymaga dostosowania do zakresu zmian chorobowych i preferencji pacjenta. Niektóre typy HPV posiadają wysoki potencjał onkogenny m.in. do raka odbytu, który najwyraźniej jest realizowany wraz z innymi czynnikami ryzyka u osób seropozytywnych z grupy MSM.
Poza optymalnym postępowaniem terapeutycznym duże znaczenie ma poradnictwo profilaktyczne wśród chorych.
Summary
In addition to bacterial aetiology, viral sexually transmitted infections, which are often latent, are becoming increasingly common. The herpes simplex virus (HSV), which is very widespread, especially among immunodeficient individuals, apart from the typical perianal blisters and small ulcerations, can lead to involvement of the anal canal and rectum. Each patient should receive treatment and, at the same time, the presence of viral genetic material and the type of virus should be confirmed. Cytomegalovirus proctitis most often affects immunocompromised individuals. The virus causes erosions and deep ulcerations, and may lead to haemorrhagic changes in HIV-positive persons. In most cases, the symptoms resolve spontaneously, but gastrointestinal bleeding and bowel perforation may occur in patients with significant immunodeficiency. Human papillomavirus (HPV) infection is the most common sexually transmitted infection, manifested by genital warts. Physical examination is usually sufficient for diagnosis. The therapeutic approach should be adjusted to the extent of the lesions and the patient’s preferences. Some types of human papillomavirus have a high carcinogenic potential (e.g. for anal cancer), which is apparently expressed along with other risk factors in HIV-positive men who have sex with men. In addition to optimal therapeutic management, preventive counselling among patients is of particular importance.
Introduction
Sexually transmitted infections (STIs) causing anorectal symptoms have become an everyday occurrence in surgical practice. Basic knowledge in this area is necessary due to the constantly growing incidence and morbidity rates for this group of infections. A surgery office is often the first place where patients seek help.
The first part of the article discusses the most frequently diagnosed bacterial STIs, while the second part focuses on some of the most common viral infections, which are often characterised by latency. HIV infection, which, when coexisting, affects the course of STIs, but at the same time can cause proctological symptoms on its own, is a topic that requires a separate, broader discussion, going beyond this study.
Herpes
Herpes simplex virus (HSV) infections are widespread throughout the human population and are particularly common among immunocompromised individuals. In the past, HSV-1 caused painful blisters in the mouth and nose area, while type 2 was responsible for anogenital symptoms. This division is no longer confirmed in practice and both types of the virus are identified at two locations. This fact is of clinical significance due to lower secretion of HSV-1, and thus limited infectivity and less pronounced symptoms during viral reactivation (1).
After entering the body, the virus multiplies and then travels through sensory neurons (usually in the trigeminal ganglion and in the ganglia of spinal nerves S2-S5), where it remains in a latent form. Symptoms develop 1-3 weeks after infection. In the case of primary infection, the virus is shed for 10-12 days, the symptoms are strongly expressed and sometimes complications develop.
Patients most often report perianal pruritus, burning and pain, as well as occasional bleeding during bowel movements. In the acute phase of a severe infection, micturition disorders, including urinary retention, gas and stool incontinence, and transient erectile dysfunctions may occur (2, 3). General symptoms of infection, such as headache, fever or weakness, are also common.
Physical examination is sufficient for diagnosis. Vesicles with serous fluid or small ulcerations can be seen in the anal area. Importantly, inflammatory lesions may progress from the perianal region to the anal canal and further to the rectum. The majority of severe infections are primary in nature (4). Activation of latent viruses is usually milder and self-limiting.
Digital rectal and endoscopic examinations are painful in the case of inflammation of the anal canal and rectum, with palpable enlarged inguinal lymph nodes.
HSV infection may have an atypical appearance in immunocompromised patients, e.g. a single, extensive rectal ulceration. This is relatively common in patients treated with azathioprine for inflammatory bowel disease (5). This creates the risk of misinterpretation of the endoscopic image as evidence of an active underlying disease, excluding HSV as the etiological factor and, as a result, delayed treatment onset.
In HIV-positive individuals, symptoms of primary infection and latent activation develop regardless of CD4 counts. A decrease in CD4 count to less than 100 cells/μL indicates a significant immune deficiency and results in frequent virus reactivation, causing atypical symptoms. The resulting ulcers are deeper, more extensive and therapeutically challenging. Condyloma-like or hypertrophic nodular lesions are another clinical manifestation of HSV in HIV-positive immunocompromised patients (6, 7). They probably develop as a result of keratinocyte growth promotion secondary to reduced INF-gamma secretion and increased production of tumor necrosis factor-alpha (TNF-alpha) (7). This clinical form should be differentiated from anal cancer due to the significant symptom overlap.
Clinical suspicion is a sufficient reason to initiate treatment. However, laboratory confirmation of HSV aetiology should be sought, especially in HIV-positive individuals and those with atypical symptoms (8). Detection of viral genetic material and determination of viral types are recommended. A swab from the base of a lesion punctured at the earliest stage of the disease offers the best chance of obtaining a representative sample (8-10). Antibody screening is currently not recommended (8-10).
Pharmacotherapy reduces both symptom duration and severity. Treatment neither eradicates the latent pathogen nor protects against recurrences. It also fails to reduce the risk of further transmission of the virus. Oral acyclovir, valacyclovir and famciclovir are used for 5-10 days in the case of poor intravenous tolerance, and 1-5 days during recurrent viral activations (10). The dosage regimen is in line with the guidelines for the treatment of genital HSV. Prolonged therapy and increased doses may be used for proctitis. Analgesics and warm sitz baths play a supportive role, improving the comfort of patients.
HIV co-infected patients with good immune status most often receive typical doses, but for an extended period of time (up to 10 days). In the case of reduced CD4 counts and other immunosuppressive states, the doses used are increased up to several times. Patients with advanced AIDS require parenteral treatment (10).
Imiquimod is used for hypertrophic lesions that may be resistant to conventional treatment (11, 12).
Patient care also involves HIV screening, follow-up, and advising patients to refrain from sexual intercourses until symptoms resolve.
Cytomegalovirus proctitis
Cytomegalovirus GI infection most often affects immunocompromised patients, although cases of symptomatic infections in immunocompetent individuals have also been reported (13, 14). Primary infection may lead to latent infection, with macrophages and monocytes being the reservoir for the virus.
In the gastrointestinal tract, the inflammatory process often involves the large bowel. Rectal bleeding after anal intercourse accompanied by characteristic mononucleosis-like symptoms (fever up to 40°C, pharyngitis with tonsillar involvement and lymphadenopathy) occurs several days to several weeks after exposure to CMV-containing secretions (15).
Endoscopic features of inflammation vary in severity, from small erosions to deep ulcerations. A small proportion of patients may also develop polypoid hyperplasia, while HIV-positive individuals may present with haemorrhagic changes.
Tissue biopsy rather than brush swab is used to confirm CMV as the causative agent of proctitis. Histopathology reveals characteristic giant cells containing intracytoplasmic and intranuclear „owl’s eye” inclusions, inflammatory infiltrates (mainly granulocytic), as well as features of vasculitis and necrosis. Serology, PCR and immunohistochemical analysis of tissue specimens allow for the diagnosis (16).
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Piśmiennictwo
| 1. Engelberg R, Carrell D, Krantz E et al.: Natural history of genital herpes simplex virus type 1 infection. Sex Transm Dis 2003; 30: 174-177.
| 2. Joseph D, Jin H, Ryan C, Chey WY: Resolution of anorectal incontinence in herpes proctitis confirmed by anorectal manometry. Gastrointest Endosc 1997; 45(5): 429-432.
| 3. Goodell SE, Quinn TC, Mkrtichian EE et al.: Herpes simplex virus proctitis in 91. Drugs for parasitic infections. The Medical Letter 1995; 37: 99-108.
| 4. Goodell SE, Quinn TC, Mkrtichian E et al.: Herpes simplex virus proctitis in homosexual men. Clinical, sigmoidoscopic, and histopathological features. N Engl J Med 1983; 308: 868-871.
| 5. Santos-Antunes J, Abreu C, Magro F et al.: Disseminated cutaneous herpes simplex infection in a patient with Crohn’s dis ease under azathioprine and steroids: first case report and literature review. J Crohns Colitis 2014; 8: 326-330.
| 6. Felt-Bersma RJ, Bartelsman JF: Haemorrhoids, rectal prolapse, anal fissure, peri-anal fistulae and sexually transmitted diseases. Best Pract Res Clin Gastroenterol 2009; 23: 575-592.
| 7. Ranu H, Lee J, Chio M, Sen P: Tumour-like presentations of anogenital herpes simplex in HIV-positive patients. Int J STD AIDS 2011; 22: 181-186.
| 8. Patel R, Kennedy OJ, Clarke E et al.: 2017 European guidelines for the management of genital herpes. Int J STD AIDS 2017; 0(0): 1-14.
| 9. Ramaswamy M, McDonald C, Smith M et al.: Diagnosis of genital herpes by real time PCR in routine clinical practice. Sex Transm Infect 2004; 80: 406-410.
| 10. de Vries HJC, Nori AV, Kiellberg Larsen H et al.: 2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. J Eur Acad Dermatol Venereol 2021; 35: 1434-1443.
| 11. Perkins N, Nisbet M, Thomas M: Topical imiquimod treatment of aciclovir-resistant herpes simplex disease: case series and literature review. Sex Transm Infect 2011, 87: 292-295.
| 12. Barroso Dos Reis HL, Tosato Boldrini NA, da Silva Campos LC et al.: Hypertrophic genital herpes in an HIV-infected female patient: Imiquimod as an alternative treatment. Int J Infect Dis 2020; 95: 153-156.
| 13. Bernard S, Germi R, Lupo J et al.: Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series. Clin Microbiol Infect 2015; 21: 1121-1127.
| 14. Galiatsatos P, Shrier I, Lamoureux E, Szilagyi A: Meta-analysis of outcome of cytomegalovirus colitis in immunocompetent hosts. Dig Dis Sci 2005; 50: 609-616.
| 15. Studemeister A: Cytomegalovirus proctitis: a rare and disregarded sexually transmitted disease. Sex Transm Dis 2011; 38: 876-878.
| 16. Shieh AC, Guler E, Tirumani SH et al.: Clinical, imaging, endoscopic findings, and management of patients with CMV colitis: a single-institute experience. Emerg Radiol 2020; 27: 277-284.
| 17. Kram HB, Shoemaker WC: Intestinal perforation due to cytomegalovirus infection in patients with AIDS. Dis Colon Rectum 1990; 33(12): 1037-1040.
| 18. de Villiers EM, Fauquet C, Broker TR et al.: Classification of papillomaviruses. Virology 2004; 324: 17.
| 19. Burchell AN, Coutlee F, Tellier PP et al.: Genital trans-mission of human papillomavirus in recently formed heterosexual couples. J Infect Dis2011; 204: 1723-1729.
| 20. Winer RL, Kiviat NB, Hughes JP et al.: Development and duration of human papillomavirus lesions, after initial infection. J Infect Dis 2005; 191: 731.
| 21. Rodríguez AC, Schiffman M, Herrero R et al.: Rapid clearance of human papillomavirus and implications for clinical focus on persistent infections. J Natl Cancer Inst 2008; 100: 513.
| 22. Jin F, Prestage GP, Kippax SC et al.: Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study. Sex Transm Dis 2007; 34: 488-493.
| 23. Yanofsky VR, Patel RV, Goldenberg G: Genital warts: a comprehensive review. J Clin Aesthet Dermatol 2012; 5: 25.
| 24. Garland SM, Steben M, Sings HL et al.: Natural history of genital warts: analysis of the placebo arm of 2 randomized phase III trials of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine. J Infect Dis 2009; 199: 805.
| 25. Tian T, Mijiti P, Bingxue H et al.: Prevalence and risk factors of anal human papil4. lomavirus infection among HIV-negative men who have sex with men in Urumqi city of Xinjiang Uyghur Autonomous Region, China. PLoS One 2017; 12(11): e0187928.
| 26. Schlecht HP, Fugelso DK, Murphy RK et al.: Frequency of occult high-grade squamous intraepithelial neoplasia and invasive cancer within analcondylomata in men who have sex with men. Clin Infect Dis2010; 51: 107-110.
| 27. Gormley RH, Kovarik CL: Human papillomavirus-related genital disease in the immunocompromised host: Part I. J Am Acad Dermatol 2012; 66: 867-871.
| 28. Yong M, Parkinson K, Goenka N, O’Mahony C: Diabetes and genital warts: an unhappy coalition. Int J STD AIDS 2010; 21: 457.
| 29. Spinu D, Radulescu A, Bratu O et al.: Giant condyloma acuminatum ? Buschke-Lowenstein disease ? a literature review. Chirurgia (Bucuresti) 2014; 109: 445-450.
| 30. Gilson R, Nugent D, Werner RN et al.: 2019 IUSTI?Europe guideline for the management of anogenital warts. JEADV 2020; 34: 1644-1653.
| 31. Oriel JD: Natural history of genital warts. Br J Vener Dis1971; 47: 1-13.
| 32. Pillsbury AJ, Quinn HE, Evans TD et al.: Population-Level Herd Protection of Males From a Female Human Papillomavirus Vaccination Program: Evidence from Australian Serosurveillance. Clin Infect Dis 2017; 65: 827.
| 33. Naleway AL, Crane B, Smith N et al.: Temporal Trends in the Incidence of Anogenital Warts: Impact of Human Papillomavirus Vaccination. Sex Transm Dis 2020; 47: 179.
| 34. Hoentjen F, Rubin TD: Infectious Proctitis: When to Suspect It Is Not Inflammatory Bowel Disease. Dig Dis Sci 2012; 57: 269-273.
| 35. Klausner JD, Kohn R, Kent C: Etiology of clinical proctitis among men who have sex with men. Clin Infect Dis 2004; 38: 300-302.
otrzymano: 2023-01-23
zaakceptowano do druku: 2023-02-13 Adres do korespondencji: *Aneta Obcowska-Hamerska Klinika Chirurgii Ogólnej, Naczyniowej i Onkologicznej Warszawski Uniwersytet Medyczny aneta.obcowska-hamerska@wum.edu.pl Nowa Medycyna 1/2023Strona internetowa czasopisma Nowa MedycynaPozostałe artykuły z numeru 1/2023: | 