Sudden anal discharge and rectal pain in a 30-year-old man

What causes this 30-year-old man’s mucopurulent anal discharge, rectal cramps, and feeling like he needs to have a bowel movement even after emptying his bowels?

That’s what doctors at the University Hospital of La Paz in Madrid, Spain, were trying to determine, as explained by Rafael Escudero-Tornero, MD, and his colleagues in their report on the case in JAMA Dermatology. When the patient presented to the clinic a week after the onset of these symptoms, he noted that 2 days earlier he had also developed itchy bumps around his anus.

Physical examination revealed multiple small vesicles and papulovesicles measuring less than one centimeter and central necrosis surrounding the anal opening. The patient appeared otherwise healthy; he was afebrile and said he had no fatigue, headaches, or joint or muscle pain. However, clinicians noted palpable lymphadenopathy in the inguinal pelvis.

The patient said he had traveled to the island of Gran Canaria in Spain the week before his symptoms started and had unprotected sex with another man 5 days before the onset of symptoms.

Clinicians obtained samples of the rectum and perirectal skin; laboratory test results were negative for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and herpes simplex virus. Blood test results for rapid plasma reagin and HIV were also unremarkable.

Given the possibility that the patient had monkeypox, clinicians obtained a swab of an intact vesicle and genome amplification tests came back positive. The team advised the patient on self-isolation measures and put him on treatment to treat his itching, pain and anal discharge. A week later, the blisters had crusted over and the proctitis had resolved.

Discussion

Escudero-Tornero and co-authors noted that in the current outbreak of monkeypox – first reported in May 2022 in non-endemic countries – cases frequently present with isolated genital and perianal presentations rather than a rash. generalized skin, unlike previous manifestations.

Initially identified around 70 years ago, monkeypox is considered endemic to parts of central and western Africa. In most cases, the infection causes a generalized rash “characterized by lesions that progress through multiple stages, including macular, papular, vesicular, and pustular morphologies with umbilication,” the authors wrote. “When diffuse, the rash follows a cephalocaudal progression, with single-site lesions often in the same phase of development.”

In more typical cases, the group explained, systemic symptoms such as fever, headache, joint stiffness, muscle pain and lymphadenopathy accompanied the skin manifestation.

According to the World Health Organization’s Interim Rapid Response Guidelines published in June 2022, rash due to monkeypox can be confused with that due to varicella zoster virus, but can be distinguished by the following differences. The rash caused by the varicella zoster virus:

  • Usually progresses faster
  • Is more central than the centrifugal distribution of monkeypox
  • Usually seen in multiple stages of development (compared to the same stage typically seen with monkeypox)
  • Usually does not involve the palms and soles of the feet
  • Is not associated with lymphadenopathy, a hallmark of monkeypox

Despite the clinical differences between the two diseases, a study conducted in the Democratic Republic of Congo reported monkeypox/varicella-zoster virus co-infection with an incidence of 10-13%.

Monkeypox develops more than 1 to 2 weeks after exposure, Escudero-Tornero and co-authors said, noting that in some reported outbreaks in the United States and United Kingdom, the disease has resolved itself from her. -even without requiring treatment.

Transmission can occur through direct contact with lesions or respiratory secretions, or result from prolonged intimate contact, Escudero-Tornero and co-authors noted, warning that despite an association with male-to-male sexual activity, contact close contact with an infected person can lead to transmission. to anyone.

Highlighting the rapid spread of the recent outbreak, the team urged clinicians to include the virus in the differential diagnosis of papules and umbilical vesicles, whether they spread throughout the body or are localized. A complete sexual history should be taken, and consideration should be given to any possible previous exposure to those affected.

Similar symptoms can be caused by localized or generalized herpes virus, as well as other viral rashes and syphilis, the group noted; additionally, in cases where skin symptoms are limited to the anogenital area, clinicians should consider the possibility of other sexually transmitted infections and possible concurrent infections, and test patients accordingly.

After diagnosis, patients with monkeypox should receive symptomatic treatment and be instructed to follow current WHO recommendations, including droplet and contact isolation for 21 days.

In people with severe disease, a large rash may be associated with exfoliation similar to partial-thickness burns, which can lead to dehydration and loss of protein. In these cases, clinicians should estimate the percentage of the body affected; the WHO notes that exfoliation affecting more than 10% of the body is of concern.

Treat exfoliation as burns would be managed, following the guidelines: minimize fluid loss, promote healing, and ensure adequate hydration and nutrition. In severe cases, consult appropriate specialists and consider bedside or surgical debridement as needed. Pets should also be isolated, advises the WHO.

“Further research will be needed to evaluate other emerging therapeutic strategies in the treatment of this new form of a long-known disease,” the case authors concluded.

  • Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

Disclosures

Escudero-Tornero and his co-authors have reported no conflicts of interest.


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