When patients present with gastrointestinal symptoms, sexually transmitted infection is unlikely to be at the top of the differential diagnosis. A 47-year-old homosexual man underwent evaluation for persistent fatigue, abdominal pain, and anemia with a positive fecal occult stool test, all of which raised concern for an acute gastrointestinal bleed. Approximately 6 months earlier, the patient began to have persistent loose bowel movements, for which he did not seek medical care. Two months before presentation, while on vacation in Thailand, he developed an asymptomatic maculopapular rash over his palms that improved spontaneously.
Six weeks before presentation, he started to experience anorexia, fatigue, nausea, emesis, and midabdominal pain, symptoms that were accompanied by an unintentional 11.4 kg (25 lb) weight loss. He visited an outside clinic, where he also described numerous nonspecific neurologic symptoms, including headaches, numbness, tingling in his hands and feet, tinnitus, and blurry vision.
The patient’s medical history was notable for chronic back pain and a previous episode of anal gonorrhea, but he denied other sexually transmitted infections. Although he had multiple male sexual partners over the past year, he reported consistent use of barrier protection. He took over-the-counter acetaminophen, naproxen, and melatonin as needed but was not taking any prescription medications.
Assessment
Upon arrival to our medical center, the patient was afebrile and hemodynamically stable. He appeared tired and nontoxic. A cardiopulmonary examination was unremarkable. The abdominal examination revealed periumbilical abdominal tenderness without rebound tenderness or guarding, and a skin examination identified right-sided cervical lymphadenopathy and a faint desquamating macular rash on his palms. Bilateral lower-extremity weakness, worse in the left lower extremity, and hypoesthesia of the hands and feet were noted on the neurologic examination. The remainder of the physical examination results were normal.
Initial laboratory results were noteworthy for the following levels: hemoglobin, 6.9 g/dL; total bilirubin, 1.8 mg/dL; direct bilirubin, 1.1 mg/dL; and alkaline phosphatase, 705 U/L. Computed tomography performed at an outside facility demonstrated periduodenal inflammation and what appeared to be an obstructing pancreatic mass. Magnetic resonance cholangiopancreatography of the liver demonstrated periduodenal and pericholecystic fluid with mild to moderate nonspecific heterogeneous hepatomegaly. To evaluate these findings further and the potential for a gastrointestinal bleed, we ordered esophagogastroduodenoscopy for the patient. The procedure demonstrated 2 to 3 ulcers in the gastric antrum (Figure 1) and multiple serpiginous ulcers in the duodenal bulb (Figure 2). Biopsies of these ulcers were obtained at the time of esophagogastroduodenoscopy.
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-Christian L. Horn, MD, Seyed Jalali, MD, Joel Abbott, DO, Michael T. Stein, MD
This article originally appeared in the October issue of The American Journal of Medicine.
