Intestinal spirochetosis

Intestinal spirochetosis involves the colonization of the colonic epithelium by Brachyspira. Patients may be asymptomatic or present with diarrhea, abdominal pain, and bloating. It generally affects immunocompromised individuals. Diagnosis requires colonoscopy with biopsies and specific staining, often missed due to its rarity. Treatment typically involves metronidazole, with macrolides as alternatives, but relapse can occur, necessitating better follow-up and documentation. We present four cases that highlight diverse presentations and responses to treatment. A 36-year-old male with multiple sclerosis (MS) and psoriasis, who experienced symptom resolution with metronidazole; a 23-year-old male with abdominal pain and diarrhea, who improved with clarithromycin; an 86-year-old diabetic with chronic diarrhea who responded to metronidazole but experienced a relapse; and a 54-year-old male with HIV-AIDS, who was treated for concurrent H. pylori with no recurrence. Diagnostic challenges arise due to symptom variability and slow growth on culture. Treatment with metronidazole is effective but prone to relapse, possibly due to spirochete translocation within colonic crypts. More research is needed to establish clear diagnostic markers, understand epidemiological patterns, and develop effective long-term treatments. • Association between HIV and intestinal spirochetosis • Possible symptomatology, diagnostic stains, and treatment options for intestinal spirochetosis • Poor eradication despite treatment and data on recurrence