S4888 A Rare Rectal Finding in Ulcerative Colitis: HPV Risk in the Era of Advanced Immunomodulators

Introduction: Condyloma acuminatum (CA) is a benign epithelial proliferation caused by human papillomavirus (HPV), typically affecting the anogenital region. While perianal involvement is common, rectal mucosal CA is rare, particularly in immunosuppressed individuals. Patients with ulcerative colitis (UC) on long-term immunosuppressive therapy may be at increased risk for HPV-related lesions due to impaired immune surveillance. Case Description/Methods: We report the case of a 60-year-old Puerto Rican woman with a history of UC and hypertension in deep remission under Tofacitinib therapy. She presented for routine UC follow-up and underwent a surveillance colonoscopy, which revealed a friable, flat, slightly raised whitish lesion in the rectal mucosa, approximately 5 cm from the anal verge, extending nearly circumferentially. Histopathological analysis of endoscopic biopsies confirmed condyloma acuminatum without dysplasia. The patient had previously undergone a colonoscopy 1 year prior, showing a colon that appeared endoscopically normal, including biopsies with quiescent disease activity. Upon further discussion, she disclosed a new sexual partner and unprotected anal intercourse. Given the extent of the disease, she was referred for colorectal surgery for further management. Discussion: This case emphasizes the importance of recognizing rectal mucosal CA as a potential hidden site within the condyloma spectrum, particularly in immunosuppressed UC patients. While the exact mechanism of rectal CA development remains unclear, chronic mucosal inflammation combined with immunosuppression may contribute synergistically to HPV persistence and lesion development. This reinforces the need for comprehensive sexual history-taking and individualized risk assessment when prescribing immunosuppressive therapy, especially in patients with prior HPV exposure, perianal disease, or a history of sexually transmitted infections. In the absence of standardized surveillance guidelines for rectal CA in inflammatory bowel disease patients, early detection, close follow-up, and a multidisciplinary approach are critical to mitigate the risk of recurrence and malignant transformation.