S5160 IBD Imposter: Rectal Gonorrhea Presenting as Chronic Proctitis

Introduction: The global incidence of sexually transmitted infections (STIs), particularly rectal gonorrhea, is rising, especially among men who have sex with men (MSM) and people living with HIV (PLWH). Rectal gonorrhea's diverse gastrointestinal symptoms often overlap with inflammatory bowel disease (IBD), necessitating careful evaluation to prevent misdiagnosis and inappropriate treatment. We present a case of an HIV-positive patient whose severe gastrointestinal symptoms were ultimately diagnosed as rectal gonorrhea. Case Description/Methods: A 39-year-old man with HIV (CD4 705, undetectable viral load) was evaluated at an outside facility for 1 month of nausea, vomiting, bloody diarrhea, and approximately 15 lbs weight loss. He initially attributed symptoms to seafood, raising suspicion for foodborne illness. A computed tomography (CT) abdomen revealed extensive rectosigmoid colitis. Colonoscopy showed inflammation and pathology revealed chronic proctitis without granulomas; concern for IBD led to the initiation of rectal steroids. Still symptomatic 3 weeks later, the patient presented for reevaluation at our facility. A stool polymerase chain reaction showed enteroaggregative E. coli (EAEC), but ongoing diagnostic uncertainty prompted a repeat colonoscopy. This showed several small ulcers and an ulcerated semi-circumferential inflammatory lesion within the rectum. Biopsies confirmed chronic active colitis without dysplasia. Given the atypical rectal lesion, a detailed sexual history revealed receptive anal intercourse and a prior syphilis infection. Empiric treatment for lymphogranuloma venereum (LGV) with doxycycline was initiated. Subsequent rectal NAAT confirmed Neisseria gonorrhoeae, and the patient’s symptoms completely resolved post-treatment. Discussion: Rectal gonorrhea, often asymptomatic or presenting with non-specific symptoms, can lead to serious complications if untreated, including increased HIV transmission risk. Its incidence, as high as 15.5 per 100 person-years in some MSM cohorts, often mimics IBD clinically, endoscopically, and histologically. This case underscores that clinicians must remain vigilant about extragenital STI testing in MSM and PLWH, even without reported recent sexual exposure. Comprehensive evaluation is crucial to avoid delays in appropriate treatment, especially given the significant clinical overlap between infectious proctitis and IBD.