Tuesday, May 24, 2011

Hanker for a Chancre?

Case of the century.

I received a consult for a GI biopsy recently. Only history was ulcers in rectum. The biopsy looked like chronic active colitis - architectural distortion, cryptitis - probably ulcerative colitis or Crohn's. History fit for UC. It was signed out as such.

The GI doc called back. "This doesn't make sense. It is a young person, but there is only one ulcer. And they have HIV."

Well, that certainly put a spin on the case. UC and Crohn's usually rat out the colon - they don't create a solitary ulcer. And with the patient's immunocompromised status, a bug hunt was in order. I threw on a silver stain for fungus, an AFB for mycobacteria, a Giemsa to hopefully highlight the mucus blebs that might be Cryptosporidium, and a Steiner for syphilis.

The bug stains were all negative. I have not yet performed a Steiner since I was in private practice, and they are tough stains to read. Dirty as hell - ochre yellow and muddy brown spattered in black paint. I didn't think I could see any spirochetes, but I sent the entire case to a GI expert for review. They agreed with me. I called the GI doc to give him our update, and he said, "Well, there is some new information. The patient has syphilis. So that could be a chancre. That would be a first, in our group's history."

I called the University and learned that there is a new, cleaner, much more sensitive stain for syphilitic spirochetes - an immunostain. I had the histo lab cut some unstained slides of the biopsy and sent them over. A couple of days later, I got an e-mail. "The immunostain is positive for spirochetes. What a great case - thanks for the consult."

Sometimes things that seem straightforward aren't, and it takes some extra phone calls and digging to get your answer. I jumped up excitedly and ran to the office next door. Two of my partners were discussing a refractory platelet patient. "Guess what!! I had a rectal chancre this week!" One of them said, with a lascivious smile, "Really, you did? Can I see it? Wait, let me get my iphone camera!" I smiled at him, glanced backward over my shoulder in the direction of my backside, and managed to look cheerfully confused. "Um, that might be tough?"

"Oh yeah, you said rectal." He tucked his iphone back in his pocket. "Oh well."

As I started to blush, my other partner said, "Giz, you walked right into that one. Now tell us about the case, that sounds really interesting."

Speaking of chancres, I had an oh so promising romantic interest at a concert I attended last Wednesday night. My friend and I were sitting down, and I looked over at her curiously. "Are you getting drops of liquid on your head?" She said, "Yeah, drops, but on my shoulder." I looked up. The ceiling was pretty far away for an air conditioner malfunction. I rubbed my finger on my head, and much more was now spilled on my shirt as well. "It smells like beer. Oh well, they say that is good for the hair, right?"

When the lights came up for intermission I glanced behind me, and there was an obviously drunk guy, sitting next to a ten year old. He slurred, "What! You got something to say to me? I'm just trying to show my son a good time here!" I turned around, reluctant to engage in any further interaction.

Later, after my friend and I had picked out t-shirts, I bumped into a pediatrician/ED couple I knew, and stopped to chat. Spilling beer guy was chatting with someone they were with, and I don't think he had any idea that he had ever seen me before. He lumbered over, and it was unclear whether he was talking to me or his friend. "I'm telling you, she's happy with her husband. Are you happy with your husband? I'll bet you are. With my luck, you are happy with your husband." I glanced down at the new t-shirt I had wrapped around my left hand, disguising my ringless finger. I smiled at him. "Yup, I am really, truly happy with my husband."

He walked away, and mumbled at his friend. "I knew it! Darn my luck."

And they say single life is fun. Be wary of chancres - both societal and rectal.


C said...

Interesting case! If a woman gets syphilis, is there a chancre? They've never taught us that in med school.

Concert guy sounds like a creep! Thank god you bought that tee shirt.

Gizabeth Shyder said...

They can. They are usually on the penis, vagina, mouth, or anus. I've never seen one in the rectum. Apparently syphilis is a dead ringer for chronic active colitis. I'll keep that in mind, but doubt I will ever have to use that knowledge again.

He was a creep! I worried about his son getting home safe all night.

rlbates said...

Interesting case, indeed!

Oh, be careful out there.

Kyla said...

That IS an interesting case!

Liana said...

Intersting case! Any chance it could be LGV?

Gizabeth Shyder said...

Thanks for your question, Liana. I researched the immunostain cross-reactivity and while the antibody can react with other spirochetes, unlikely that it would have picked up lymphogranuloma venereum, which is caused by Chlamydia, as you know. So I don't think so, but you are right, the physical symptoms are similar.

Liana said...

Oops. I read through the post quickly and got to the point where you didn't see spirochetes on the Steiner... that'll teach me to skim things over.

Gizabeth Shyder said...

You are not the only one guilty of skimming blogs, Liana - I do it myself. I love that you made me research. Don't be a stranger, here.

The Mother said...

And it would make life much, much easier if this history CAME ON THE REQUISITION, wouldn't it????

Gizabeth Shyder said...

My favorite is not when there is no history, but when the history is completely wrong. Nothing like spending your day on a wild goose chase.