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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The differential diagnosis of proctitis in men who have sex with men &#40;MSM&#41; tends to be difficult&#44; given that it includes numerous infectious&#44; inflammatory&#44; and even traumatic causes&#46; Lymphogranuloma venereum &#40;LGV&#41; is a sexually transmitted disease caused by <span class="elsevierStyleItalic">Chlamydia trachomatis</span> &#40;<span class="elsevierStyleItalic">C&#46; trachomatis</span>&#41;&#46; It usually manifests first as an ulcerated&#44; painless papule in the genitals&#44; then as inguinal lymphadenopathy&#44; and finally as distal proctitis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In relation to late diagnosis&#44; disease progression can result in severe complications&#44; such as rectal stricture&#44; obstruction&#44; and perforation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present herein a 35-year-old patient&#44; with a history of HIV diagnosed in 2012 in relation to Epstein Barr-associated meningitis&#44; currently treated with highly effective antiretroviral therapy with raltegravir 400&#8239;mg and tenofovir&#47;emtricitabine 300&#47;200&#8239;mg&#46; He had a CD4&#43; lymphocyte count of 248 cells and an undetectable viral load&#44; and in addition&#44; was identified as an asymptomatic carrier of hepatitis B infection&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was admitted to the hospital due to clinical symptoms of intense pain in the rectoanal region of 3-month progression&#44; painful defecation&#44; straining&#44; and tenesmus&#44; associated with frequent episodes of rectal bleeding&#46; In the systems review&#44; the patient stated having occasional fever peaks&#44; asthenia&#44; adynamia&#44; hyporexia&#44; myalgias&#44; and arthralgias&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Upon physical examination&#44; the presence of pain in the hypogastrium&#44; with no peritoneal irritation&#44; stood out&#46; The perianal evaluation revealed a deep posterior anal fissure&#44; with marked edema of the anal canal&#46; No adenopathies were palpated in the inguinal region&#44; nor were there lesions on the skin&#46; Due to the patient&#8217;s medical history&#44; coinfection with other sexually transmitted diseases or opportunistic infections was ruled out&#46; A VDRL test and IgM for Epstein-Barr virus were ordered&#44; along with rectosigmoidoscopy&#44; to evaluate the mucosa and anal canal and take biopsies&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The rectosigmoidoscopy revealed severe inflammatory changes and deep inflammatory ulcers with irregular edges that compromised the middle and distal rectum&#44; with anal canal involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A-C&#41;&#46; Biopsies were taken to identify the causal agent&#46; Included in the pathology study was abundant lymphoplasmacytic infiltrate of the mucosa&#44; with no viral cytopathic changes&#44; with atrophy&#44; and no dysplasia&#46; Direct testing with techniques for mycobacteria&#44; cytomegalovirus&#44; and fungi was negative&#44; as were the Thayer-Martin agar for <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> infection and the PCR for fungi and mycobacteria&#44; and so PCR in <span class="elsevierStyleItalic">C&#46; trachomatis</span> tissue was ordered&#46; The VDRL serologic test for syphilis was reactive at 16 dilutions&#46; Thus&#44; in addition to treatment with 100&#8239;mg&#44; every 12&#8239;h&#44; of oral doxycycline&#44; 2&#46;4 million units of benzathine penicillin was administered weekly for 3 weeks&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Two weeks later&#44; the patient was readmitted to the emergency service for abdominal pain&#44; with scant rectal bleeding&#46; A computed axial tomography scan and rectosigmoidoscopy were ordered&#46; The first image ruled out perforation and associated collections&#46; The rectosigmoidoscopy revealed significant improvement of the inflammatory changes&#44; as well as ulcers in the process of healing &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A-C&#41;&#46; After symptom control&#44; the patient was released and completed the treatment with doxycycline in 21 days&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Infectious proctitis in MSM&#44; especially those with a history of HIV&#44; is varied&#46; The most frequent pathogens are <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>&#44; <span class="elsevierStyleItalic">C&#46; trachomatis</span>&#44; the herpes simplex virus&#44; and <span class="elsevierStyleItalic">Treponema pallidum&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In an Australian study&#44; differences in the prevalence of the causal agents of infectious proctitis in MSM were found&#44; according to their immune status&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most frequent causal agent was the herpes simplex virus in men that had a history of HIV infection&#44; whereas LGV was the most frequent in men that were HIV-negative&#46; No statistically significant differences related to HIV status regarding symptoms were found in that study&#46; LGV proctitis is characterized by a purulent anal discharge&#44; straining&#44; tenesmus&#44; painful defecation&#44; and altered bowel habit&#46; On occasion&#44; there can be fever&#44; general malaise&#44; weight loss&#44; rectal bleeding&#44; or hematochezia&#46; In a Spanish study that analyzed anorectal manifestations in patients with sexually transmitted diseases&#44; the most frequent symptoms were anal pain&#44; painful defecation&#44; purulent anorectal secretion&#44; straining&#44; tenesmus and&#47;or rectal bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Those authors found that LGV was present in 74&#37; of the patients that had anorectal symptoms lasting more than 1 month&#44; and in all the patients that had documented proctitis associated with rectal ulcers&#46;<span class="elsevierStyleSup">4</span> Three stages of LGV are recognized&#58; the first is characterized by the presence of painless or painful ulcers at the site of contagion that can last up to 4 weeks&#59; in the second stage&#44; lymphadenopathies and abscesses are formed&#59; and in the third stage&#44; if there has not been adequate treatment&#44; the infection advances to include severe complications&#44; such as fistulas&#44; infertility&#44; elephantiasis&#44; or stricture&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Endoscopic study findings range from mild inflammatory changes&#44; deep ulcers with elevated edges and sharply demarcated morphology&#44; and a frequently observed fibrinoid and&#47;or mucopurulent exudate&#44; to stricture and the appearance of tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a> Those findings can be indistinguishable from inflammatory bowel disease&#44; adenocarcinoma&#44; or rectal lymphoma&#46; The most frequent biopsy findings are granulation tissue with lymphoplasmacytic infiltrates and fibrosis&#44; which are signs of nonspecific proctitis&#46; Endoscopic findings are not specific&#44; thus there must be a high degree of clinical suspicion in MSM that present with ulcerated proctitis&#44; to be complemented with nucleic acid amplification through PCR testing from secretions or samples of affected tissue&#44; even in the presence of other sexually transmitted diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The present work complies with the current bioethical research norms and was approved by the institutional ethics committee&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Data confidentiality</span><p id="par0050" class="elsevierStylePara elsevierViewall">Written informed consent was not requested&#44; given that the data were carefully protected&#46; There are no clinical history or imaging data that allow the patient of the clinical case to be identified&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that the present article contains no personal information that could identify the patient&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Financial disclosure</span><p id="par0060" class="elsevierStylePara elsevierViewall">No financial support was received in relation to this article&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mosquera-Klinger G&#44; Berrio S&#44; Carvajal JJ&#44; Juliao-Ba&#241;os F&#44; Ruiz M&#46; Proctitis ulcerada asociada a linfogranuloma ven&#233;reo&#46; Rev Gastroenterol M&#233;x&#46; 2021&#59;86&#58;313&#8211;315&#46;</p>"
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