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case of an anal problem

case of an anal problem. brought to you by the GI Consult Team friday april 25, 2008. ID : 61M HIV+ CD 4 =256 admitted to psychiatry awaiting LTC placement for HIV-related dementia RFR : “anal abnormality” with anal leakage

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case of an anal problem

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  1. case of an anal problem brought to you by the GI Consult Teamfriday april 25, 2008

  2. ID: 61M HIV+ CD4=256 admitted to psychiatry awaiting LTC placement for HIV-related dementia RFR: “anal abnormality” with anal leakage PMH: HIV HAART since 2007 no known opportunistic infectionsHIV-related dementia since 2007 remote penile warts & syphilis (treated 1970’s) bipolar depression (quiescent) smoker 40 pkyrs +FHx breast ca (aunt) Meds: Norvir RITONAVIRTruvada TENOFOVIR-EMTRICITABINE Telzir FOSAMPRENAVIR septra prophylaxis olanzapine SHx: caucasian MSM r. clinical psychologist rare EtOH no illicits/IVDU ever

  3. HPI: Admitted for LTC placement Otherwise well, no fevers Constant anal leakage of fecal material ~1yr (+) sensation of discrete episodes of need to evacuate (+) has control over discrete bowel movements (+) formed BMs daily Never pain/bleeding FMD cannot recall doing DRE

  4. O/E: 120/70 82 RR16-100% RA Tmax 36.6 H+N no icterus, no oral or perioral lesions, no cerv/axill lymphadenopathy CVS normal Resp normal Abdo abdo soft & benign, no HSM(+) 2cm L non-tender inguinal lymph node On rectal exam…

  5. Photo Courtesy of Alex McDonald, St. Michael’s Hospital Media Centre

  6. differential diagnosis?

  7. Ddx New Anal Mass in an HIV+ Pt Infectiouscondyloma accuminata (HPV), condyloma lata (syphilis)perirectal/perianal abscess, fistulaehypertrophic HSV, VZV, CMV Structuralhemorrhoids, skin tags, rectal prolapse, traumatic Neoplast (Malig)anal cancer (squamous-adeno-neuroendo-lymphoma-leiomyosarc) Kaposi’s, Bowen’s, Paget’s, BCC, melanomamets ( and rarely ) Neoplast (Benign)lipoma, etc. granular cell tumour, etc

  8. anorectal disease in HIV+ patients

  9. Epidemiology • 59,000 HIV+ adults in Canada 20051 • 1.2 million HIV+ adults in USA 20051 • 33.2 million HIV+ adults worldwide2 Anorectal Disease • reported to MD by ~1/3 of all HIV+ patients3,4 • #1 reason for surgical referral in HIV+4 1. UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2006.2. WHO AIDS Epidemic Update, 2007. 3. Edwards et al. The gastrointestinal manifestations of AIDS. Aust N Z J Med 1990;20:141-8. 4. Miles et al. Surgical management of anorectal disease in HIV-positive homosexuals. Br J Surg 1990;77:869-71.

  10. Which Anorectal Diseases in HIV? Populations of HIV+ pts with anorectal complaints: n=1860 Nadal et al. Dis Colon Rectum 1999;42:649-54 n=260Barrett et al. Dis Colon Rectum 1998;41:606-612 n=180Yuhan et al. Dis Colon Rectum 1998;41:1367-70. n= 148Puy et al. Int J Colorect Dis 1992;7:26-30. n=88Retamozo et al. Rev de Soc Brasil Med 40(3):286-9. n=83Sanchez et al. Rev Gastroenterol Mex 1998;63:89-920. 1 2 3 4 5 6

  11. Nadal et al., 1999 n=1860 Avg age “30’s to 40’s” “>88%M” (?CD4 ?MSM)Instituto de Infectologia Emiolio Ribas, Sao Paulo anorectal pain bleeding discharge obstipation 1 2 3 4 5 6

  12. Barrett et al., 1998 n=260 Avg 35yo CD4175 96%M 75%MSMColorectal Clinic, George Washington University 55% anorectal pain 19% mass 16% blood in stools 11% blood PR 2 1 3 4 5 6

  13. Yuhan et al., 1998 n=180 Avg 34yo CD4160 96%M 55%MSMColorectal Surgery Clinic, Chicago Cook County Hospital 57% anorectal pain 28% mass 12% blood PR 11% discharge 3 1 2 4 5 6

  14. Puy-Montbrun et al., 1991 n=148 Avg 34yo CD4? 97%M 69%MSMColoproctology Department, Hopital Leopold Bellan, France anorectal pain pruritus discharge mass 4 1 2 3 5 6

  15. Other Conditions Reported • Molluscum, HSV, CMV, M. fortuitum • Proctitis • Pruritis ani, excoriation, lichenification • Anal sinus, rectal stenosis • Mucosal prolapse, sphincter atonia • Anal Crohn’s disease, ulcerative colitis • Various malignancies • Traumatic wound

  16. Anorectal Disease Pre/Post HAART Generally, HAART: • Can attenuates some pathologies (i.e. KAPOSI’S, NHL) • Can exacerbate some pathologies ~IRIS (i.e. TB, CMV, PCP, JC) • Can have no significant effect (i.e. HL, ANAL SCC) Gonzalez et al., 2004

  17. Anorectal Diseases HIV+ vs. HIV- Instituto de Infectologia de Sao Paolo 1989-1996HIV+ 88% were male aged 30’s-40’s Conjunto Hospitalar Mandaqui 1991-1996HIV-neg male=female, most aged 40’s-50’s 1. Nadal et al. Dis Colon Rectum 1999;42:649-54

  18. Caveats of Anorectal Disease in AIDS • common probs exaggerated/atypical in appearance • rare conditions need to be considered in the Ddx • treatment complicated by immunosuppression

  19. infectious DeToma G et al. Eur Surg Res 2006;38:418-22.

  20. infectious Condylomata Acuminata of HPV • Previous photo: Giant Condyloma Acuminatum • Marked papillary proliferation • Tendency to deep invasion displacing surrounding tissues • not verrucous carcinoma • No infiltration of BM, lymphatics, blood vessels • No distant mets • possibly regional variant of verrucous carcinoma? 1. DeToma G et al. Surgical management of perianal giant condyloma acuminatum. Eur Surg Res 2006;38:418-22.

  21. infectious Begovac J. NEJM 2005;352(7):708.

  22. infectious Condyloma Lata of 2’ Syphilis • Secondary syphilis • Rash (one of many manifestations) is usually: • symmetrical macular or papular covering entire trunk-extremities-palms-soles • in moist areas: condyloma lata • broad-based raised flat greyish-white • most commonly near 1’ chancre site • HIV+ cases of exaggerated condyloma lata described

  23. infectious Medscape.com

  24. infectious Abscesses & Fistulae Of 163 HIV+ presenting to Colorectal Surgery Clinic,n=47 “likely infectious etiology” • 18 perirectal abscess requiring incision & drainage: • 9 usual bowel flora • 3 HSV • 3 CMV • 2 Neisseria gonorrhea • 1 M. fortuitum • 14 perianal fistulas 1. Goldberg et al. Microbiology of human immunodeficiency virus anorectal disease. Dis Colon Rectum 1994;37:439-43.

  25. infectious Utdol.com

  26. infectious Molluscum Contagiosum In HIV, molluscum is associated with • larger & more numerous lesions • more incidence of polypoid with stalk • more resistance to therapy1 • decreased incidence with HAART2 1. Koopman et al. Molluscum contagiosum: a marker for advanced HIV infection. Br J Dermatol 1992;126:528. 2. Calista et al. Resolution of disseminated molluscum contagiosum with HAART in patients with AIDS. Eur J Dermatol 1999;9(3):211-3.

  27. infectious Simonsen et al. Clinics, 2008;63(1):143-6.

  28. infectious Nodular HSV • Previous Photo: • 39M MSM HIV on HAART CD4=400painful perianal nodules 3 months • Bx: cytoarchitectural alterations c/w HSVimmunohistochemical test (+)HSV-2 • Potentially verrucous-like hyperplastic in HIV1: • HSV, VZV, molluscum, CMV 1. Simonsen et al. Atypical perianal herpes simplex infection in HIV-positive patients. Clinics, 2008;63(1):143-6.

  29. structural Hemorrhoids

  30. structural http://www.stanford.edu/class/humbio103/ParaSites2002

  31. structural Rectal Prolapse This photo: • prolapse 2’ to Trichuris trichiura (whipworm) • 2nd most common nematode infxn after pinworm • worms bury their heads into intestinal walls elastic epithelial loosening rectal prolapse • rare -- seen occ in severe pediatric Trichiuriasis

  32. neoplastic http://www.acthiv.org

  33. neoplastic Anal Canal Cancers • Previous photo: 40MSM CD4=450 on HAARTulcerating lesion biopsied: invasive squamous cell ca http://www.acthiv.org

  34. neoplastic Rakoto. Annales de chirurgie, 2003;128:265-7..

  35. neoplastic Lymphoma • Previous photo: Anal Burkitt’s Lymphoma1 • Primary anorectal lymphoma rare ~3-6% of GIT lymphomas amongst gen pop3,4but higher incidence in case series of HIV+ patients who develop lymphoma2 1. Ioachim HL et al. EBV-associated anorectal lymphomas in patients with acquired immune deficiency syndrome. Am J Surg Pathol 1997;21:997-1006. 2. Ioachim et al. AIDS-associated lymphomas. Hum Pathol 1991;22:659-73. 3. Saraga et al. Hum Pathol 1981;12:713-23…3/66 4. Papadimitiou et al. Cancer 1985;55:870-9…2/83

  36. back to our case…

  37. Ddx Anal Mass in Our HIV+ Patient Infectiouscondyloma accuminata, condyloma lataperirectal/perianal abscess, fistulae hypertrophic HSV-VZV-CMV-molluscum Structuralhemorrhoids, skin tags, rectal prolapse, trauma Neoplast (Malig)anal cancer (squamous-adeno-neuroendo-lymphoma-leiomyosarc) Kaposi’s, Bowen’s, Paget’s, BCC, melanoma mets ( and rarely ) Neoplast (Benign)lipoma, etc. granular cell tumour, etc.

  38. Investigations 122M84 952.5 Bloodwork: Colonoscopy: 1364.7 11125 208 9.1 Ca/Mg/Phos normalbumin 26AST/ALT/bili/ALP norm INR/PTT norm Hard near-circumferential massExtends ?6cm from anal verge Origin ?below dentate No synchronous lesions

  39. Moderately-Differentiated Invasive Squamous Cell Carcinoma

  40. Moderately-Differentiated Invasive Squamous Cell Carcinoma

  41. CT Chest-Abdo-Pelvis

  42. MRI T2 Weighted

  43. MRI T2 Weighted

  44. MRI with Gadolinium

  45. anal squamous cell carcinomain HIV+ patients

  46. Background: Anatomy Inferior Mesentericvein & lymph nodes Superior rectalveins Endoderm Ectoderm Inferiorrectalveins Internal Iliac vein & Superficial inguinallymph nodes

  47. Klas et al., 1999n=192 consecutive anal canal malignancy patients 19% 74% 4% 3% Background: Other Anal Cancers “rectal cancer” Roughly, Classification is actually histology-based • anal adenocarcinomas are really rectal cancers • anal squamous cell carcinomaabove dentate line are anal non-keratinizing squamous cell carcinomabelow dentate line are anal keratininzing squamous cell carcinoma • anal melanoma • other (neuroendocrine, carcinoid, Kaposi’s, leimyosarcoma, lymphoma) “anal cancer” 1. Klas et al. Malignant tumours of the anal canal. Cancer 1999;85(8):1686-93.

  48. Klas et al., 1999n=192 consecutive anal canal malignancy patients 19% 74% 4% 3% Background: Other Anal Cancers “rectal cancer” Roughly, Classification is actually histology-based • anal adenocarcinomas are really rectal cancers • anal squamous cell carcinomaabove dentate line are anal non-keratinizing squamous cell carcinomabelow dentate line are anal keratininzing squamous cell carcinoma • anal melanoma • other (neuroendocrine, carcinoid, Kaposi’s, leimyosarcoma, lymphoma) “anal cancer” 1. Klas et al. Malignant tumours of the anal canal. Cancer 1999;85(8):1686-93.

  49. Epidemiology 1. Jemal et al. Cancer statistics 2007. CA Cancer J Clin 2007;57:43-66. 2. Frisch et al. HPV-associated cancers in HIV-AIDS. J Natl Cancer Inst 2000;92:1500-1510. 3. Klencke et al. Anal cancer: an HIV-associated cancer. Hem Onc Clin N Amer 2003;17(3):859-72. 4. Melbye M et al. High incidence of anal cancer among AIDS patients. Lancet 1994;343:636-9. 5. Diamond et al. Increased incidence of anal cancer among men with AIDS. Sex Trans Dis 2005;32:314-20. 6. Hessol et al. The impact of HAART on non-AIDS-defining cancers. Am J Epidemiol 2007;165:1143-53.

  50. Population-based ctrl studyAnorectal intercourse among: 17% anal cancer patients 11% colon cancer patients Daling et al., NEJM 1987 Population-based ctrl studyRelative risk 9.4 among men Daling et al., NEJM 1987 Clinical Presentation1,2 • anal bleeding (freq attrib to hemorrhoids) • mass • 20% asymptomatic • groin pain sometimes assoc /w inguinal LN involvement Risk Factors:HIV, HPV, anoreceptive sex history of cervical cancer or CIN smoking 1. Ryan et al. Carcinoma of the anal canal. NEJM 2000;342:792-800. 2. Ryan et al. Anal carcinoma: histology, staging, epidemiology, treatment. Curr Opin Oncol 2000;12:345-52.

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