This document presents the case of a 31-year-old man with AIDS who was evaluated for rectal pain and discharge. He reported unprotected anal intercourse with his HIV-positive partner and others. Examination found perianal condylomas but no external ulcerations or hemorrhoids. Tests ruled out common infections but rectal pain increased, so a diagnostic procedure was performed to determine the cause.

1. PRESENTATION OF CASE
DR CARLOS ALEGRIA MOTTE: 13-11--2012
A 31-year-old man with the acquired immunodeficiency syndrome (AIDS) was evaluated at
the infectious disease clinic of this hospital because of rectal pain and a mucopurulent rectal
discharge.Four days before this evaluation, the patient first noticed rectal discharge, pain on
defecation, and blood in his stools. He described pelvic pain, nausea, and generalized
weakness but no fever, chills, or emesis. He had regular anal-receptive intercourse without
condoms with his usual partner, who was also infected with the human immunodeficiency
virus (HIV), and with other partners. In the patient under discussion, HIV infection had been
diagnosed 12 years earlier. He had received sporadic medical care over the course of the
following 10 years and had taken antiretroviral therapy (including zidovudine, lamivudine,
nelfinavir, and ritonavir–lopinavir) inconsistently. Approximately 1 year before the current
evaluation, he had been admitted to this hospital for 10 days with fever, diarrhea, rash, a
CD4 cell count of six per cubic millimeter, and an HIV viral load of 207,000 copies of RNA
per milliliter of plasma. Diagnoses of disseminated infection with Mycobacterium avium–
intracellulare and staphylococcal ecthyma were made, and the conditions were treated with
cephalexin, clarithromycin, and ethambutol.
After discharge, the patient was seen in the infectious disease clinic, and antiretroviral
therapy with didanosine, stavudine, and efavirenz was begun. Cutaneous Kaposi's sarcoma,
oral thrush, rectal herpes simplex, and anal condylomas developed over the course of the
next year. Treatment with acyclovir, fluconazole, and dapsone was given. His CD4 cell count
rose to 175 per cubic millimeter, and his HIV viral load fell to less than 50 copies of RNA per
milliliter over the course of the year before this evaluation.
He smoked one pack of cigarettes per day, used no alcohol, and was a regular user of
marijuana and methamphetamine. He was unemployed. His aunt had Crohn's disease.
On examination, the blood pressure was 122/88 mm Hg, the pulse 88 beats per minute, the
respiratory rate 10 breaths per minute, and the temperature 36.8°C. The weight was 86.8
kg. There were flat, pigmented skin lesions over the right tibia and left shoulder consistent
with inactive Kaposi's sarcoma. There was no thrush or oral hairy leukoplakia. Small cervical
and inguinal lymph nodes were palpable. The lungs and heart were normal. The abdomen
was soft and nontender, without hepatosplenomegaly. On rectal examination, there were
bulky perianal condylomas but no external ulcerations. Digital rectal examination and
anoscopy were not possible because of rectal pain.
The results of a complete blood count, the levels of serum electrolytes, and tests of renal
and liver function were normal. The CD4 cell count was 188 per cubic millimeter and the

2. viral load fewer than 50 copies of RNA per milliliter. Ceftriaxone and azithromycin were
prescribed. Rectal-swab cultures for Neisseria gonorrhoeae and herpes simplex virus were
negative, as was the serum rapid plasma reagin.
Two weeks later at a follow-up visit, the pain on defecation had improved, but mucus and
blood were still seen in the stools. Anoscopy showed mucus but no blood or ulcerations.
There were no internal hemorrhoids or anal-canal condylomas. A stool culture grew scant
normal enteric flora without enteric pathogens or N. gonorrhoeae. Five days later, rectal pain
had increased. A diagnostic procedure was performed.