Endgames Case Report

A patient with rectal discharge and fever

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5981 (Published 23 September 2011) Cite this as: BMJ 2011;343:d5981
  1. Kate Atkinson, specialist registrar,
  2. Daniel M Bradshaw, specialist registrar,
  3. Nneka Nwokolo, consultant in genitourinary medicine
  1. 1Chelsea and Westminster NHS Foundation Trust, London SW10 9NH, UK
  1. Correspondence to: K Atkinson kateatkinson{at}doctors.org.uk

A 50 year old man presented to a sexual health clinic with a three week history of fever, rectal discharge, pain, and bleeding. He did not have diarrhoea, constipation, urethral symptoms, or urinary symptoms.

He had no medical or family history of note and was taking no drugs, including recent antibiotics. He lived in an inner city area and had no history of recent travel. He was immune to hepatitis B.

Four weeks previously he had had unprotected insertive and receptive anal sex with a regular and a casual male partner on the same occasion. He had had no other sexual contacts in the previous six months.

Examination showed inflammation of the perianal skin and proctoscopy showed inflamed mucosa, discharge, and contact bleeding. Digital rectal examination was unremarkable, as was examination of the genitals, abdomen, and pharynx. He did not have lymphadenopathy.

A full sexual health screen was performed, taking samples from the urethra, rectum, and pharynx for Chlamydia trachomatis and Neisseria gonorrhoeae and blood samples for HIV, syphilis, and hepatitis B and C serology. A point of care test for HIV antibodies was negative. Microscopy of a Gram stained sample of rectal discharge showed 0-5 polymorphonuclear leucocytes per high power field; microscopy of urethral discharge was unremarkable.


  • 1 What is the differential diagnosis for a patient presenting with this history and these findings?

  • 2 How should this patient be managed?

  • 3 Who else should be involved in this patient’s management?

  • 4 What factors should be considered in the follow-up of this patient?


1 What is the differential diagnosis for a patient presenting with this history and these findings?

Short answer

Lymphogranuloma venereum is the most likely diagnosis. Differential diagnoses include infection with the non-lymphogranuloma venereum biovar of C trachomatis, herpes simplex, and enteric pathogens in addition to gonorrhoea and inflammatory bowel disease.

Long answer

A diagnosis of lymphogranuloma venereum should be considered in all men presenting with rectal …

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