AM report 5/6: proctitis + meningitis

Framework for proctitis:

  • noninfectious:
    • IBD
    • radiation
  • infectious: (HSV and chlamydia are starred and bolded because these patients can look toxic and have an aseptic meningitis!)
    • Common bugs for infectious colitis that can also cause infectious proctitis: Salmonella, Shigella, Campylobacter, C diff; GNRs
    • Sexually transmitted (e.g. Via anal intercourse)
      • HSV (esp HSV2)* 
      • Syphilis
      • Gonorrhea
      • Chlamydia (lymphogranuloma venerum)*

A few clinical pearls on the sexually transmitted causes of proctitis!!

HSV ?         Can also get aseptic meningitis and look very ill!

?         Treat with acyclovir

Syphilis ?         Usually syphilitic proctitis is asymptomatic

?         Treponema pallidum is tropic to CSF so aseptic meningitis is common! 1/3 of patients with early syphilis have invasion into the CSF (regardless of HIV status)!

?         About 1/4 of patients with HIV present with concomitant primary syphilis (chancre) and secondary syphilis (rash) at time of diagnosis

?         (more here:

Gonorrhea ?         Usually localized (unlikely to see proctitis and meningitis)
Chlamydia (LGV) ?         Can get aseptic meningitis and look very ill!

?         Treat with doxy (also should get a dose of IM CTX)


And, for meningitis:

  • In general, studies quote that gram stain for bacterial meningitis is positive 60% of the time, and cultures return positive 90% of the time
  • Cultures sterilize by 6 hours after starting antibiotics
  • If you are worried about strep pneumo meningitis, give dexamethasone before antibiotics! Not as helpful after antibiotics are already given
    • *Steroids can potentially worsen some causes of meningitis (e.g., cause disseminated HSV infection in the case of HSV meningitis)





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