Anorectal disease in HIV-infected patients

Abstract

PURPOSE: Anorectal diseases are common in human immunodeficiency virus-infected individuals. The aim of this prospective study was to assess the cause and clinical presentation of anorectal disease in this human immunodeficiency virus-infected population. METHODS: A registry of all human immunodeficiency virus-seropositive patients with anorectal complaints who were referred to and followed up in the colorectal surgery clinic at a county hospital was maintained, with all data collected prospectively. All patients underwent examination under anesthesia with random cultures and biopsies, along with specific sampling of any suspicious lesions. RESULTS: Data from 180 consecutive human immunodeficiency virus-seropositive patients with anorectal symptoms were analyzed. Mean age of the population was 34 years, with a male-to-female ration of 14:1. This group comprised homosexual and bisexual males (55 percent), injection-drug users (15 percent), heterosexuals (12 percent), and others (18 percent). The average lag time from diagnosis of human immunodeficiency virus to anorectal symptoms was 48 months. The average CD₄ lymphocyte count was 160 cells/mm³. The most common symptom was anorectal pain (57 percent), followed by lumps or warts (28 percent), rectal bleeding (12 percent), discharge (11 percent), and pruritus (6 percent), with 24 percent of patients having multiple complaints. Anal condyloma was the most prevalent pathology observed (43 percent), of which 10 percent was associated with anal intraepithelial neoplasia. Wide-based anal ulcers were the most frequent noncondylomatous lesions, occurring in 32 percent of patients, with the majority (91 percent) presenting with the chief complaint of anorectal pain. Some of these ulcers were associated with viral infections: herpes simplex virus (12 percent) and cytomegalovirus (7 percent). However, most ulcers were idiopathic, with negative cultures and biopsies. Other lesions encountered included fistulas (14 percent), abscesses (12 percent), hemorrhoids (6 percent), and malignancy, with two cases of Kaposi's sarcoma, one case of non-Hodgkin's lymphoma, and one case of squamous-cell carcinoma. More than one anorectal condition was identified in 16 percent of the patients. CONCLUSIONS: Human immunodeficiency virus infection is associated with a wide spectrum of anorectal disease, of which the most common lesions are anal condylomata and painful ulcers. The majority of these anal ulcers gave negative culture and biopsy results. In addition, there seems to be a high incidence of anorectal neoplasia in this patient population.