Thanks Kristy for presenting an excellent case! This was a case of a young MSM man with high risk sexual activity presenting with subacute onset of B symptoms, BRBPR found to have infectious proctitis.
1) Postexposure prophylaxis (PEP) for HIV should be a 3 drug combination, usually emtricitabine-tenofovir + raltegravir and should be started as soon as possible for 28 days prior to awaiting HIV test results. See the CDC website for more.
2) Proctitis, or inflammation of the lining of the rectum, usually presents with symptoms of bloody diarrhea with urgency and tenesmus. There are non-infectious and infectious causes. See below for the differential of rectal pain.
3) An illness script for sexually transmitted CMV proctitis is: a triad of mononucleosis-like illness with rectal bleeding shortly after unprotected anal intercourse
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Differential diagnosis of rectal pain
Common non-infectious: hemorrhoids, fissures, pruritus ani
Non-infectious: IBD, s/p radiation, trauma, foreign body, malignancy
Infectious: STDs, LGV, abscess, proctitis (various bacterial, viral infections… also medication-associated, ischemic, chronic GVHD), anogenital ulcers
• HIV – consider HIV defining malignancy such as kaposi’s sarcoma, NHL; also opportunistic infections more common
• Gonorrhea/ chlamydia and syphilis may also present asymptomatically
Primary care for Men who have Sex with Men
•Men who have sex with men as a population are at increased risk for certain health conditions both related to sexual activity and psychosocial factors that influence physical and mental health, and PCPs should be aware of these and direct questions to gather more history and screen for these conditions. See this great NEJM article for more information.