Curious intra-rectal “laterally spreading tumor” in immunosuppressed patient with ulcerative colitis

A 46-year-old man was admitted in June 2015 for the first time in our department for a colonoscopy in a context of ulcerative colitis, diagnosed 4 years earlier (ulcerative proctitis). At time of diagnosis (2011), he was treated by oral Mesalazine, 5ASA suppositories and enema, Budesonide enema and then Azathioprine. Patient was asymptomatic for a long time but no follow-up had been achieved for at least 3 years. A colonoscopy was performed prior to potential immunosuppressive treatment discontinuation. This examination showed a kind of circumferential “laterally spreading tumor” with villous appearance located in the rectum 4 to 7 centimeters from the anal margin with a little triangular extension to the dentate line. Surprisingly rectal biopsies revealed a condyloma acuminatum with very focally high-grade intra-epithelial lesion and an overexpression of the p16 protein (cell marker induced by oncogenic HPV). Azathioprine was stopped and a transanal surgical resection was performed. This led to a scarring rectal substenosis and further rectoscopies permitted destruction of some little condylomatous persistent lesions. At guided anamnesis on sexual behavior, patient confirmed to be an active “men who have sex with men” (MSM). No recurrence of active ulcerative proctitis occured despite Azathioprine discontinuation.
Condyloma acuminatum is a manifestation of Human Papillomavirus (HPV) infection and usually occurs in the genital and perianal regions. Involvement of the rectal mucosa is a rare condition and treatment strategy is not well established. This may have been in this case promoted by immunosuppressive treatment. As sexually transmitted anorectal disease may mimic inflammatory bowel disease, first diagnosis of ulcerative proctitis may be questioned even more with absence of recurrence despite treatment.