Anus and perianal area
Inflammatory diseases
Human immunodeficiency virus

Author: Arvind Rishi, M.D. (see Authors page)

Revised: 27 September 2017, last major update August 2014

Copyright: (c) 2002-2017,, Inc.

PubMed Search: Human immunodeficiency virus [title] anus

Cite this page: Rishi, A. Human immunodeficiency virus. website. Accessed July 23rd, 2018.
Definition / general
  • Anorectal symptoms may reflect significant underlying disease in HIV infected patients
  • General diagnostic approach is based on clinical findings, risk factors and duration of disease
  • Clinical findings include rectal pain and discomfort related to proctitis, perianal abscess, fistula, ulceration, anal warts and mass lesions
  • Infections
    • Bacterial: gonorrhea, syphilis (Treponema), Shigella, Escherichia coli, Myobacterium tuberculosis (Indian J Dermatol Venereol Leprol 2008;74:386), Clostridium difficile
    • Viral: herpes simplex, molluscum contagiosum, CMV
    • Others: candidiasis (fungal), lymphogranuloma venereum (LGV Chlamydia trachomatis serovars L1, L2 and L3), Entamoeba histolytica (protozoal)
  • Neoplastic: HPV related anal intraepithelial lesions (low and high grade), perianal Bowen disease, squamous cell carcinoma, Kaposi sarcoma (Case Rep Gastroenterol 2011;5:416), AIDS related lymphoma
  • Anal symptoms are most common in men who have sex with men (MSM)
  • Significantly younger age presentation for anal cancers
  • Perianal condyloma reported in pediatric patients with congenital HIV
  • Most common bacterial infection in MSM is gonorrhea
  • LGV may cause extensive disease, which may mimic Crohn's disease
  • 5.8% of HIV patients have concomitant positive serology for syphilis
  • Concomitant two or more perianal diseases reported in 16.7% cases in one series
  • Major risk factors for abnormal cytology for neoplastic screening are presence of multiple human papilloma virus types, immunosuppression, anal intercourse
Clinical features
  • Rectal and perirectal disease in the form of ulceration, polypoid lesions, abscess, sinus and fistula
  • Mimic Crohn's disease
  • Primary nonsuperinfected syphilitic lesions are painless
  • The diagnostic tests are based on the clinical and histological findings
  • Rectal swab for gonococcal organisms
  • For chlamydia:
    • Rectal swab and isolation in cell culture
    • Enzyme immunoassays for screening of larger population - polyclonal antibodies are used to detect chlamydial lipopolysaccharide
    • Direct cytology smear using fluorescein conjugated monoclonal antibodies directed against OMP1
    • Nucleic acid amplification method is currently the most sensitive method
  • Anal cytology for dysplastic lesions
Case reports
Clinical images

Images posted on other servers:

Perianal wart

Perianal molluscum contagiosum

Gross description
  • Gross findings are based on underlying condition:
    • Polypoid lesions in anal warts
    • Ulcerated tissue in fistulas and sinuses
  • Consider microbiological studies if biopsy is received fresh and no cultures were obtained in OR
  • For AIN lesions, specimen may be received as:
    • Shave biopsy: margin evaluation is not required
    • Local resection: margin evaluation for involvement by dysplasia is essential and inking of specimen is useful
Microscopic (histologic) description
Microscopic (histologic) images

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Chlamydia, intracytoplasmic elementary bodies

Cytology images

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Various images (fig 26 - 35)

Electron microscopy images

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Chlamydia elementary body (EB)