Rectal chancre is an unusual case, especially in Korea. Most physicians have a tendency to consider rectal ulceration as a neoplasm (7
). Similarly in our case symptoms and signs suggested rectal neoplasia and the clinical history did not reveal homosexuality. However, after the VDRL test the patient confessed that he had been raped by a homosexual male. Therefore, when rectal syphilis is suspected (i.e., perianal condyloma acuminatum associated with inguinal lymphadenopathy) the history of sexual intercourse, especially rectal intercourse, has to be taken.
A positive VDRL test is not diagnostic because it is nonspecific. A dark-field examination is recommended by many studies (3
). In our case, however, a dark-field examination was not performed, because rectal chancre was highly suggested by the clinical history, anorectal lesions, pathologic findings and positive serologic test. Additionally, like other syphilis cases benzathine penicillin therapy induced a rapid regression of the rectal lesions. We believe when a positive serologic syphilis test is associated with ulcerative lesion, additional laboratory tests are not necessary.
Inguinal lymphadenopathy need not require an initial biopsy when evidence of regional infection is present. Usually after antibiotic therapy of at least 4 weeks, most physicians might decide whether a biopsy is necessary. In this case, however, the physician did not have experience recognizing rectal syphilis, so he immediately obtained a biopsy specimen from the inguinal lesion. We think that this is an unnecessary procedure.
In western countries the incidence of rectal syphilis is rising, especially in groups of active homosexual males. Bassi et al. emphasized in his case report that endoscopists should keep in mind the rising incidence of syphilis (3
). Therefore syphilis should be considered whenever anorectal lesions are found. Sexual history is also important. Active homosexual male have a tendency to conceal sexual history from a physician. Moreover a patient raped by a homosexual male wants to hide the accident. Therefore an initial physician should encourage his/her patient to inform him/her of the patient's sexual history.