EP686 - The importance of routine histopathology after excisional hemorrhoidectomy: a case report of incidental syphilis during routine hemorrhoidectomy

Purpose/Background: Occult pathologies identified in hemorrhoidectomy specimens are rare, with an estimated incidence of 4-5% across multiple studies. The most commonly encountered incidental finding is anal intraepithelial neoplasia (AIN), observed in approximately 3.35% of cases. In contrast, incidental malignancies, including squamous cell carcinoma, verrucous carcinoma, adenocarcinoma, neuroendocrine carcinoma, and melanoma, are significantly less common, accounting for only about 0.4% of cases. Recent literature indicates a rising incidence of high-grade AIN, particularly in certain at-risk populations. In this case report, we are presenting a rare histopathology in a patient presenting with symptomatic hemorrhoids.

Methods/Interventions: We report the case of a 38-year-old African American female presenting with clinically significant symptomatic grade III internal hemorrhoids with an external component, which failed conservative management. The patient underwent an excisional hemorrhoidectomy. Intraoperatively, no abnormal findings were noted on the perianal area , however examination of the anal canal showed mild erythema only. Her past medical history was notable for a remote episode of a sexually transmitted infection, which had been treated by her primary care physician. Histopathological examination of the excised hemorrhoids, which included right posterior and right anterior compartments, revealed marked acute and chronic inflammation with lymphoplasmacytic infiltration and non-necrotizing granulomas. Immunohistochemical staining was positive for Treponema pallidum. A final diagnosis of syphilis was established. The patient is referred to infectious control diseases and receives appropriate treatment accordingly.

Results/Outcomes: Syphilitic involvement of the rectum, although recognized, remains diagnostically challenging due to its variable clinical and histological presentations. Classic findings such as rectal ulcers or chancres may not always be present, and syphilis may mimic other inflammatory or neoplastic processes. Notably, to date, there have been no reported cases of syphilis diagnosed incidentally through routine hemorrhoidectomy specimens. In our patient, the only intraoperative abnormality noted was mild rectal erythema, which did not raise immediate concern. This subtle finding underscores the importance of maintaining a high index of suspicion and the value of histopathological examination, particularly when clinical or physical findings are atypical.

Conclusion/Discussion: Although the incidence of significant findings in hemorrhoidectomy specimens is low, routine histopathological evaluation may uncover rare but clinically important diagnoses requiring intervention and follow-up. This case underscores the diagnostic value of tissue examination, particularly when any abnormalities are noted during clinical assessment.