“Anal angina”—pelvic sepsis and streptococcal toxic shock syndrome after rectoscopy and mucosal biopsy

Waldeyer’s tonsillar ring is a ring of lymphoid tissue that encircles the nasopharynx and oropharynx. It is formed by the lymphatic tissue of the pharynx, the palatine tonsil, and the lingual tonsil, as well as other collections of lymph tissue in the area. It is postulated that the anal orifice is protected by an immune barrier of lymphoid tissue comparable to the Waldeyer’s tonsillar ring. We report on a case of pelvic sepsis and streptococcal toxic shock syndrome caused by S. pyogenes—the typical causative organism for tonsillitis— occurring after rectoscopy and rectal biopsy due to proctalgia of unknown origin. A previously healthy man aged 35 years presented with a 2-week history of severe anal pain. Anal intercourse, pruritus, perianal itching, blood-streaked stool, melaena or constipation were denied. Upon physical examination, he was in excellent general condition. An inspection of the perineal skin and anus showed no signs of a local or systemic infection. Routine laboratory results were unremarkable at that time. Rectal digital examination was painful, and rigid rectoscopy revealed a severely reddened and highly vulnerable mucosa. Two anal crypts were incised, and two hypertrophic papillae were resected for diagnostic purposes. The patient was discharged in good health 2 days later. The following day, he complained of fever (39.8°C), nausea and vomiting, abdominal pain and oliguria. One day later, the patient was readmitted severely ill but conscious with dyspnea, anuria, and a distended and painful abdomen. His temperature was 39.0°C, blood pressure 90/60 mmHg, heart rate 110 beats/min, and respiration rate 17/min. There was no rash. Signs of soft tissue infection, and tonsillitis or pharyngitis were absent. His haemoglobin was 141 g/l, haematocrit 41%, leucocytes 9.7×10/l, thrombocytes 126×10/l (thrombin time 13 s); partial thromboplastin time 39 s, d-dimers 1,155 μg/l, fibrinogen>1,000 mg/dl, C-reactive protein 310 mg/dl, IL-6 10983 ng/l, procalcitonin 16.8 μg/l, albumin 23 mg/dl, aspartate aminotransferase Int J Colorectal Dis (2008) 32:225–226 DOI 10.1007/s00384-007-0328-5