Intestinal Spirochetosis: To Treat or Not to Treat

Abstract

Spirochete colonization of the gastrointestinal tract is a poorly understood phenomenon presenting with varying signs and symptoms. Due to the lack of a unified approach and its varying presentations, the management decision for intestinal spirochetosis (IS) has always been challenging. While metronidazole is the commonly preferred antimicrobial treatment, it remains unclear if therapeutic intervention is indicated for everyone, especially asymptomatic patients. We present three patients, diagnosed with IS. They presented with varying demographics, clinical presentations, and past medical histories and underwent different clinical managements. Our decisions for treatment not only included presenting symptoms but also factors like history of pre-existing gastrointestinal diseases, age, and immune status.

Keywords: helicobacter pylori; inflammatory bowel diseases; intestinal spirochetosis; management; metronidazole; ulcerative colitis.

Figure 1. Intestinal spirochetosis as visualized on a colonic biopsy specimen

A. Hematoxylin and eosin stain shows a purple, fuzzy "false-brush border" on luminal epithelial cells (arrows) in a colon biopsy specimen. B. Warthin-starry silver stain highlights the bacterial organisms as a black, fuzzy line covering the luminal epithelial cells (arrows).

Figure 2. Intestinal spirochetosis in a rectal biopsy

A. Hematoxylin and eosin stain with a false-brush border on luminal epithelial cells (arrow). B. Warthin-starry silver stain highlighting the bacterial organisms (arrow).

Figure 3. Intestinal spirochetosis seen in a patient with ulcerative colitis

A. Hematoxylin and eosin stain with faint, fuzzy appearance on the surface of luminal epithelial cells (arrows). B. Warthin-starry silver stain highlighting diffuse involvement by spirochetes (arrow).