Kissing Rectal Ulcers With Associated Occult Rectal Mucosal Prolapse: A Distinct Endoscopic Presentation of Solitary Rectal Ulcer Syndrome in an HIV Positive Patient With Comprehensive Infectious Exclusion.

Solitary rectal ulcer syndrome (SRUS) is a rare benign disorder of the rectum strongly associated with chronic straining and rectal mucosal prolapse, which may be overt or occult. Its endoscopic appearance is highly variable, and atypical presentations can create significant diagnostic challenges, particularly in immunocompromised patients in whom infectious etiologies must be systematically excluded. We report a case of SRUS presenting as simultaneous contralateral kissing rectal ulcers in an HIV positive patient. Histopathology demonstrated the characteristic triad of fibromuscular obliteration of the lamina propria, smooth muscle extension between distorted crypts, and muscularis mucosae hypertrophy, establishing occult internal mucosal prolapse as the underlying mechanism. Comprehensive infectious evaluation including targeted testing for cytomegalovirus, herpes simplex virus, Neisseria gonorrhoeae, and Chlamydia trachomatis including lymphogranuloma venereum serovars was entirely negative. The patient achieved complete symptomatic resolution on conservative therapy with psyllium fiber supplementation at 2-month follow-up. This case illustrates an uncommon endoscopic presentation of SRUS, the diagnostic importance of histopathology in the absence of visible mucosal prolapse, and a systematic infectious exclusion approach in an HIV positive patient that may serve as a clinical reference for similar presentations.