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Discussion: IS is typically asymptomatic but may present with chronic, watery diarrhea or vague abdominal pain. Diagnosis is made incidentally on histology of colonic mucosal biopsies. Some reports have described polypoid and erythematous lesions associated with IS, but they are typically not easily identifiable. Histologically, silver stains or immunostains for Treponema pallidum may be necessary to identify these organisms . A hallmark of IS is the "false brush border" formed by a band of spirochetes adhering to the epithelial layer . Originally, IS was mainly found in areas of low socioeconomic status in veterinary medicine. Human colonization has been observed more recently predominantly in HIV and homosexual male populations. IBD patients are at a higher risk of infection due to immunocompromised status. Asymptomatic patients do not require treatment. However, for those requiring treatment, a trial of metronidazole can be use. One case report documented IS in an IBD patient with symptoms of abdominal pain and watery diarrhea that was successfully treated with metronidazole leading to complete resolution of symptoms. (Figure) This case highlights a rare etiology of chronic diarrhea that should be considered, especially in immunocompromised patients with no other clear cause of symptoms.[2739] Figure 1. A -Attached to the luminal border are fuzzy basophilic structures, recall that colonic mucosa does not have a microvillus border, and even if it did, this is too thick (hematoxylin and eosin 40X). B -The organisms are positive on silver based stains.

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