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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 …