Ano-perianal tuberculosis--solving a clinical dilemma

Perianal tuberculous ulcer with active pulmonary, intestinal and orificial tuberculosis: A case report

BACKGROUND

Orificial tuberculosis is a rare type of tuberculosis, which is easy to be misdiagnosed, and can cause great damage to the perianal skin and mucosa. Early diagnosis can avoid further erosion of the perianal muscle tissue by tuberculosis bacteria.

CASE SUMMARY

Here, we report a case of disseminated tuberculosis in a 62-year-old male patient with a perianal tuberculous ulcer and active pulmonary tuberculosis, intestinal tuberculosis and orificial tuberculosis. This is an extremely rare case of cutaneous tuberculosis of the anus, which was misdiagnosed for nearly a year. The patient received conventional treatment in other medical institutions, but specific treatment was delayed. Ultimately, proper diagnosis and treatment with standard anti-tuberculosis drugs for one year led to complete cure.

CONCLUSION

For skin ulcers that do not heal with repeated conventional treatments, consider ulcers caused by rare bacteria, such as Mycobacterium tuberculosis.

Perianal tuberculosis presenting as a Fournier's gangrene

Key Clinical Message

In the setting of Fournier's gangrene, atypical clinical manifestations and complications in an immunocompetent patient warrant consideration of perineal tuberculosis as a potential underlying cause.

Abstract

Tuberculosis cutis orificialis is a rare form of extrapulmonary tuberculosis that affects the perianal region. Fournier's gangrene is an aggressive necrotizing fasciitis that primarily involves the perianal area and external genitalia. A previously healthy 38-year-old man presented with a left perianal abscess. His condition deteriorated, leading to septic shock and multiorgan dysfunction syndrome. A CT scan displayed extensive necrotizing fasciitis. Treatment included broad-spectrum antibiotics, numerous surgical perineal debridements, a transverse loop colostomy, and hyperbaric oxygen therapy. We believe the patient had pre-existing asymptomatic, non-diagnosed perianal tuberculosis, and a subsequent bacterial superinfection resulted in a perineal local abscess that progressed to severe Fournier's gangrene. The diagnosis of tuberculosis was confirmed through positive cultures and molecular identification in perineal biopsies. The patient experienced a complex clinical course with complications such as myocardial necrosis, acute respiratory distress syndrome, rhabdomyolysis with severe critical illness polyneuromyopathy and internal jugular thrombosis. Fournier's gangrene resulted in air dissection throughout the perineal fasciae, extending to the abdominal wall muscles resulting in an infected extraperitoneal spontaneous hematoma, probably caused by therapeutic anticoagulation. An extraperitoneal surgical drainage was performed. This case emphasizes the complexities in diagnosing and managing both perianal tuberculosis and Fournier's gangrene.

Prevalence of Anal Fistulas in Europe: Systematic Literature Reviews and Population-Based Database Analysis

Introduction

Despite the fact that perianal fistulas are associated with significant morbidity and impaired quality of life, their prevalence in Europe is unknown. The aim of this study was to estimate the prevalence of perianal fistulas in Europe, overall and according to etiology.

Methods

Two independent literature reviews were performed using different search strategies to maximize the identification of potentially relevant studies. Data from relevant articles were used to estimate the prevalence of perianal fistulas in Europe. The robustness of the estimate was evaluated using data from a large population-based database from the UK.

Results

A total of 26 studies provided epidemiological data on perianal fistulas, of which 16 provided suitable data to estimate the prevalence. Estimations using these data yielded a total prevalence of 1.69 per 10,000 population. Cryptoglandular infection and Crohn’s disease (CD) were the predominant etiologies, with prevalence rates at 0.86 and 0.76 per 10,000 population, respectively. Comparison of prevalence data from the UK population-based database with the European population resulted in a standardized prevalence estimate of all perianal fistulas of 1.83 per 10,000 population, confirming the robustness of the literature-based estimate.

Conclusion

Although in terms of incidence cryptoglandular fistulas were clearly predominant, the prevalence of fistulas in CD and cryptoglandular infection appeared more balanced. This is due to the longer duration and higher frequency of relapses of fistulas in CD. The estimated prevalence implies that perianal fistulas meet the criteria to be considered as a rare condition in Europe (prevalence less than 5 per 10,000 population).

Funding

This study was funded by Takeda Pharmaceutical U.S.A., Inc. and TiGenix SAU.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01117-y) contains supplementary material, which is available to authorized users.

Mycotic and Bacterial Infections

This article reviews the salient clinical features, evaluation, and treatment of mycotic and bacterial infections of the perianal and contiguous zones of the human body.

Prevalence of anal fistula in the United Kingdom

BACKGROUND

Anal fistula is a pathological connection between the anal canal and perianal skin, which most commonly develops from an infected anal crypt. While the majority of anal fistulas are idiopathic, they are also associated with Crohn’s disease (CD) and other inflammatory conditions. The prevalence of anal fistula is estimated to be 1-2 per 10000 patients, but population-based studies on anal fistula epidemiology are limited and outdated.

AIM

To assess the prevalence of anal fistula and relevant comorbidities, with and without CD in the United Kingdom and Europe.

METHODS

A retrospective population-representative observational cohort study was performed in The Health Improvement Network (THIN), a United Kingdom primary care database. Mid-year point prevalence of anal fistula was calculated on the first of July for each year between 2014 and 2017. Estimates were calculated for anal fistula overall and by CD status and standardized to the United Kingdom and European population. Prevalence of relevant comorbidities including lymphogranuloma venereum, hidradenitis suppurativa, anal presentation of sexually transmitted diseases, diabetes mellitus, and radiation in the pelvic area was reported.

RESULTS

The United Kingdom-standardized overall point prevalence of anal fistula was 1.80 (95%CI: 1.65-1.94) per 10000 patients in 2017, while the Europe standardized estimate was 1.83 (95%CI: 1.68-1.98) per 10000 patients. Both these standardized point prevalence estimates ranged from 1.89 to 2.36 between 2014-2016. The United Kingdom-standardized point prevalence of anal fistula without CD was 1.35 (95%CI: 1.23-1.48) per 10000 patients, while the Europe-standardized estimate was 1.39 (95%CI: 1.26-1.52) per 10000 patients. In contrast, the standardized point prevalence estimate of anal fistula with CD was lower for both United Kingdom and Europe (0.44; 95%CI United Kingdom: 0.37-0.52, 95%CI Europe: 0.37-0.51) per 10000 patients in 2017. In 2017, 19% of anal fistula patients without CD and 13% of anal fistula patients with CD had at least one relevant comorbidity. These results show that anal fistulas are infrequent in the general population. 24.5% of prevalent anal fistulas are associated with CD, but other potentially etiological comorbidities are rare.

CONCLUSION

This real-world evidence study estimated the United Kingdom-standardized prevalence of anal fistula was 1.80 per 10000 patients in 2017. Approximately 25% of cases may be associated with CD, while other comorbidities are rare.

Comparison of histopathology and real-time polymerase chain reaction (RT-PCR) for detection of Mycobacterium tuberculosis in fistula-in-ano

PURPOSE

Histopathology is commonly used to diagnose tuberculosis in fistula-in-ano. The aim was to compare the sensitivity of polymerase chain reaction and histopathology in detecting tuberculosis in fistula-in-ano.

METHODS

The histopathology and polymerase chain-reaction of tissue (fistula tract) was done in all the consecutive operated cases. When pus sample was also available, polymerase chain reaction-pus was also done RESULTS: Three hundred forty seven samples (179 patients) were tested over 2 years (median 6.5 months). The mean age was 38.8 ± 10.7 years, and male/female was 170/9. Histopathology and polymerase chain reaction of tissue (fistula tract) was done in 152 and 165 patients, respectively. Polymerase chain reaction (pus) could be done in 30 patients. Overall, tuberculosis was detected in 20/179 (11.2%) patients. Of these, tuberculosis was detected by histopathology (tissue) in 1/152 (0.7%) and by polymerase chain reaction (tissue) in 14/165 (8.5%) patients. In pus, polymerase chain reaction detected tuberculosis in 6/30 (20%) patients. Both polymerase chain reaction of tissue and pus were positive in one patient. Polymerase chain reaction (tissue) and polymerase chain reaction (pus) were significantly more sensitive than histopathology (tissue) for detecting tuberculosis [histopathology 1/152 vs. polymerase chain reaction (tissue) 14/165, p = 0.0009] [histopathology 1/152 vs. polymerase chain reaction (pus) 6/30, p < 0.0001]. In 20 patients detected to have tuberculosis, four drug anti-tubercular therapy was recommended for 6 months. The therapy was completed in 13 patients and 12/13 (92.3%) were cured. The therapy is continuing in 3/20 patients. Four patients did not take the therapy. None of them was cured.

CONCLUSIONS

Polymerase chain reaction was significantly more sensitive than histopathology in detecting tuberculosis in fistula-in-ano. Histopathology might be missing out tuberculosis in many patients leading to recurrence of the fistula.

Anal tuberculosis complicating anti-TNFα therapy

A 42-year-old man receiving anti-tumour necrosis factor α (anti-TNFα) therapy with adalimumab due to psoriatic arthritis presented with a 2-month-old anal ulcer. An apical right lung infiltrate was found in his chest X-ray, although he had no pulmonary symptoms. Two biopsies of the ulcer were taken and reported as granulomatous, necrotising, with chronic inflammation (first), and as hyperplasic epidermis with linfocitary infiltrate and the presence of plenty of plasmatic cells (second). Histochemical techniques, including Ziehl-Neelsen, Grocott and periodic acid-Schiff stains, and PCR for Mycobacterium tuberculosis on both biopsies were negative. Serology for HIV, syphilis and hepatitis were also negative. In the second biopsy culture, moderate colonies of M. tuberculosis finally grew. The patient started a four-drug antituberculosis regimen. Adalimumab was discontinued and etanercept introduced after 2 months of antituberculosis therapy. The patient remained on therapy for 9 months with complete ulcer resolution.

Clinicopathological profile and surgical treatment of abdominal tuberculosis: a single centre experience in northwestern Tanzania

BACKGROUND

Abdominal tuberculosis continues to be a major public health problem worldwide and poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. This study was conducted to describe the clinicopathological profile and outcome of surgical treatment of abdominal tuberculosis in our setting and compare with what is described in literature.

METHODS

A prospective descriptive study of patients who presented with abdominal tuberculosis was conducted at Bugando Medical Centre (BMC) in northwestern Tanzania from January 2006 to February 2012. Ethical approval to conduct the study was obtained from relevant authorities. Statistical data analysis was performed using SPSS version 17.0.

RESULTS

Out of 256 patients enrolled in the study, males outnumbered females. The median age was 28 years (range = 16-68 years). The majority of patients (77.3%) had primary abdominal tuberculosis. A total of 127 (49.6%) patients presented with intestinal obstruction, 106 (41.4%) with peritonitis, 17 (6.6%) with abdominal masses and 6 (2.3%) patients with multiple fistulae in ano. Forty-eight (18.8%) patients were HIV positive. A total of 212 (82.8%) patients underwent surgical treatment for abdominal tuberculosis. Bands /adhesions (58.5%) were the most common operative findings. Ileo-caecal region was the most common bowel involved in 122 (57.5%) patients. Release of adhesions and bands was the most frequent surgical procedure performed in 58.5% of cases. Complication and mortality rates were 29.7% and 18.8% respectively. The overall median length of hospital stay was 32 days and was significantly longer in patients with complications (p < 0.001). Advanced age (age ≥ 65 years), co-morbid illness, late presentation, HIV positivity and CD4+ count < 200 cells/μl were statistically significantly associated with mortality (p < 0.0001). The follow up of patients were generally poor as only 37.5% of patients were available for follow up at twelve months after discharge.

CONCLUSION

Abdominal tuberculosis constitutes a major public health problem in our environment and presents a diagnostic challenge requiring a high index of clinical suspicion. Early diagnosis, early anti-tuberculous therapy and surgical treatment of the associated complications are essential for survival.

Perianal tuberculosis: a case report and a review of the literature

Extra pulmonary tuberculosis accounts for less than 15% of all cases of tuberculosis whereas the Intestinal one constitutes less than 1% of the extrapulmonary forms of the disease. The lesions of abdominal organs are more common while they rarely occur in the anoperineal area for the spread of the disease to the anus is extremely rare. We report a case of a 37-year-old male patient with large bilateral infected perianal tubercular ulcerations as well as pulmonary and peritoneal tuberculosis. The treatment was both surgical and medical and the therapy lasted for seven months. After six months from the beginning of the treatment, the lesion had totally disappeared and there is still no recurrence after one year of followup. Tuberculosis should generally be taken into consideration in the differential diagnosis of the ulcerative lesions of the anal and perianal regions for these lesions do occur in the said areas despite their rarity. The treatment is usually both surgical and medical so as to get excellent results.