Fig. 1 Deep and sharply demarcated ulcer at 12 o clock position

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Fig. 1 Deep and sharply demarcated ulcer at 12 o clock position Powered By Docstoc
					Case Report                                                                                                                       229

    PERIANAL TUBERCULOUS ULCER IN AN IMMUNO COMPETENT PATIENT

                 Jagdish Rawat1, R.K. Verma2, Girish Sindhwani1 , Ruchi Dua3 and Geeta Negi1

                            (Received on 12.5.2009; Accepted after revision on 4.8.2009)


         Summary: Perianal tuberculosis, without the presence of any previous or active pulmonary infection, is extremely
         rare. A wide range of differential diagnosis for perianal ulcers might be one reason for a possible delay in establishing this
         diagnosis. [Indian J Tuberc 2009; 56: 229-231]

         Key words: Perianal Tuberculosis, Immuno Competent




INTRODUCTION

         Although prevalence of tuberculosis has
decreased after introduction of Directly Observed
Treatment Short course (DOTS) worldwide, it has
been reported that there is an increase in cases of
tuberculosis due to the increasing incidence of
Acquired Immuno Deficiency Syndrome (AIDS) 1.
On the other hand, perianal tuberculosis, without
the presence of previous or active pulmonary
infection, is extremely rare. Here, we present a case
of perianal tuberculosis without gastrointestinal or
pulmonary lesion.                                                   Fig. 1: Deep and sharply demarcated ulcer at
                                                                            12 o’ clock position with everted margine
CASE REPORT                                                                 and ulcer floor formed by necrotic tissue.
           A forty-year old male patient was admitted               deep and sharply demarcated ulcer about transverse
with history of perianal discharge and ulceration for               diameter of 5cm and vertical diameter of 3.5cm at
the last six months. Treatment with topical antibiotics             12 o’ clock position with everted margin and ulcer
and ointments had been ineffective. He was                          floor formed by necrotic tissue (Fig. 1). No
alcoholic, non-smoker and had no past history of                    abnormality on rectal examination was found.
anti-tubercular treatment. The patient was afebrile                 Anoscopy was normal and no fistulas were noted.
on admission. No lymphadenopathy was found on                       The patient’s tuberculin test was positive (15mm).
palpation, and physical examination of the respiratory              Laboratory investigation showed normal value of
tract was normal. No palpable mass or                               hemoglobin, hematocrit, total leukocyte count,
organomegaly was detected on abdominal                              platelet and erythrocyte sedimentation rate. Renal
examination. Perianal region examination revealed a                 function test and liver enzyme were also within the
1. Assistant Professor* 2. Associate Professor** 3. Senior Resident
* Departments of Pulmonary Medicine3 & Pathology
** Department of Surgery
Himalayan Institute of Medical Sciences, Dehradun (Uttarakhand)
Correspondence: Dr. Jagdish Rawat, Assistant Professor, Department of Pulmonary Medicine, Himalayan Institutge of Medical
                   Sciences, Dehradun, Uttarakhand. Phone: +911352471362, 9410932981; Fax +911352471317;
                    E-mail: drjagdishrawat@yahoo.com



                                                                                                 Indian Journal of Tuberculosis
230                                      JAGDISH RAWAT ET AL

                                                         DOTS. No side-effects of anti-tubercular treatment
                                                         (ATT) were found. His symptoms resolved and the
                                                         perianal ulcer began to heal within second month of
                                                         treatment. Patients completed six months of ATT
                                                         under DOTS with complete disappearance of
                                                         perianal ulcer (Fig. 3).

                                                         DISCUSSION

                                                                  In extra pulmonary tuberculosis, the anal
                                                         involvement is rare (0.7%) 2. Anal tuberculosis has
                                                         been sub-divided into four categories3: ulcerative,
                                                         verrucous, lupoid and miliary. Ulcerative tuberculosis
                                                         is common form and is usually secondary to a focus
Fig. 2: Wedge biopsy revealed epithelioid                in lung or intestine.
          granuloma,       Langhen’s       type
          multinucleated giant cell and caseous                   Tuberculosis of gastrointestinal tract (GIT)
                                                         is responsible for 1% of all cases of tuberculosis.
          necrosis.
                                                         Tuberculosis may involve any part of gastrointestinal
normal range. Chest x-ray revealed no abnormal           system, of which tuberculous peritonitis is the most
finding.                                                 common. The most frequently affected part of
                                                         intestinal tract is ileocaecal region. Involvement of
        The wedge biopsy was taken from perianal         the appendix and jejunum is uncommon and spread
lesion and sent for histopathological examination.       to the anus is much rare. Tuberculosis of the GIT
Histopathological examinination revealed epithelioid     usually occurs as a result of spread from
granuloma, Langhen’s type multinucleated giant cell,     tuberculosis foci in the lung. Ingestion of the bacilli
caseous necrosis and a few acid fast bacilli( Fig. 2).   from sputum may lead to invasion of the intestinal
Ultrasound of whole abdomen revealed no                  wall. Other mechanisms that have been considered
pathological finding. HIV antibody test was negative.    are haemetogenous spread and retrograde spread
                                                         of M. tuberculosis in to abdominal lymph node from
        We made a diagnosis of isolated perianal         a pulmonary site4. In our patient, no pulmonary or
tuberculosis and started CAT-1 treatment under           gastro intestinal focus was found despite an
                                                         extensive investigation. Crohns disease, ulcerative
                                                         colitis, venereal diseases, sarcoidosis, ulcerative
                                                         neoplasm plays a significant role in differential
                                                         diagnosis. Differentiation between perianal
                                                         tuberculosis and crohns disease may be difficult
                                                         because both conditions have certain similar macro
                                                         and microscopic features. So when tuberculosis is
                                                         considered, biopsy should be taken from the lesion
                                                         and subsequently acid fast staining, culture for M.
                                                         tuberculosis and PCR should be done for accurate
                                                         diagnosis.

                                                                 It should be kept in mind that cases of
                                                         persistent perianal tuberculosis may appear as
Fig. 3: Complete disappearance of perianal ulcer         incipient disease without the presence of any
                                                         previous or active pulmonary infection.
        after six months of ATT.


Indian Journal of Tuberculosis
                                         PERIANAL TUBERCULOUS ULCER                                                       231

Tuberculosis origin should be considered in such               2.   Mehta JB, Dutt A, Harvill L, Mathew KM. Epidemiology
lesion to avoid delay in the treatment of this                      of extra pulmonary tuberculosis. A comparative analysis
                                                                    with pre – AIDS era. Chest 1991; 99: 1134-38.
rare form of tuberculosis.
                                                               3.   Bacon He. Anus, rectum, sigmoid; Diagnosis and
                                                                    treatment.Vol.1, 3rd ed.philadelphia: J B lippncott co.
REFERENCES                                                          428-33.
                                                               4.   Candela F, Serrano P, Arriero JM, Terual A,Reyes D.
1.   Raviglione MC, Sinder DE, Kochi A. Global epidemiology         Perianal disease of tuberculosis origin: report of the case
     of tuberculosis. Morbidity and mortality of a worldwide        and review of the literature.Dis colon rectum 1999; 42:
     epidemic. JAMA 1995; 273: 220-26.                              110-2.




                                                                                          Indian Journal of Tuberculosis

				
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