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Non-healing perianal ulcer: A rare presentation of cutaneous tuberculosis

  • Author(s): Ghosh, Sudip Kumar
  • Bandyopadhyay, Debabrata
  • Ghosh, Arghyaprasun
  • Mandal, Rajesh Kumar
  • Bhattacharyya, Kumkum
  • Chatterjee, Sumanta
  • et al.
Main Content

Non-healing perianal ulcer: A rare presentation of cutaneous tuberculosis
Sudip Kumar Ghosh MD DNB DDerm1, Debabrata Bandyopadhyay MD1, Arghyaprasun Ghosh MD1, Rajesh Kumar Mandal MBBS1, Kumkum Bhattacharyya MD2, Sumanta Chatterjee, MBBS2
Dermatology Online Journal 15 (3): 9

1. Department of Dermatology, Venereology, & Leprosy
2. Department of Microbiology
R.G.Kar Medical College, Kolkata, India. dr_skghosh@yahoo.co.in


Abstract

Perianal tuberculosis is an extremely rare form of tubercular disease. We report here a case of chronic non-healing perianal tubercular ulcer associated with, asymptomatic pulmonary tuberculosis in a 16-year-old boy for its rarity and to emphasize the importance of considering tubercular etiology in the work up of persistent perianal ulcer.



Introduction

Perianal tuberculosis is an exceedingly rare disease [1]. A wide range of differential diagnoses for perianal ulcers may often lead to delay in establishing the diagnosis. We describe a male homosexual patient with non-healing perianal tubercular ulcer associated with active, asymptomatic pulmonary tuberculosis for its rarity and to emphasize the importance of considering tubercular etiology in the work up of persistent perianal ulcer.


Case report

A 16-year-old boy from rural West Bengal, India, presented with a history of a slowly growing, non-healing, perianal ulcer with discharge for a duration of 6 months. Treatment with various topical and systemic antibiotics had been ineffective. The patient was otherwise healthy without any systemic symptoms. However, he had a history of receptive anal intercourse 8 months prior, but contact tracing was not possible in the present case. His past medical history was noncontributory. Dermatological examination revealed a shallow and sharply demarcated oval ulceration with a transverse diameter of 3 cm and vertical diameter of 5 cm with a purulent floor (Fig. 1). The ulcer was non-tender and the margin was undermined. Inguinal lymph nodes were not enlarged. No abnormality on anorectal examination was found. Coarse breath sounds were heard in the left upper lung fields. In the lower portion of the left lung field dullness to percussion was noted. In addition, diminished breath sounds and diminished vocal resonance were appreciated . Otherwise the systemic examination was non-contributory.


Figure 1Figure 2
Figure 1. Shallow and sharply demarcated oval perianal ulceration with purulent exudates
Figure 2. X-ray chest PA view showing left apical infiltrations and left-sided pleural effusion

Laboratory findings, including a complete blood count, liver function tests, and urinalysis were normal, except for a raised ESR (66 mm in 1st hour). Syphilis serology (VDRL, TPHA), hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) serology were negative. Chest X-ray showed left apical infiltrations with evidence of pleural effusion in lower zone of left side (Fig. 2). Sputum, examined on 3 consecutive days, revealed no acid-fast bacilli. Double-contrast barium studies of colon and small bowel were normal. No significant findings were detected on upper gastrointestinal endoscopy and rectosigmoidoscopy. Ultrasonography of the abdomen and computed tomography of the abdominal and pelvic region revealed no pathological findings. Mantoux test (with 5TU of PPD) showed an induration of 18 mm x 18 mm. Ziehl-Neelsen stain of the swab taken from the ulcer showed numerous acid-fast bacilli. Gram staining did not reveal any microorganisms. Histopathological examination of the biopsy obtained from the edge of the ulcer revealed acanthosis with pseudoepitheliomatous hyperplasia, granulomatous infiltrates in the dermis consisting of epitheloid cells with a few Langhan giant cells, and features of neovascularisation. Focal areas of caseation necrosis were also noticed. Culture of swabs taken from the ulcer eventually grew Mycobacterium tuberculosis. Pleural fluid had an exudative character with a predominance of lymphocytes. Pleural fluid culture for mycobacteria was negative, but the Polymerase Chain Reaction was positive for tubercular DNA. KOH mount and fungal culture did not reveal any fungal elements. These findings established a diagnosis of perianal tuberculous ulcer with underlying pulmonary tuberculosis. Antituberculosis therapy was started, consisting of isoniazid 5 mg/kg, rifampicin 10 mg/kg, ethambutol 15 mg/kg, and pyrazinamide 30 mg/kg. Within one month of starting treatment, the ulcer showed signs of healing and the pleural effusion resolved before the patient was lost to follow up.


Discussion

Perianal tuberculosis comprises less than 10 percent of all perianal diseases and 0.7 percent of all tuberculosis cases [2]. In a report from India, 19 (15.6%) of 122 cases of anal fistula were diagnosed as having tubercular etiology. Only 3 cases presented with a clinical picture of concomitant pulmonary tuberculosis; none were HIV-positive [3]. Another study showed 14 percent of 64 patients with extra-pulmonary tuberculosis had tubercular anal fistula [2]. It is speculated that perianal tuberculosis may be the result of hematogenous or lymphatic dissemination from a distant pulmonary focus in a few patients; in others it is usually associated with gastrointestinal tract (GIT) tuberculosis [4]. In our patient however, we have failed to document any evidence of GIT involvement, even after an extensive work-up. Sultan et al. (2002) documented data from seven cases of ano-perineal tuberculosis observed between 1982 and 1999; an association with pulmonary tuberculosis was found in each case [5]. The diagnosis of perianal tuberculosis is difficult and requires a high index of suspicion, especially in patients with perianal involvement as the first presentation of tuberculosis.

Tuberculosis in the anal and perianal region presents as non-healing, ulcer-like fissures, recurrent fistulas, perianal warty growths, abscesses, and lupoid miliary forms [1]. The most common is the ulcerative type, which tends to have well-defined boundaries and is characterized by mucopurulent discharge [6]. Because of the absence of sufficiently diagnostic symptoms and signs, the diagnosis of perianal tuberculosis can be much more complicated among HIV-positive patients [2], although it is considered to be an important marker of HIV infection [7].

Histological examination of the lesion can provide valuable clues to the diagnosis of perianal tuberculosis. Overlooking the diagnosis of perianal tuberculosis can result in chronic morbidity and often mortality, especially among immunocompromised patients. In general, tuberculosis should be considered in the differential diagnoses of perianal lesions, especially in recurrent ones [4]. In such cases, the physician must take a thorough history, look for acid-fast bacilli in the discharge from the lesion, carefully examine excised tissue, and culture for Mycobacterium tuberculosis to make the correct diagnosis of this potentially curable disease. Our patient presented with perianal ulceration and no abscess or anal fistula was noted. Crohn disease has many similarities to perianal tuberculosis. Other conditions that should be considered are ulcerative colitis, herpes simplex, syphilis, sarcoidosis, amoebiasis, pyoderma gangrenosum, deep mycosis, and ulcerative neoplasms. Differentiating between perianal tuberculosis and Crohn disease may be difficult. Both conditions may have certain analogous features including colonic skip lesions, ileocaecal spread, and granulomas on histological examination [6]. An acid fast stain and a polymerase chain reaction test can rapidly solve the dilemma before cultural confirmation of the diagnosis of tuberculosis. Although our patient had a history of receptive anal intercourse, it was probably not contributory to the causation of the ulcer.

References

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7. Ghiya R, Sharma A, Marfatia YS. Perianal ulcer as a marker of tuberculosis in the HIV infected. Indian J Dermatol Venereol Leprol. 2008 Jul-Aug; 74(4): 386-8. [PubMed]

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