Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature.

BACKGROUND: Few data are published on perianal tuberculosis. OBJECTIVE: This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. DATA SOURCES: The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. INTERVENTION: Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. MAIN OUTCOME MEASURES: The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. RESULTS: In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. LIMITATIONS: The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. CONCLUSIONS: The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

FORMATION OF BIOFILMS BY BACTERIA EXCRETED FROM CHRONIC ANAL FISSURE AND THE INFLUENCE OF THE DIRECT CURRENT ELECTRIC FIELD ON THEM.

Chronic anal fissures (CAF) are considered to be the illness with chronic course and characterized by frequent relapses. Although today the attention of researchers concerning the role of biofilm bacterial forms in pathogenesis of this pathology remains inadequate. Тherefore we investigated biofilms density of bacteria isolated from CAF and determined the current density possessing an optimal bactericidal effect on bacteria and destruct microbial biofilms. Bacteria isolated from CAF in monoculture manifest stronger adhesive properties and exopolysaccharide biofilm matrix in them is denser, which might provide better protection for microbe cells against environmental factors and antimicrobial drugs. To determine the optimal current strength essential for galvanization of CAF the effect of direct current electric field of different density was examined. The action of direct current electric field with the density of 0,025 mА/cm2 did not produce bactericidal effect on biofilm cells, although ruined biofilm matrix, which density decreased in 1,5 times as much in an average. In case the current density increased to 0,05-0,1 mА/cm2 biofilm matrix was ruined more intensively, its density decreased from high to average and low. It killed bacteria, their number decreased in the ruined biofilm from 10,7 to 56,4 times. The antibiotic fluoroquinolones and antiseptic Dioxisolum were found to produce the best effect on biofilm forms of bacteria. Although none of the examined antibacterial drugs possessed a complete bactericidal action, since bacteria were protected by biofilm matrix of high density causing resistance to pharmacological agents. Considering the mentioned above we recommend to supplement a comprehensive antibacterial therapy of CAF with intra-tissue electrophoresis with the current density 0,05-0,1 mА/cm² with antiseptic, and antibacterial therapy should be administered after preliminary detection of sensitivity of isolated microorganisms in biofilm from CAF to antibiotics and antiseptics.

Cutaneous presentation of disseminated histoplasmosis as a solitary peri-anal ulcer. Case report and discussion.

Disseminated histoplasmosis has a diverse and non-specific range of clinical signs and symptoms. In a significant minority of patients, cutaneous lesions are apparent at the time of initial presentation, affording an opportunity to establish the diagnosis from a skin biopsy. The most frequently reported clinical scenario in immunocompromised patients with cutaneous involvement is that of multiple papulo-nodular lesions on the face, trunk or extremities. The following report features an immunocompetent patient who presented with a solitary ulcerated plaque on the buttocks close to the anal verge. This case presentation underscores the broad spectrum of clinical presentations as well as the potential for diagnostic confusion with protozoa such as Leishmania or Trypanosoma species during histopathologic examination if special stains for fungal organisms are not performed.

[Perianal infection in patients with hemoblastosis: Risk factors and possibilities of prevention]. / Perianal'naya infektsiya u bol'nykh gemoblastozami: faktory riska i vozmozhnosti profilaktiki.

AIM: to identify poor prognostic factors for perianal infection (PI) in patients with hemoblastosis and to define an effective tactic for preventive and therapeutic measures. SUBJECTS AND METHODS: The prospective study enrolled 72 patients (37 men and 35 women; mean age, 47 years) with hemoblastosis that was complicated by the development of one of the following forms of PI: abscess, infiltrate, multiple ulcers. Different clinical and laboratory characteristics of the patients were examined to identify risk factors for PI. The species-specific concordance of microorganisms isolated from the anus and blood in the development of PI was assessed to record the latter as a source of sepsis. Treatment policy was defined according to the clinical form of PI. RESULTS: Acute myeloid leukemias and lymphomas were the most common background diseases in 30 (41.7%) and 22 (30.6%) patients, respectively. During induction chemotherapy cycles, perianal tissue infection occurred twice more frequently (66%) than totally at the onset of hemoblastosis (13%) and after achievement of remission (during consolidation and maintenance therapy) (21%; Fisher's exact test; p=0.01). PI in agranulocytosis was more than twice as common as in its absence: 69.4% vs 30.6% (p=0.01) and was responsible for sepsis in 9 (18%) of 50 patients. The main source of perianal tissue infection in patients with granulocytopenia was anal fissures and fistulas and ulcers of the anal canal: 44 (88%) cases of the 50 cases. In PI as an abscess, the average white blood cell count was 5 times higher (p=0.01) than that in PI as an infiltrate (or multiple ulcers): 6.6·109/l and 1.2·109 g/l. Abscess formation was observed in 16 (22.2%) patients and an indication for surgical drain. The inflammatory infiltrate was found to develop in 48 (66.7%) patients; multiple ulcers were seen in 8 (11.1%); in this group, parenteral antimicrobial therapy proved to be effective in 36 (78%) patients. 29 patients were operated on for anal fissures and fistulas at intercycle intervals. After continuing CT, PI recurrences were observed in 4 (9.1%) patients. In the operated versus medically treated patients, the risk of complications associated with abnormalities in the perianal area during continued CT was 5 times statistically significantly lower (odds ratio=0.2; 95% confidence interval 0.1 to 0.5; p=0.04; Cochran-Mantel test). CONCLUSION: Induction CT cycles, the status of granulocytopenia, and the presence of infection sources in the anal canal as an anal fissure, skin ulcerations, or a fistula should be considered as independent statistically significant prognostic risk factors for PI. The number of granulocytes determines the form of inflammation, the course of infection, and the chance of developing sepsis. The effective prevention encompassing surgical treatment for anal canal diseases reduces the risk of septic complications and the number of paraproctitis recurrences, contributing to the implementation of a planned CT program in patients with hemoblastosis.

The etiology of infectious proctitis in men who have sex with men differs according to HIV status.

We compared the spectrum of pathogens responsible for infectious proctitis between HIV-positive and HIV-negative men who have sex with men. Only 32% of men with herpes simplex virus (HSV)-associated proctitis had visible external anal ulceration.The etiology of infectious proctitis among HIV-positive and HIV-negative men is as follows: chlamydia (23.4% vs. 21.7%, P = 0.7), gonorrhea (13.4% vs. 10.8%, P = 0.5), HSV-1 (14.2% vs. 6.5%, P = 0.04), HSV-2 (22% vs. 12.3%, P = 0.03), lymphogranuloma venereum (7.8% vs. 0.7%, P = 0.004), and multiple infections (17.7% vs. 8.6%, P = 0.017). Thirty-two percent with HSV proctitis had external anal ulceration.

Lymphogranuloma venereum presenting as perianal ulceration: an emerging clinical presentation?

An outbreak of lymphogranuloma venereum (LGV) infection has been recognised in the UK since 2004, predominantly affecting HIV-positive men who have sex with men (MSM). Patients typically present with proctitis symptoms. The prevalence of rectal LGV in MSM attending sexually transmitted infection clinics in London is estimated at 1%. Health Protection Agency surveillance has shown a decrease in anorectal manifestations despite little demographic change. Two cases of HIV-infected patients presenting with isolated perianal ulcer disease are reported here. Both cases were confirmed to have rectal Chlamydia trachomatis-specific DNA of an LGV associated serovar. As presentations of LGV diversify, further education and surveillance are needed in order to reduce transmission and prevent long-term complications. A strong argument already exists for the incorporation of chlamydia nucleic acid amplification tests in the management of MSM with proctitis; this paper provides evidence that this should be extended to MSM with perianal ulcer disease.

[Role of selective decontamination in combined treatment of chronic anal fissure].

Effectiveness of selective decontamination in combined treatment of patients with chronic anal fissure and concomitant proctitis was studied in clinical randomized investigation including 103 patients. The etiologically significant flora colonizing the chronic defect of the anoderma does not coincide with the composition of feces microflora and is presented by anaerobic microorganisms or a combination of aerobes and anaerobes. It was established that topical etiotropic antibacterial therapy in combination with medicamentous sphincterotomy in the outpatient treatment resulted in quicker arrest of the pain syndrome, accelerated epithelization of the fissure and made the period of treatment 2 times shorter as compared with control.

Molecular epidemiology of syphilis in Scotland.

OBJECTIVE: To examine the molecular epidemiology of syphilis in Scotland. METHODS: Ulcer specimens were collected from 85 patients with infectious syphilis. Typing of Treponema pallidum was performed using a method that examines variation in two loci; the number of 60-basepair repeats within the arp gene and sequence variation in the tpr genes. RESULTS: Patients were predominately white men who have sex with men (MSM). Treponemal DNA was detected in 75 specimens and a total of six subtypes were identified from 58 typeable specimens (77%). The most common subtypes were 14d (44/58, 76%), followed by 14e (7/58, 12%), 14j (3/58, 5%), 14b (2/58, 3%), 14p and 14k (1/58, 2%). CONCLUSIONS: This study shows that subtype 14d is the predominant subtype circulating in Scotland and there is a surprising level of genetic diversity within the Scottish MSM community.

Pseudomembranous necrotising pharyngitis in a child with Pseudomonas aeruginosa bacteraemia.

Pseudomonas aeruginosa is a common infection in immunocompromised patients. However, it can also cause severe infections in otherwise healthy individuals. We describe pseudomonal bacteraemia in a 6-month-old boy with significant obstruction of the nasopharynx by pseudomonal debris, which we termed pseudomembranous nectrotising pharyngitis. To prevent aspiration and suffocation, early recognition and removal of the obstruction by endoscopy is recommended.

Perianal ulcerative skin tuberculosis: A case report.

RATIONALE: Ulcerative skin tuberculosis (TB) is a rare form of extrapulmonary TB. CASE REPORT: We present a case of a 65-year-old patient with perianal ulcer, which had been present for 1 year. Anamnesis revealed he had been persistently coughing for the same period of time. Histological examination of perianal skin showed necrotizing granulomatous lesions, acid-fast staining in sputum samples was ++++, TB antibody in the blood was positive, TB DNA test was positive, and chest scan that showed secondary pulmonary TB accompanied by possible pulmonary cavity formation in the 2 upper lungs. INTERVENTIONS: Anti-TB therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide for 6 months. The skin ulcer completely healed after 6 months. CONCLUSION: TB should be suspected for nonhealing ulcers. Pertinent studies should be done early during the lesion; finally, TB treatment should be initiated immediately after diagnosis is made.

The effects of topical application of metronidazole for treatment of chronic anal fissure: A randomized, controlled pilot study.

BACKGROUND: Chronic anal fissures (CAFs) rarely heal with conservative management. Because they are associated with strong anal sphincter tone, most treatment aim to reduce anal pressure. Although infections can cause fissures, as can traumatic injury to the anal canal, antimicrobial treatment is not recommended. In a previous study, we reported identifying a wide spectrum of pathogenic microorganisms in the bases of CAFs, anaerobic bacteria being present in half the cases. We postulated that microbial colonization delays healing of CAF and aimed to determine whether decreasing the bacterial load with topical antibacterial treatment accelerates fissure healing. METHODS: We cultured fecal samples and swabs from the bases of CAFs in 103 patients. Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate in a prospective randomized clinical trial comparing topical metronidazole with conventional treatment. The primary endpoint was fissure healing confirmed on anoscopy. Secondary endpoints of maximum pain on defecation assessed by visual analog scale, maximum anal resting pressure, and rectal pH were recorded on entry and at 10, 21, and 28 days. RESULTS: The CAFs were colonized by mixtures of gram-positive/gram-negative anaerobic bacteria or gram-negative aerobic monocultures. Patients with anaerobic bacteria in their swabs who received topical metronidazole treatment experienced rapid relief of pain and anal sphincter spasm along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048). CONCLUSION: Topical antimicrobial treatment can be effective in patients with CAF provided the relevant microorganisms are correctly identified.

Anal mycobacterial infections / Infecções micobacterianas do ânus

Abstract Background Mycobacterial infections are a serious public health problem worldwide. Involvement of the anal canal and perineum is very rare, but constitute an important differential diagnosis with other equally serious pathologies that may affect the region, such as malignant neoplasms and Crohn's disease. Objectives To conduct a literature review on mycobacterial infections of the perianal region considering the most recent information for diagnostic and therapeutic guidance of this disease. Methods Research was performed on the PUBMED and LILACS databases with the expressions Mycobacterium, Anal, Infection and Tuberculosis. We reviewed articles referring to series of treated cases, clinical reports and literature review published since 2005. Results Information was compiled on the epidemiology of mycobacterial infections; the clinical behavior of affected individuals; diagnostic options and their validity in clinical practice; and, finally, therapeutic options. Conclusions Mycobacterial infections of the anus and perineum are rare. The most common clinical presentations are the presence of ulceration and fistulization. The diagnosis involves more than one procedure for identifying the bacilli and should consider the presence of manifestations in more than one organ. The treatment is based on pharmacological intervention. Surgery is recommended for acute complications or chronic sequelae of the disease.

Resumo Introdução Infecções micobacterianas constituem um grave problema de saúde pública a nível mundial. As manifestações anoperineais são raras, mas constituem um importante diagnóstico diferencial com outras patologias igualmente graves que podem acometer a região, como as neoplasias malignas e a doença de Crohn. Objetivos Realizar um levantamento da literatura sobre infecções micobacterianas da região anoperineal, considerando as informações mais atuais para orientação diagnóstica e terapêutica dessa enfermidade. Métodos Foi realizada pesquisa nos bancos de dados PUBMED e LILACS com as expressões Mycobacterium, Anal, Infection e Tuberculosis. Foram revisados artigos referentes a séries de casos tratados, relatos clínicos e revisão da literatura publicada a partir de 2005. Resultados Foram compiladas informações sobre a epidemiologia das infecções micobacterianas; o comportamento clínico dos indivíduos afetados; opções diagnósticas e sua validade na prática clínica; e, por fim, opções terapêuticas. Conclusões Infecções micobacterianas da região anoperineal são raras. As apresentações clínicas mais comuns são a formação de ulceras e a fistulização. O diagnóstico envolve mais de um procedimento para identificação dos bacilos, e deve considerar a presença de manifestações em mais de um órgão. O tratamento é principalmente medicamentoso, sendo a cirurgia recomendada nas complicações agudas ou sequelas crônicas da doença.

Severe anal ulceration secondary to Histoplasma capsulatum in a patient with HIV disease.

Severe fungal infections have become increasingly common in the immunocompromised patient, including those infected with human immunodeficiency virus. Histoplasma capsulatum occurs in about five per cent of acquired immunodeficiency syndrome patients in the endemic areas of the Mississippi and Ohio River Valley. Immunocompromised patients who present with severe ulceration and suppuration of the anus require exam under anesthesia and thorough laboratory evaluation for opportunistic infections. Thus, surgeons play a critical role in diagnosis and initiation of treatment. A case of infiltrating H. capsulatum of the anus is presented, including the natural history, presentation, diagnosis, and treatment.

[Perianal cutaneous ulcerations in the tropical zone. Proposal for a diagnostic and therapeutic decision tree. A case report]. / Ulcérations cutanées périanales en zone tropicale. Proposition d'arbre décisionnel diagnostique et thérapeutique. A propos d'un cas.

Perianal cutaneous ulcerations in tropical countries have multiple causes: bacterial, viral and parasitic. Taking the opportunity of a case observed in Bambari (CRA) of which the etiologic origin was not clearly established, the authors offer a proposal for a diagnostic and therapeutic protocol aimed at easing decision. Etiologies quickly cured, such as amoebiasis and tuberculosis have to be explored in priority.

A rare presentation of a common disease: orificial tuberculosis.

Tuberculosis is a common condition with increasing incidence worldwide. Clinicians should be aware of cutaneous manifestations, even though these are uncommon, as recognition can lead to early diagnosis. Here, we present a case of orificial tuberculosis in a young HIV-negative man.