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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 97-100

Tuberculous fistula-in-ano


Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission21-Jun-2020
Date of Decision20-Jul-2020
Date of Acceptance03-Jul-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Parmeshwar Bambrule
Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_9_20

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  Abstract 


Perianal tuberculosis (TB) is a rare diagnosis in cases of fistula-in-ano, especially in cases where healing has not occurred despite multiple surgical interventions. One should consider a high level of possibility of harboring TB, which may be the reason behind the failure of treatment and multiple recurrences. The histopathological finding includes epithelioid cell granulomas, and caseation necrosis would be an essential guide in such cases along with the other tests such as acid-fast bacillus staining and culture and Mantoux test. The treatment of tuberculous fistula-in-ano includes not only surgical but also the full course of four-drug anti-tubercular treatment for at least 6 months and regular follow-up to cope up with recurrence.

Keywords: Anti-tubercular treatment, fistula-in-ano, perianal tuberculosis


How to cite this article:
Bambrule P, Sheikh MT, Mittal T, Dey A, Ahuja A, Agarwal B, Patel D, Mailk VK. Tuberculous fistula-in-ano. Indian J Colo-Rectal Surg 2019;2:97-100

How to cite this URL:
Bambrule P, Sheikh MT, Mittal T, Dey A, Ahuja A, Agarwal B, Patel D, Mailk VK. Tuberculous fistula-in-ano. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2022 May 20];2:97-100. Available from: https://www.ijcrsonweb.org/text.asp?2019/2/3/97/295859




  Introduction Top


Tuberculosis (TB) is a major health problem not only in India but also worldwide, especially in developing countries. TB can effect virtually every organ in human body. However, the most common tuberculosis infection is pulmonary TB. From lungs, it may get disseminated to the other organs in body. Broadly, it is divided into pulmonary and extrapulmonary TB, of which intestinal TB is a type of extrapulmonary TB, the incidence of which is increasing in the recent past.[1] According to the World Health Organization report 2019, there were an estimated 10 million annual cases of TB globally and 1.3 million people died from the disease in 2019. The burden of the disease varies enormously among countries, from fewer than five to more than 500 new cases per 100,000 population per year, with the global average being around 130 new cases per year.[2] India accounts for 27% of those cases. However, extrapulmonary TB accounts for 20% of all TB cases, among this, the incidence of gastrointestinal tract (GIT) TB is very less, i.e., 1%–3%. The infection of the abdominal organ is more common than the perianal region and the anorectal region. The presentation may not be characteristically distinct. It can be mild perianal symptoms to the perianal sepsis in the form of multiple fistulous opening.[2],[3],[4]

As anorectal TB is rare, the diagnosis and management is very challenging. A high level of suspicion is very important in the diagnosis. It may include histopathological examination (HPE), polymerase chain reaction (PCR) and TB culture, Mantoux (tuberculin) test, chest X-ray, and sputum examination to rule out pulmonary TB. Management requires multiple surgeries and use of proper anti-tubercular drugs.


  Case Reports Top


Case 1 is a 49-year-old woman who presented with a history of nonhealing wound in the perianal region for 2 months. She was evaluated outside the hospital and was diagnosed to have complex fistula-in-ano. She underwent surgical interventions three times in the form of fistulotomy and fistulectomy, but still, there was recurrent fistula formation. She was admitted in our hospital and underwent evaluation under anesthesia – intraoperatively; the perianal skin was ulcerated and there was destruction of internal anal sphincter. The plan was made to rule out Crohn's disease and other rare possibilities such as TB. She underwent colonoscopy and biopsy, which were suggestive of chronic nonspecific colitis. Histopathological report of the fistulous tissue was not suggestive of TB though focal granulomatous reaction was present. Acid-fast bacilli (AFB) stain was negative. She was evaluated for pulmonary TB, which was found to be negative. Because of the perianal sepsis and regular fecal contamination, diversion loop ileostomy was done. Her internal anal sphincter was almost entirely replaced with granulation tissue [Figure 1]. She also had suprapubic eczematous lesions for which she was being managed by an experienced dermatologist. These lesions were also biopsied, which showed some giant cells and granulation tissue. These lesions were present before the start of the perianal disease. In consultation with the dermatologist, it was decided to give her a therapeutic trial of anti-tubercular drugs. Rifampicin, isoniazid (INH), ethambutol, and pyrazinamide (PYZ) were started. The patient started responding after 2 months of therapy and started to show signs of healing [Figure 1]. Anti-tubercular medicines were continued for 1 year. Her perianal lesion healed completely but with significant anal stenosis. Serial Hegar dilations were done over a period of several weeks while she was still on anti-tubercular medications. Eventually, sufficient dilation was achieved to admit 20 G Hegar dilator [Figure 2]. Ileostomy was reversed after the completion of anti-tubercular medications. She had few episodes of urgency but remained continent and did not need diapers. She has completed her 3½ years of follow-up and has no recurrence. Her suprapubic lesions also have healed.
Figure 1: Case 1 – Perianal skin destruction and seton

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Figure 2: Case 1 – Healed perianal skin after 6 months of anti-tubercular treatment with anal stenosis

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Case 2 is a 38-year-old gentleman who was admitted with pain in the perianal region and was diagnosed to have perianal abscess [Figure 3]. He had undergone perianal abscess drainage outside our hospital, but it recurred within 2 weeks. An examination under anesthesia was performed and the abscess was drained. A draining seton was placed. He persisted with pain and was taken to the operating room. A fistulectomy was performed and a fistula tract was sent for biopsy. Biopsy revealed epithelioid cell granulomas and Langerhans type giant cells. Stain for AFB was negative. His fistulous tract did not show any signs of healing for 2 months. His Mantoux test was reactive. Finally, anti-tubercular medication with four drugs was started (rifapicin, INH, PYZ, and ethambutol). His anti-tubercular medication was continued for 1 year. He responded well to the medication, and his fistula healed completely. After 3 years of follow-up, he is free of recurrence.
Figure 3: Case 2 – Tubercular anterior high anal fistula

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  Discussion Top


TB of the GIT constitutes 1%–3% of all cases of TB. It may involve any part of the gastrointestinal system, which may be the peritoneum, mesentery, stomach, duodenum, ileocecal region, colon, rectum, and anus. The most common form of abdominal TB is peritoneal. However, the ileocecal region the most frequently involved site of intestinal tract which may linked to intestinal content transit time which is very slow at the terminal ileum because of ileocecal valve and more numbers of the lymphatics in the region. The presentation varies depending on the region of the GIT involved.

Perianal TB may manifest in various forms such as anorectal abscess, chronic nonhealing fistula-in-ano, hemorrhoid thrombosis, and very rarely as anal stenosis. The usual presentation may be anal pain, discharge, ulceration, multiple fistulous opening, low-grade fever, and cough. Pathogenesis postulated may be by hematogenous spread from the primary lung infection and ingestion of the bacilli from the sputum in active primary lung disease which may lodge in the anal or perianal tissue through minor abrasion, sometimes direct spread or through the lymphatics from the infected nodes.[5],[6],[7],[8]

J. M. Findlay has described five types of anal and perianal TB, which may be of ulcerative, verrucous, lupoid, military, and fissure forms. Ulcerative type is the most common form of perianal TB.

The differential diagnosis could be bacterial, viral, parasitic, malignancy, Crohn's disease, secondary to trauma, secondary to radiation therapy, or hidradenitis suppurativa. It may occur secondary to surgical interventions such as hemorrhoidectomy, sphincterotomy, and episiotomy.[9],[10],[11]

However, Crohn's disease and TB fistula are very difficult to differentiate clinically and even on HPE because of the similarity in the presentation and HPE, such as nonhealing fistula-in-ano and granulomas on HPE. Pathological differentiation is very difficult if there is no evidence of caseation and AFB. Hence, other measures such as PCR and colonoscopic evaluation can help to make accurate diagnosis.[12]

The diagnosis of perianal TB is a difficult task. A high level of clinical suspicion along with bacteriological evidence and histopathological evidence is important before making the diagnosis of tuberculous fistula-in-ano. Use of tuberculin test for the diagnosis is unreliable. A negative Mantoux test in a nonimmune compromised with normal chest X-ray patient makes the diagnosis of tuberculous fistula highly unlikely. However, the positive tuberculin test has less significance. Considering the fact, the value of tuberculin test is limited in adults in India as about 40% of the adult population is infected with TB. The test has a poor positive predictive value for current active disease.[13],[14],[15]

The diagnosis is usually dependent on microscopic detection using Ziehl–Neelsen stain and mycobacterial culture,[7] but the sensitivity and specificity of these two methods are low.[16],[17]

Other tests such as PCR testing using pus and tissue specimen, which detect the DNA of TB bacilli, may be useful in the rapid detection of the TB infection. However, it has low sensitivity which requires multiple sampling to overcome the problem. Other nucleic acid amplification tests such as gene Xpert MTB/RIF assay can also be used for the rapid diagnosis.[18],[19]

Histological examination of the excised fistula is very important for the diagnosis of anal TB. The histopathological features include epithelioid granulomas and giant cell caseation necrosis.[20]

Treatment of tuberculous fistula includes both surgical and medical treatment in the form of anti-tubercular drugs, also antibiotics. Surgical intervention may include drainage of abscess, fistulotomy with or without marsupialization of the tract, and fistulectomy. For high and complex fistula-in-ano, seton tie may be required so as to avoid the anal sphincter damage. In the case of severe perianal sepsis, diversion stoma may be required.[5],[6],[9],[11],[16],[17],[21]

In one of our patients, diversion stoma was done in the form of loop ileostomy and the other patient was managed without the need for diversion stoma.

Conventional anti-tubercular drugs should be continued along with surgical intervention for at least 1 year.

Our patient had been under anti-tubercular treatment for 1 year, which led to complete healing of the fistulae in both.[22],[23]


  Conclusion Top


Although perianal TB is a rare disease, clinical suspicion is most important in diagnosing and adequate treatment. Histopathology provides supportive diagnosis but may not be conclusive. Patients recover fully after taking anti-tubercular medications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to thank Sujata Parde for editing the fonts and formatting the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Expert MTB/RIF Assay for the Diagnosis of Pulmonary and Cardiopulmonary TB in Adults and Children. Policy Update. Geneva: World Health Organization; 2013.  Back to cited text no. 15
    
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Ionization O, Jawan M, A so S. A case of tuberculous anal fistula complicated by pulmonary tuberculous. Karakul 1994;69:689-92.  Back to cited text no. 16
    
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Ohse H, Ishii Y, Saito T, Watanabe S, Fukai S, Yanai N, et al. A case of pulmonary tuberculosis associated with tuberculous fistula of anus. Kekkaku 1995;70:385-8.  Back to cited text no. 17
    
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Lee JY. Diagnosis and treatment of cardiopulmonary tuberculosis. Tuber Aspire Dis 2015;78:47-55.  Back to cited text no. 18
    
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Menezes N, Waingankar VS. Solitary rectal ulcer of tuberculous origin (a case report). J Postgrad Med 1989;35:118-9.  Back to cited text no. 19
[PUBMED]    
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Le Bourgeois PC, Poniard T, Modal J, Archery C, April MF, Kaput JC. Keri-anal ulceration. Tuberculosis should not be overlooked. Precise Med 1984;13:2507.  Back to cited text no. 20
    
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Barker JA, Conway AM, Hill J. Supranational fistula-in-Kano in tuberculosis. Collectable Dis 2011;13:210-4.  Back to cited text no. 21
    
22.
Standards for TB Care in India. New Delhi: Country Office for India. World Health Organization; 2014.  Back to cited text no. 22
    
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Revised National TB Control Programme, Technical and Operational Guidelines for Tuberculosis Control in India 2016. New Delhi: Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2016.  Back to cited text no. 23
    


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