A 41-year-old male presented with purulent discharge and pain in the perianal region. There was no history of fever or weight loss. The patient gave a history of being operated 14 times earlier for the same complaints. Perioperative discharge showed acid-fast bacilli on Ziehl-Neelsen (ZN) stain. No pulmonary focus of tuberculosis (TB) was found. The patient was started on antitubercular treatment and has not reported any pain or discharge from the perianal region for the last 1 year. A high index of suspicion of TB should be kept in mind in perianal lesions, especially recurrent lesions, even when no primary focus is found. Surgery and medical treatment combined may be needed in such cases.
Keywords: Extrapulmonary, fistula-in-ano, fistulectomy, perianal tuberculosis, tuberculosis (TB)
|How to cite this article:
Dawar R, Jain SK, Rani H, Mendiratta L, Sardana R. Recurrent high fistula-in-ano: Think of tuberculosis!. Ann Trop Med Public Health 2016;9:273-5
|How to cite this URL:
Dawar R, Jain SK, Rani H, Mendiratta L, Sardana R. Recurrent high fistula-in-ano: Think of tuberculosis!. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Nov 26];9:273-5. Available from: https://www.atmph.org/text.asp?2016/9/4/273/184808
One-fourth of the global incident tuberculosis (TB) cases occur in India annually. In 2012, out of the estimated global annual incidence of 8.6 million TB cases, 2.3 million were estimated to have occurred in India.
Studies on extrapulmonary TB in India give a rough estimate of 10-15% of TB cases in general hospitals. Among human immunodeficiency virus (HIV)-positives, it could be around 50%.
Gastrointestinal TB ranks sixth among the extrapulmonary TB. The presenting picture may be varied with atypical and noncharacteristic features that make it difficult to diagnose preoperatively. Anorectal TB represents 2-7% of cases of fistula-in-ano from endemic areas. It is crucial to diagnose the cause of fistula-in-ano as the treatment is specific for tubercular etiology.
A 41-year-old male, resident of London, England, presented to Indraprastha Apollo Hospitals, New Delhi, India with the complaint of perianal pain and pus discharge. The patient gave a history of being operated 14 times earlier for the same and was last operated in June 2014. He was admitted for further evaluation and management.
On examination (O/E), he was afebrile, conscious, oriented; blood pressure (BP)-110/70 mg; pulse-80/min; respiratory rate-20/min; cardiac sounds S1 and S2 were normal; the chest was clear bilaterally. Per abdominal examination and central nervous system (CNS) examination were uneventful. O/E no icterus/cyanosis /pallor/clubbing were found. There was no regional lymphadenopathy.
Local examination per rectum showed anal openings with fistula diagnosed provisionally as high fistula-in-ano [Figure 1]. The patient was a known diabetic and a smoker. There was no history of weight loss.
|Figure 1: Fistula-in-ano
Click here to view
Routine blood tests were unremarkable; chest X-ray lung fields were clear.
Pus discharge peroperatively was sent for Ziehl-Neelsen (ZN) stain and it revealed acid-fast bacilli. Aerobic culture grew nonenterococcal group D Streptococcus, which is a normal flora of human feces.
Surgical pathology report of excised fistula tract revealed chronic active inflammation.
High transsphincteric fistula with extrasphincteric supralevator extension was operated 14 times elsewhere.
Indication for operation — Treatment and diagnosis
Fistulectomy for high fistula-in-ano under general anesthesia (GA) with provisional diagnosis of recurrent high complex fistula-in-ano was done. Based on the detection of acid-fast bacilli in the pus sample preoperatively, the patient was put on isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient’s wound had healed well and the patient was asymptomatic till 1 year after surgery follow-up.
Intestinal TB accounts for less than 1% of extrapulmonary cases. Anal location is still rarer.,
Anal abscess is a painful collection of pus. An anal abscess usually develops after a small gland just inside the anus becomes infected. The cause of the abscess is often unknown, although abscesses are more common in people with immune deficiencies such as HIV and acquired immune deficiency syndrome (AIDS).
If an anal abscess bursts before it has been treated, it can sometimes cause an anal fistula to develop. Additionally, a fistula may occur if an abscess has not completely healed, or if the infected fluid has not been entirely drained away.
Approximately, 30-50% of people with an anal abscess will develop an anal fistula. Around 80% of all anal fistulas develop from an infection in the anus. Fistulas may occur with much less frequency from trauma, iatrogenic perforation, after hemorrhoidectomy, infected episiotomy or repair of a fourth-degree sphincter tear during delivery, infected anal fissure, or Crohn’s disease. An anal fistula may develop as well, as a result of a complication of surgery. Fistula-in-ano is a benign perianal condition that may be due to various etiological factors like repeated perianal infections, TB, diverticulitis, hidradenitis suppurativa, cancer of the anorectum, HIV infection, Lymphogranuloma venereum, syphilis, secondary to trauma (e.g., rectal foreign bodies), radiation therapy, actinomycoses, etc. A complex variety is encountered in very few patients that require special treatment for its cure. Extrasphincteric fistulae occur in only 5% of total fistula-in-ano patients.
Clinically, the distinction between anorectal TB and Crohn’s disease may be difficult and, therefore, microbiological investigation and histology are required.
Since the 1980s, tuberculous fistulae-in-ano have been reported in India, France, Africa, Japan, Australia, Germany, Turkey, and the United Kingdom., Tuberculous fistulae-in-ano can mimic fistulae from cryptoglandular origin, inflammatory bowel disease, foreign body reaction, sarcoidosis, lymphoma, lymphogranuloma venereum amebiasis, and syphilis. Anoperineal TB is commonly seen in males (4:1 ratio) and usually starts in the fourth decade of life.
Anoperineal TB is considered an uncommon event and anorectal fistula is the most frequent presentation (up to 90% of cases), indistinguishable from those of cryptoglandular origin.
TB incidence in complex fistulae is above 60%.
Research shows that smoking increases the risk of an anal abscess or fistula. Our patient was also a chronic smoker.
Anal TB may or may not occur secondary to or coexisting with a pulmonary lesion  that may even be revealed later. There may be no pulmonary focus, which is very rare.
No pulmonary findings were present in our patient.
Demonstration of TB in culture or biopsy is most specific, although, diagnostic yield is low. Granulomas can be demonstrated in biopsies in 27% of cases and culture is positive in 36% of patients with rectal TB. In a study from Cape Town, South Africa, histopathological examination and ZN staining failed to diagnose TB in two of seven patients with anal fistula.
Out of three patients with supralevator fistula-in-ano reported in 2011 from Manchester, England, one patient was diagnosed by perianal biopsy, the second by the culture of pus and the third by sputum culture.
In a study from India of 122 patients with fistulae-in-ano operated upon in a 5-year period, 15.6% were found to have tubercular fistulae on histopathological examination. There was no characteristic clinical picture and concomitant pulmonary TB was present in only three patients. Histological examination of the excised fistula is mandatory for the diagnosis of anal TB. Shukla et al. have reported confirmed tubercular origin in 16% of the cases from India. There were no cases of Crohn’s disease of the anal region.
Unlikely ulcerative anorectal and perianal TB forms, where it is easy to determine clinical cure (clinical healing findings in response to treatment), anal fistulas with multiple/meandering paths, and complex presentation may have local TB cure difficult to determine, raising the risk of failure of definitive surgical treatment, and the consequent unfortunate recurrence.
The surgical removal of fistulas and sinuses should be both complete and considerate. It should be complete, because otherwise infected tissues, septic anal ducts, and glands draining into primary crypt openings and even tubercular or malignant lesions may be unrecognized or left in place. All patients with tubercular etiology should receive conventional anti-TB therapy (ATT) therapy for at least 6 months, including initial 2 months of rifampicin, isoniazid, pyrazinamide, and ethambutol.,,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Revised National TB Control Programme, Annual status report TB India 2014. Available from: http://www.tbcindia.nic.in. [Last accessed on 2015 Dec 07].
Wares FR. Balasubramanian R, Mohan A, Sharma SK. Extrapulmonary tuberculosis: Management and control. In: Agarwal SP, Chauhan LS, editors. Tuberculosis Control in India. Directorate General Health Services. Ministry of Health and Family Welfare. New Delhi: Elsevier; 2005. p. 95-114.
Bendjaballah A, Taieb M. Tuberculosis of rectum mimicking malignancy. A case report and review of literature. Abdominal Surgery Winter2012/Summer2013.
Oliveiraa LG, Netoa JA, Vieira E, Kim P, Flach LD, Almeida BC, et al. Proposed tuberculosis investigation and management protocol in complex and recurrent fistula-in-ano. J. Coloproctol 2015;35:113-9.
Yurt S, Filiz Kosar A, Isik N, Yaman N, Arpinar B, Yegen A. et al. Two cases of pulmonary tuberculosis with extrapulmonary involvement in tongue and anus. Respir Med Extra 2005;1:1-3.
Romelaer C, Abramowitz L. Anal abscess with a tuberculous origin: Report of two cases and review of the literature. Gastroenterol Clin Biol 2007;31:94-6.
Myers SR. Tuberculous fissure-in ano. J R Soc Med 1994;87:46.
Abcarian H. Anorectal infection: Abscess-fistula. Clin Colon Rectal Surg 2011;24:14-21.
Belekar D, Dewoolkar V, Desai A, Anam J, Parab M. An unusual case of complex transphincteric fistula-In-Ano. The Internet Journal of Surgery 2009;19:9.
Favuzza J, Brotman S, Doyle DM, Counihan TC. Tuberculous fistulae in ano: A case report and literature review. J Surg Educ 2008;65:225-8.
Harland RW, Varkey B. Anal tuberculosis: Report of two cases and literature review. Am J Gastroenterol 1992;87:1488-91.
Fulton JO, Lazarus C. Varicose anorectal tuberculosis: A case report. S Afr Med J 1987;71:108-9.
Ibn Majdoub Hassani K, Ait Laalim S, Toughrai I, Mazaz K. Perianal tuberculosis: A case report and a review of the literature. Case Rep Infect Dis 2012;2012:852763.
Sultan S, Azria F, Bauer P, Abdelnour M, Atienza P. Anoperineal tuberculosis: Diagnostic and management considerations in seven cases. Dis Colon Rectum 2002;45:407-10.
Akgun E, Tekin F, Ersin S, Osmanoglu H. Isolated perianal tuberculosis. Neth J Med 2005;63:115-7.
Samarasekera DN, Nanayakkara PR. Rectal tuberculosis: A rare cause of recurrent rectal suppuration. Colorectal Dis 2008;10:846-7.
Bhargava DK, Tandon HD, Chawla TC, Shriniwas, Tandon BN, Kapur BM. Diagnosis of ileocecal and colonic tuberculosis by colonoscopy. Gastrointest Endosc 1985;31:68-70.
Stupart D, Goldberg P, Levy A, Govender D. Tuberculous anal fistulas — prevalence and clinical features in an endemic area. S Afr J Surg 2009;47:116-8.
Barker JA, Conway AM, Hill J. Supralevator fistula-in-ano in tuberculosis. Colorectal Dis 2011;13:210-4.
Shukla HS, Gupta SC, Singh G, Singh PA. Tubercular fistula in ano. Br J Surg 1988;75:38-9.
Rosser C. Comments on the treatment of lesions resulting from anal infections. Am J Surg 1954;88:818-20.
Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res 2004;120:305-15.
Bokhari I, Shah SS, Inamullah, Mehmood Z, Ali SU, Khan A. Tubercular fistula-in-ano. J Coll Physicians Surg Pak 2008;18: 401-3.
Source of Support: None, Conflict of Interest: None