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1</a>A&#41;&#46; The patient presented no other skin lesions in the area or in other skin folds and reported no gastrointestinal discomfort&#46; An ultrasound examination was performed using a high-resolution probe &#40;Esaote Mylab Class C&#44; 18<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#44; which showed a broad hypoechoic band connecting the skin lesion with the anal canal&#44; with no associated abscesses&#46; Color Doppler mode revealed no vascularization &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; These findings suggested a diagnosis of primary perianal fistula and we requested a perianal transcutaneous ultrasound examination &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and a magnetic resonance imaging study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#59; the patient was referred to general surgery for surgical treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The second patient was a 32-year-old man who was referred to our department from the emergency department to rule out HS&#46; The patient presented an indurate plaque on the left buttock that had appeared 6 months earlier in addition to 2 erosive and exudative nodules &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The patient presented no other skin lesions in the area or in other skin folds&#46; The ultrasound examination revealed a broad hypoechoic subcutaneous band connecting the visible cutaneous orifice with the skin of the perianal region &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; He also presented associated local thickening of the dermis&#44; dilation of the hair follicles&#44; and a positive color Doppler study of the periphery&#46; In light of the suspected diagnosis of perianal fistula as a form of presentation of HS&#44; we recommended treatment with infiltration of triamcinolone acetonide and follow-up in the dermatology department&#46; A magnetic resonance imaging study confirmed the subcutaneous path of the fistular tract&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Primary perianal fistulas originate with an abscess in the anal crypts&#59; their pathogenesis has not been clearly established&#46; They appear in young adults &#40;mostly men&#41; and require no further studies when they present as a single episode&#46; Magnetic resonance imaging is currently the gold-standard examination for diagnosing and classifying these entities&#44; which makes it possible to plan surgical treatment that conserves sphincter function and prevents recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; perianal fistulas may also constitute the onset or complication of CD or HS and these diseases should be ruled out in patients who repeatedly present with these fistulas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Twenty percent of patients with CD present perianal involvement&#44; with complex fistulas that occasionally show branching paths that run through deep anatomical structures from the perineal skin&#44; passing through sphincters to the anal canal&#44; and may form collections of fluid in their path&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> Perianal fistulas are highly invalidating and respond poorly to medical treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Involvement of the perianal and gluteal region in HS is not infrequent&#44; particularly in men and in the LC3 phenotype of the Canoui-Poitrine classification&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> According to some studies&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> the disease may be complicated with perianal fistulas in as much as 9&#37; of cases&#46; These are superficial fistulas with single simple paths between the skin of the region and the lower end of the anal orifice&#44; below the pectinate line&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> As well as the path of the fistula&#44; ultrasound will reveal other changes characteristic of HS&#44; such as thickening of the dermis and the subcutaneous cellular tissue&#44; dilated follicles&#44; and hypoechoic collections&#44; which facilitate the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Presence of these fistulas indicates severe HS and a multidisciplinary approach is required&#44; although local medical treatments may be tried prior to surgical excision&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Recent studies<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> suggest that endoanal ultrasound and transcutaneous perianal ultrasound may be the examinations of choice&#44; as they are accessible and minimally invasive techniques that make it possible to accurately determine the path of the fistula&#46; An ultrasound study is essential in patients who present with perianal&#44; perineal or gluteal lesions similar to those we describe&#59; together with the patients&#8217; medical history&#44; this will guide the diagnosis and the appropriate therapeutic approach&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Diagnostic and Therapeutic Implications of Ultrasound Imaging of Perianal Fistulous Tracts in Patients with Suspected Hidradenitis Suppurativa
Repercusión diagnóstica y terapéutica del estudio ecográfico en los trayectos fistulosos perianales en pacientes con sospecha de hidradenitis supurativa
A. Gómez-Zubiaura,
Corresponding author
agomezubiaur@gmail.com

Corresponding author.
, F. Alfagemeb, E. Martínez-Lorenzoc, G. Roustánb
a Servicio de Dermatología y Venereología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
b Servicio de Dermatología y Venereología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
c Servicio de Dermatología y Venereología, Complejo Hospitalario de Toledo, Toledo, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">fistula</span> is defined as an abnormal or surgically made passage between a hollow or tubular organ and the body surface&#44; or between 2 hollow or tubular organs&#46; A perianal fistula connects the anal canal and the skin of the perineum&#46; The fistulas may follow different paths through the structures of this anatomical region and can be classified&#44; according to Parks&#44; as intersphincteric&#44; trans-sphincteric&#44; suprasphincteric&#44; and extrasphincteric fistulas&#46; Moreover&#44; some authors identify a fifth group of fistulas called <span class="elsevierStyleItalic">superficial fistulas</span>&#44; which run from the lower end of the anal canal to the skin of the perineum&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Perianal fistulas are more common in men&#44; with peak incidence between the third and fifth decades of life&#46; They manifest in the skin of the perianal region&#44; perineum or buttocks as an orifice or violaceous&#44; indurate&#44; painful nodule that drains serosanguinous matter&#46; They may be primary &#40;primary cryptogenic fistulas&#41; or appear secondary to Crohn disease &#40;CD&#41; or hidradenitis suppurativa &#40;HS&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report on 2 patients with no history of CD or HS&#44; both with indurate violaceous lesions in the perineal region&#44; which drained serosanguinous matter&#59; the ultrasound study provided the definitive diagnosis and indicated the therapeutic approach&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The first case was a 73-year-old man who was referred to our department from general surgery owing to suspected HS&#46; He presented an indurate nodule on the left side of the perineum that was painful on palpation and had appeared a year earlier &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; The patient presented no other skin lesions in the area or in other skin folds and reported no gastrointestinal discomfort&#46; An ultrasound examination was performed using a high-resolution probe &#40;Esaote Mylab Class C&#44; 18<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#44; which showed a broad hypoechoic band connecting the skin lesion with the anal canal&#44; with no associated abscesses&#46; Color Doppler mode revealed no vascularization &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; These findings suggested a diagnosis of primary perianal fistula and we requested a perianal transcutaneous ultrasound examination &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and a magnetic resonance imaging study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>b&#41;&#59; the patient was referred to general surgery for surgical treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The second patient was a 32-year-old man who was referred to our department from the emergency department to rule out HS&#46; The patient presented an indurate plaque on the left buttock that had appeared 6 months earlier in addition to 2 erosive and exudative nodules &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The patient presented no other skin lesions in the area or in other skin folds&#46; The ultrasound examination revealed a broad hypoechoic subcutaneous band connecting the visible cutaneous orifice with the skin of the perianal region &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; He also presented associated local thickening of the dermis&#44; dilation of the hair follicles&#44; and a positive color Doppler study of the periphery&#46; In light of the suspected diagnosis of perianal fistula as a form of presentation of HS&#44; we recommended treatment with infiltration of triamcinolone acetonide and follow-up in the dermatology department&#46; A magnetic resonance imaging study confirmed the subcutaneous path of the fistular tract&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Primary perianal fistulas originate with an abscess in the anal crypts&#59; their pathogenesis has not been clearly established&#46; They appear in young adults &#40;mostly men&#41; and require no further studies when they present as a single episode&#46; Magnetic resonance imaging is currently the gold-standard examination for diagnosing and classifying these entities&#44; which makes it possible to plan surgical treatment that conserves sphincter function and prevents recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; perianal fistulas may also constitute the onset or complication of CD or HS and these diseases should be ruled out in patients who repeatedly present with these fistulas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Twenty percent of patients with CD present perianal involvement&#44; with complex fistulas that occasionally show branching paths that run through deep anatomical structures from the perineal skin&#44; passing through sphincters to the anal canal&#44; and may form collections of fluid in their path&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> Perianal fistulas are highly invalidating and respond poorly to medical treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Involvement of the perianal and gluteal region in HS is not infrequent&#44; particularly in men and in the LC3 phenotype of the Canoui-Poitrine classification&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> According to some studies&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> the disease may be complicated with perianal fistulas in as much as 9&#37; of cases&#46; These are superficial fistulas with single simple paths between the skin of the region and the lower end of the anal orifice&#44; below the pectinate line&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> As well as the path of the fistula&#44; ultrasound will reveal other changes characteristic of HS&#44; such as thickening of the dermis and the subcutaneous cellular tissue&#44; dilated follicles&#44; and hypoechoic collections&#44; which facilitate the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> Presence of these fistulas indicates severe HS and a multidisciplinary approach is required&#44; although local medical treatments may be tried prior to surgical excision&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Recent studies<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> suggest that endoanal ultrasound and transcutaneous perianal ultrasound may be the examinations of choice&#44; as they are accessible and minimally invasive techniques that make it possible to accurately determine the path of the fistula&#46; An ultrasound study is essential in patients who present with perianal&#44; perineal or gluteal lesions similar to those we describe&#59; together with the patients&#8217; medical history&#44; this will guide the diagnosis and the appropriate therapeutic approach&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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ISSN: 15782190
Original language: English
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