Case and Research Letter
Patient with disseminated tuberculosis and rare perianal involvement
Paciente con tuberculosis diseminada y un raro compromiso perianal
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Uribe-Bojanini, C. Santa-Vélez, A. Ruiz-Suarez, N. Buchely-Ibarra" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Uribe-Bojanini" "email" => array:1 [ 0 => "uribe.esteban@uces.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Santa-Vélez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Ruiz-Suarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "N." "apellidos" => "Buchely-Ibarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Dermatology Department, Universidad CES, Medellin, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital General de Medellin, Medellin, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Dermatopathology Department, Universidad CES, Medellin, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paciente con tuberculosis diseminada y un raro compromiso perianal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 762 "Ancho" => 995 "Tamanyo" => 159529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the perianal lesion. (A) Prior to diagnosis. (B) After 2 months of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 59-year-old homeless male patient presented to the emergency department with a 3-month history of a rapidly enlarging, painful perianal mass associated with rectal bleeding. He also reported nocturnal sweats, fever, weight loss, and a chronic productive cough. The patient had no past medical history of note and was not on any medication, but he was a smoker and consumed marihuana on a daily basis. He stated that he had unprotected sex with occasional women, but denied anal sex.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On inspection, the patient was cachectic, with a weight of 45<span class="elsevierStyleHsp" style=""></span>kg. Physical examination revealed numerous enlarged cervical lymph nodes, some measuring over a centimeter in diameter, and chest auscultation was abnormal. In the perianal area, multiple skin-colored nodules had coalesced into a larger mass associated with a well-defined, indurated, painful, hemorrhagic perianal ulcer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Serology for HIV and hepatitis was negative, and kidney and liver function was normal. Chest X-ray and high-resolution computed tomography revealed widespread reticulonodular opacities in both lung fields (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Sputum bacilloscopy was positive for acid-alcohol-fast bacilli, confirming the diagnosis of active pulmonary tuberculosis. The GeneXpert MTB/RIF test on material from a biopsy of a cervical lymph node was positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> DNA. On colonoscopy an isolated ulcer with positive bacilloscopy for acid-alcohol-fast bacilli was discovered in the cecum. Biopsy of the perianal lesion reveled caseous necrosis and a granulomatous inflammatory process with positive bacilloscopy for acid-alcohol-fast bacilli and a GeneXpert MTB/RIF test that was positive for <span class="elsevierStyleItalic">M. tuberculosis</span> DNA, with a negative rifampicin resistance test (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Based on this information we made a diagnosis of disseminated tuberculosis (TB) with pulmonary, lymph node, intestinal, and perianal involvement. The patient started treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol daily for 2 months, followed by rifampicin and isoniazid 3 times a week for 7 months (total treatment duration, 9 months). A good response was achieved after completing the first phase, with a decrease in the size of the perianal lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and resolution of the systemic symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">M. tuberculosis</span> is an aerobic gram-positive bacillus that is a member of mycobacterium tuberculosis complex. Approximately 2 billion people, a third of the world's population, are infected by <span class="elsevierStyleItalic">M. tuberculosis</span>. Nine million new cases of active TB occur worldwide each year, leading to about 1.8 million deaths annually. The global incidence increased up to the year 2003, since which time there has been a slight fall. The incidence in Colombia is 25–35 cases per 100,000 people, this corresponds to a intermediate incidence in comparison to African countries, where 100–300 cases per 100,000 have been reported.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Extrapulmonary TB occurs in 15% of cases and can be the result of primary or reactivated TB. The organs the most commonly affected are the lymph nodes (40%), pleura (20%), urinary tract (15%), bone (10%), central nervous system (5%), and heart (3%). Multiple risk factors have been established for primary and disseminated TB, the most important of which are HIV infection (relative risk [RR], 30), hemodialysis (RR, 20), transplant (RR, 20), intravenous drugs abuse (RR, 20), and infection in the previous year (RR, 13).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> A study on mortality in TB patients in Medellin, Colombia, detected social risk factors such as homelessness, drug addiction, or having no fixed address, in 58.1%.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Gastrointestinal tract and skin involvement are very rare and have been reported in less than 1% of cases of extrapulmonary TB. Gastrointestinal TB can affect any organ of the digestive tract, but peritonitis is the most common presentation. When the intestine is compromised the infection is localized at the ileocecal valve in 85% of cases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Anal TB is a very rare condition, occurring in less than 1% of intestinal TB and in less than 0.0015% of all cases of TB. In 2008, Mathew et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> described the case of an 80-year-old patient with anal TB and reported that only 3 cases have been published in the United Kingdom. Perianal TB is categorized as periorificial cutaneous tuberculosis or tuberculosis cutis orificialis. It accounts for approximately 2% of cases of cutaneous TB. Tuberculosis cutis orificialis results from self-inoculation of <span class="elsevierStyleItalic">M. tuberculosis</span> into the periorificial oropharyngeal, anal, or genital mucosa from an initial pulmonary, intestinal, or genitourinary infection. Bacilli may reach the perianal area by hematogenous dissemination or by swallowing infected sputum. Numerous forms of anal TB have been described. The most common presentation is as an ulcerated lesion; fissures, verrucous forms, and masses have been reported in fewer cases. In 2009, Antonello et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> described the case of a 40-year-old HIV-positive patient with perianal TB that presented as an ulcerating mass, a compound lesion very similar to the finding in our patient. The patient presented by Cheon et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> in 2013 was a 46 year-old man diagnosed with Crohn disease 30 years earlier and treated with mesalazine with no improvement of his rectal ulcers. Anal TB was diagnosed and the patient presented a marked improvement after 3 months of treatment. Another case of anal TB was reported in a 42-year-old patient on Adalimumab therapy for psoriatic arthritis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The treatment of anal TB is the same as for other forms of extrapulmonary TB. Patients should receive rifampicin, isoniazid, pyrazinamide, and ethambutol daily for 2 months, followed by rifampicin and isoniazid 3 times a week for 7 months (total treatment time, 9 months).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In order to prevent the appearance of active tuberculosis, the Centers for Disease Control and Prevention advocates targeted screening and treatment of latent tuberculosis infection with 9 months of isoniazid. A newer regimen of weekly combined therapy with isoniazid and rifapentine for 12 weeks was cost-effective in directly observed therapy programs, particularly for populations that would not otherwise complete therapy and are at high risk for conversion to active disease, such as homeless patients.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 762 "Ancho" => 995 "Tamanyo" => 159529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the perianal lesion. (A) Prior to diagnosis. (B) After 2 months of treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 663 "Ancho" => 1599 "Tamanyo" => 143357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray and high-resolution computed tomography showing widespread bilateral reticulonodular opacities.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 741 "Ancho" => 990 "Tamanyo" => 320978 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Biopsy of the perianal lesion showing caseous necrosis and a granulomatous inflammatory process. Hematoxylin and eosin, original magnification ×40. (B) Positive bacilloscopy for acid-alcohol-fast bacilli.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The WHO 2014 global tuberculosis report—further to go" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Zumla" 1 => "A. George" 2 => "V. Sharma" 3 => "R.H.N. Herbert" 4 => "A. Oxley" 5 => "M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 1 | 6 |
| 2024 Octubre | 34 | 45 | 79 |
| 2024 Septiembre | 52 | 26 | 78 |
| 2024 Agosto | 60 | 52 | 112 |
| 2024 Julio | 47 | 25 | 72 |
| 2024 Junio | 72 | 34 | 106 |
| 2024 Mayo | 56 | 28 | 84 |
| 2024 Abril | 62 | 20 | 82 |
| 2024 Marzo | 47 | 27 | 74 |
| 2024 Febrero | 37 | 26 | 63 |
| 2024 Enero | 33 | 30 | 63 |
| 2023 Diciembre | 42 | 17 | 59 |
| 2023 Noviembre | 47 | 26 | 73 |
| 2023 Octubre | 33 | 15 | 48 |
| 2023 Septiembre | 35 | 23 | 58 |
| 2023 Agosto | 35 | 14 | 49 |
| 2023 Julio | 52 | 27 | 79 |
| 2023 Junio | 33 | 24 | 57 |
| 2023 Mayo | 39 | 21 | 60 |
| 2023 Abril | 39 | 17 | 56 |
| 2023 Marzo | 40 | 17 | 57 |
| 2023 Febrero | 36 | 23 | 59 |
| 2023 Enero | 33 | 26 | 59 |
| 2022 Diciembre | 42 | 34 | 76 |
| 2022 Noviembre | 38 | 38 | 76 |
| 2022 Octubre | 55 | 26 | 81 |
| 2022 Septiembre | 47 | 36 | 83 |
| 2022 Agosto | 90 | 41 | 131 |
| 2022 Julio | 87 | 42 | 129 |
| 2022 Junio | 48 | 24 | 72 |
| 2022 Mayo | 67 | 30 | 97 |
| 2022 Abril | 69 | 43 | 112 |
| 2022 Marzo | 47 | 52 | 99 |
| 2022 Febrero | 30 | 21 | 51 |
| 2022 Enero | 34 | 39 | 73 |
| 2021 Diciembre | 35 | 26 | 61 |
| 2021 Noviembre | 39 | 45 | 84 |
| 2021 Octubre | 39 | 57 | 96 |
| 2021 Septiembre | 35 | 33 | 68 |
| 2021 Agosto | 30 | 35 | 65 |
| 2021 Julio | 35 | 30 | 65 |
| 2021 Junio | 27 | 21 | 48 |
| 2021 Mayo | 30 | 31 | 61 |
| 2021 Abril | 50 | 55 | 105 |
| 2021 Marzo | 55 | 23 | 78 |
| 2021 Febrero | 71 | 20 | 91 |
| 2021 Enero | 24 | 21 | 45 |
| 2020 Diciembre | 28 | 18 | 46 |
| 2020 Noviembre | 31 | 21 | 52 |
| 2020 Octubre | 32 | 25 | 57 |
| 2020 Septiembre | 35 | 13 | 48 |
| 2020 Agosto | 33 | 18 | 51 |
| 2020 Julio | 45 | 16 | 61 |
| 2020 Junio | 32 | 33 | 65 |
| 2020 Mayo | 21 | 23 | 44 |
| 2020 Abril | 32 | 18 | 50 |
| 2020 Marzo | 37 | 26 | 63 |
| 2020 Febrero | 4 | 0 | 4 |
| 2019 Octubre | 1 | 2 | 3 |
| 2019 Mayo | 1 | 0 | 1 |
| 2019 Abril | 2 | 3 | 5 |
| 2019 Marzo | 1 | 0 | 1 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Agosto | 1 | 0 | 1 |
| 2018 Julio | 1 | 0 | 1 |
| 2018 Febrero | 9 | 1 | 10 |
| 2018 Enero | 17 | 16 | 33 |
| 2017 Diciembre | 15 | 9 | 24 |
| 2017 Noviembre | 9 | 10 | 19 |
| 2017 Octubre | 12 | 10 | 22 |
| 2017 Septiembre | 11 | 14 | 25 |
| 2017 Agosto | 10 | 14 | 24 |
| 2017 Julio | 14 | 16 | 30 |
| 2017 Junio | 17 | 20 | 37 |
| 2017 Mayo | 14 | 15 | 29 |
| 2017 Abril | 22 | 24 | 46 |
| 2017 Marzo | 13 | 19 | 32 |
| 2017 Febrero | 15 | 18 | 33 |
| 2017 Enero | 9 | 15 | 24 |
| 2016 Diciembre | 27 | 72 | 99 |
| 2016 Noviembre | 15 | 34 | 49 |
| 2016 Octubre | 0 | 24 | 24 |
| 2016 Agosto | 1 | 1 | 2 |
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