Perianal ulcers in a human immunodeficiency virus-seropositive man

Abstract

A 44-year-old man infected with human immunodefi ciency virus presented with 1-month history of fever, night sweats, weight loss, and two perianal ulcerations. He had a history of primary syphilis and pulmonary tuberculosis and underwent complete treatment for both diseases. He had never been administered highly active antiretroviral therapy. Physical examination showed a large submaxillary lymphadenitis, two perianal ulcers with indurated erythematous margins and exophytic verrucous lesions compatible with condyloma acuminata or anogenital warts due to human papillomavirus ( Figure A). Initial laboratory fi ndings included anemia and high erythrocyte sedimentation (60mm/h). CD4 T-cell count was 107 cells/µL. The colonoscopy was normal and chest computed tomography showed an infiltrate compatible with miliary tuberculosis. Scarifi cation of the perianal lesions was performed; Ziehl-Neelsen stain was positive for acid-fast bacilli (AFB) ( Figure B) and Grocott's methenamine silver stain identifi ed numerous fungal intracellular organisms compatible with Histoplasma ( Figure C). A skin biopsy revealed granulomatous infi ltration with multinuclear giant cells, lymphocytes and histiocytes without necrosis. The culture of skin biopsy smears was positive for Mycobacterium tuberculosis. Direct examination and cultures of sputum, bronchoalveolar lavage and aspiration of the cervical lymph node were positive for AFB and M. tuberculosis. Treatment with the antituberculous fi rst-line drug regimen and amphotericin B resulted in rapid clinical improvement. Two months later, the perianal lesions were completely healed.Perianal lesions represent a rare form of periorificial cutaneous tuberculosis and an unusual skin manifestation of disseminated histoplasmosis and tend to occur predominantly in patients with AIDS(1) (2) (3) . 3. Kahi CJ, Wheat LJ, Allen SD, Sarosi GA. Gastrointestinal histoplasmosis. Am J gastroenterol 2005; 100;220-231.

Primary extensive perianal cutaneous tuberculosis: A challenging diagnosis. Case report and a review of the literature

“…TB is also related to immunocompromised states, as the infection occurs in cases of HIV infection and leprosy, 13 which were not observed in the patient.…”