Exceptional dissemination of perineal tuberculosis up to the right flank: a tribute to J.P. Nesselrod’s study on the anatomy of pelvic lymphatics published in 1936 in the Annals of Surgery
A 56-year-old cachectic male in poor general and hygienic condition collapsed and was subsequently admitted to hospital in a severe sepsis. The personal history was negative for preexisting intraabdominal and cardiorespiratory ailments. Recent journeys to tropical countries were denied. However, a lengthy stay at a psychiatric clinic due to alcohol abuse several years ago was noteworthy. The patient had been suffering from perineal fistula for years without any medical treatment. At admission, we found a complex of perianal and gluteal abscesses with involvement of the skin of the right lower back. The abdomen was clinically unsuspicious. The laboratory studies revealed a severe inflammatory syndrome measuring a white cell count of 30 × 109/L, CRP value of 226 mg/L, and slightly elevated procalcitonine with 0.47 μg/L.\nA CT scan revealed an extensive subcutaneous abscess on the right flank with involvement of the right iliopsoas muscle (Fig. ), the presacral space, the fossa ischiorectalis with involvement of the external sphincter, and the levator ani (Fig. ) with subcutaneous fistula in the perianal region and the adjacent right gluteus. However, no internal orifice was found by rigid rectoscopy. An endoanal ultrasound to investigate the presence of trans- or intersphincteric fistula was omitted due to the patient's bad condition. The MRI performed to analyze whether there was an involvement of vertebral bodies or an involvement of intervertebral disks was not suitable to evaluate the anal sphincter.\nThere were no particular intraabdominal findings such as significant lymphatic nodes, wall thickening of the bowel, or ascites. All findings were restricted to the extraperitoneal space.\nDespite immediate surgical drainage of the subcutaneous abscess on the right flank and in the perianal region as well as antibiotic treatment with piperacilline/tazobactam, the patient's condition showed signs of deterioration such as weight loss, hypotension, and fever. Additionally, upcoming perianal abscesses were surgically evacuated, and the presacral space was partially drained initially by CT-guided puncture and finally emptied by open surgery over an extraperitoneal right–anterior access to the right iliopsoas muscle. The drained perianal wounds did not show any signs of healing and continued to produce serous turbid secretion. Crohn's disease was suspected early, but not confirmed in an ileocolonoscopy. The microbial culture from the wound secretion demonstrated growth of Streptococcus intermedius, whereas the surgically obtained specimens from the right presacral abscess evolved to be sterile. Serological screening for syphilis and HIV was negative. In a histological sample from the perineal region, tuberculoid granuloma was found, while an interferon gamma release assay (Quantiferon Gold) in the blood was positive. The patient did not suffer from any pulmonary symptoms, but a CT scan of the chest showed reticulonodular infiltrates typically suggestive of pulmonary tuberculosis. Microscopy of the sputum was negative for acid-fast bacilli, but the culture of surgical probes from the perineum and the retroperitoneal space finally became positive for Mycobacterium tuberculosis about 1 month after admission. The patient was prescribed a classic tuberculostatic treatment combining rifampin, isoniazid, pyrazinamide, and ethambutol. We observed a rapid healing of the wounds, a significant increase of the patient's body weight, and recovery of the general condition.