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Perianal ulcer

1999; Elsevier BV; Volume: 353; Issue: 9167 Linguagem: Inglês

10.1016/s0140-6736(05)75085-6

1474-547X

JFGM Meis, Harry van Goor, Paul E. Verweij,

Parasites and Host Interactions

Matthias Schmid and colleagues (March 13, p 894)1Schmid ML McKendrick MW Lobo A Leach M A perianal ulcer.Lancet. 1999; 353: 894Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar report a patient with leishmaniasis who had a chronic granulomatous perianal ulcer that was initially mistaken for Crohn's disease and which worsened with steroids. We draw your attention to another imported disease, histoplasmosis, which can also present as a perianal ulcer and be confused with Crohn's disease.2Koot RAC Van Uum SHM Naber AHJ Meis JFGM Gegeneraliseerde histoplasmose door endogene reactivering van een latente infectie bij een HIVseronegatieve man.Ned Tijdschr Geneeskd. 1995; 130: 1454-1456Google Scholar A retired Dutch man aged 63 years presented with a 6-month perianal ulcer. Local therapy was ineffective and subsequent colonoscopy showed another ulcer in the sigmoid colon. Biopsy samples of both ulcers were histologically consistent with Crohn's disease but he did not improve on steroids and mesalazine. During several weeks he lost 20 kg in weight and developed pyrexia. It transpired after thorough and comprehensive history that he had stayed for 3 months Honduras 2 years earlier. Routine blood cultures were negative, as were HIV serological tests. A diverting colostomy was constructed in attempt to heal the ulcer. In the postoperative phase he went into hypovolaemic shock from gastrointestinal bleeding, which proved fatal. At necropsy there were generalised granulomatous lesions adrenal glands, kidneys, liver, spleen, lungs, myocardium, lymph nodes, and bone marrow, within which intracellular micro-organisms consistent with Histoplasma, Leishmania, or Toxoplasma spp were seen but which proved to Histoplasma capsulatum on culture. In retrospect, this case may well have been endogenous reactivation histoplasmosis originally contracted Honduras. Re-examination of the original biopsy samples of the perianal ulcer with a silver stain showed that intracellular microorganisms consistent with Histoplasma spp were present. Thus, the diagnosis of refractory perianal ulcers should include silver staining of biopsy material and preferably fungal culture, especially when indicated by a history of travel to endemic areas.