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CASE REPORT
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 138-139

Recurrent pilonidal sinus with mycobacterial infection: Implications


Department of General Surgery Unit-II, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission18-Oct-2019
Date of Decision23-Nov-2019
Date of Acceptance24-Nov-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Dr. Gigi Varghese
Department of General Surgery Unit II, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_46_19

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  Abstract 

Pilonidal sinus disease is a chronic inflammatory disease classically found in the sacrococcygeal region. We describe a rare case of pilonidal disease associated with mycobacterial infection which resolved only after appropriate surgery and adequate antimycobacterial therapy.

Keywords: Mycobacterium, pilonidal sinus, recurrent, surgery, tuberculosis


How to cite this article:
Kalipatnapu S, Varghese G. Recurrent pilonidal sinus with mycobacterial infection: Implications. Curr Med Issues 2019;17:138-9

How to cite this URL:
Kalipatnapu S, Varghese G. Recurrent pilonidal sinus with mycobacterial infection: Implications. Curr Med Issues [serial online] 2019 [cited 2020 Jan 22];17:138-9. Available from: http://www.cmijournal.org/text.asp?2019/17/4/138/272804




  Introduction Top


First described by Mayo in 1833, pilonidal sinus disease is a disease spectrum involving chronic draining abscesses and sinuses, classically described in the sacrococcygeal region. It is commonly seen in adults in their second and third decades of life. Uncommon locations of this disease include the interdigital areas on the hands, umbilicus, chest wall, ear, and scalp.[1] Although there are many theories, the definitive etiology of pilonidal disease continues to be elusive. It is postulated to be due to the foreign body reaction generated by the penetration of the skin by hair shafts.[2] Pilonidal sinus associated with mycobacterial infection is a rare presentation, with only one case having been reported in English literature.[3]

Case Presentation

A 21-year-old male with no known medical comorbidities had presented with complaints of persistent pus discharge from multiple openings in the lower back for 3 months. There was no history of altered bowel habits or symptoms suggestive of gastrointestinal bleeding. Digital rectal examination and proctoscopy were normal. He was diagnosed to have pilonidal sinus disease and underwent excision of the same. Following the surgery, he was initially well. He later developed pus discharge from the operated site and had presented to the outpatient clinic 1.5 years following the first operation. On examination, there was a pus discharging sinus in the midline 6 cm above the gluteal cleft with a fluctuant abscess over it. He then underwent incision and drainage of the abscess, and samples were sent for histopathology and culture/sensitivity. The histopathology sample taken from the second surgery showed discrete and confluent granulomas with Langhans giant cells with foci of incipient necrosis, suggestive of tuberculosis. A concurrent tissue sample grew Mycobacterium species. Concurrent chest X-ray was normal. He did not have any symptoms suggestive of bone or gastrointestinal mycobacterial infection. He was advised empiric antitubercular treatment in consultation with infectious disease specialists for 6 months, and he was compliant with the same. After completion of the antitubercular therapy, he underwent local excision of the area, including the sinus and all its tracts [Figure 1]. Following the third surgery, he did not have any immediate postoperative complications and the wound healed completely. Follow-up at 2 years revealed that he was asymptomatic and had not developed any recurrence [Figure 2].
Figure 1: Photograph of the surgical site in the immediate postoperative period.

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Figure 2: Photograph at 2-year follow-up with no evidence of recurrence.

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  Discussion Top


Clinical presentation of pilonidal sinus depends on the duration of the disease process. Male gender, hirsute individuals, Caucasians, sitting occupations, deep natal cleft, presence of hair within the natal cleft, obesity, and local trauma have been described to increase the risk of pilonidal sinus. Histopathological examination of excised specimens has demonstrated abscesses and sinus cavities lined by chronic granulomatous tissue with foreign body giant cells centered around hair shafts.[2]

Mycobacterium is a genus of slow-growing bacteria, leading to the development of chronic granulomatous inflammation, affecting virtually all organs and organ systems. As mycobacterial infection can mimic other disease conditions, diagnosis should be based on either histopathological evidence or culture. Initiation of appropriate treatment based on culture and sensitivity is necessary for resolution of the infection.[2]

Pilonidal sinus disease requires excision of the sinuses with appropriate reconstruction. However, this should only be done after completion of adequate antibiotic regimen.[2] Due to the significant side effects of the treatment, it is imperative to confirm the presence of mycobacterial infection as it can be confused on histopathology with other causes of granulomatous inflammation.[4] Facilitated discussions between pathologists and microbiologists with added inputs from infectious disease consultants will aid in the treatment of this condition.

Potential implications of this association include cases of recurrent pilonidal sinus where there would be no resolution of the condition without adequate antibiotics in addition to surgery. It would be prudent on the part of the surgeon to test for this association in patients who have a prior history of tuberculosis or contact with tuberculosis/other mycobacterial infections.


  Conclusions Top


  • Mycobacterial infection presents as chronic inflammatory conditions and can affect any organ system
  • It is important to acknowledge and be aware of this association in the appropriate clinical setting, especially in endemic countries
  • A high index of suspicion is required to diagnose tuberculosis in recurrent/atypical presentations of pilonidal sinus.
  • Adequate operative management and timely appropriate antitubercular therapy should be ensured for complete resolution of the disease.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interes



 
  References Top

1.
Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82:1169-85.  Back to cited text no. 1
    
2.
Gupta PJ. Pilonidal sinus disease and tuberculosis. Eur Rev Med Pharmacol Sci 2012;16:19-24.  Back to cited text no. 2
    
3.
Gupta PJ. Tubercular infection in the sacrococcygeal pilonidal sinus-a case report. Int Wound J 2008;5:648-50.  Back to cited text no. 3
    
4.
Tanwar R, Rathore KV, Jain S, Gora NK. Tubercular etiology in a pilonidal sinus of the forehead: Truth or myth? J Wound Care 2014;23:S13-5.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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