IDIOPATHIC AND RAPIDLY PROGRESSIVE PERINEAL DESTRUCTION IN A PATIENT WITH ACQUIRED IMMUNODEFICIENCY SYNDROME

Case Presentation A 29-year-old man living with HIV presented to our outpatient clinic with a one-year history of a perianal nodule, hematochezia, and anal pain with discharge. Over the past six months, his condition progressively worsened, requiring three drainages of perianal abscesses, two fistulotomies with seton placement in the operating room, and prolonged antibiotic therapy, none of which resulted in complete healing. He developed fecal incontinence and subsequently underwent ileostomy creation. Since the stoma procedure, the anal lesion progressed rapidly, accompanied by refractory pain, difficulty sitting and walking, erectile dysfunction, and urine leakage through the perineum. The patient reported unintentional weight loss of 35 kg over one year and the development of inguinal lymphadenopathy. Proctological examination under anesthesia revealed an open pelvic cavity, the rectum opening into the perineum, the urethra transected at the prostate level, and surgical absence of the sphincter apparatus. A urinary catheter was inserted through the perineum, and multiple biopsies (including inguinal lymph nodes) were performed, though no definitive diagnosis was established. The patient was placed on systemic antibiotic therapy and received intensive care for the perineal wound, which showed partial granulation.

Discussion The perineal region can be affected by severe and advanced malignancies or by infectious diseases that may progress to deep involvement and complete tissue destruction. Squamous cell carcinoma, although rare, has seen a global increase in incidence, particularly among individuals living with HIV, and was our primary diagnostic suspicion in this patient. In 30–40% of cases, inguinal lymph node involvement is observed, as seen in this case. In addition to physical examination findings, biopsy is crucial for histological confirmation. In this case, biopsies were inconclusive, and the treatment aimed to promote wound healing through urinary diversion, intestinal bypass, antibiotic therapy, and intensive local care.

Conclusion The perineal region can harbor severe lesions, especially in immunocompromised patients. Even without a definitive diagnosis, prompt treatment is essential to control infection and encourage wound healing.

 

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Artikel online veröffentlicht:
25. April 2025