Beware the perianal granuloma! A case report

Background: Crohn's disease (CD) can often present initially with ex-traintestinal manifestations and/or perianal disease. Cytol-ogy oft such a lesion helps arrive at the diagnosis. Case: A 27'-year-old woman pre-sented with recurrent, painful, discharging perianal lesions. On examination, multiple perianal abscesses, sinuses, skin tags and healed scars were noted. Fine needle aspiration cytology (FNAC) of the perianal lesions performed as a first line investigation revealed epithelioid granulomas in a sup-purative background. The possibility of tuberculosis vs. ex-traintestinal manifestation of CD was considered. Endo-scopic studies revealed involvement of distal ileum and the entire colon by deep, serpiginous ulcers, internal fistulae and a distorted ileocecal valve. Biopsy of the intestinal lesions re-vealed chronic inflammation, aphthous ulcers and micro-granulomas, favoring a diagnosis of CD. Conclusion: A granulomatous lesion in any location arouses the clinical suspicion of tuberculosis, given its prevalence in the Indian subcontinent. In view of the increasing incidence of CD in our setting, the finding of a perianal, granulomatous lesion on cytology should prompt a workup for CD in addition to the more common granulomatous counterpart, tuberculosis. Perianal aspiration is an underused diagnostic procedure that can help in narrowing the differential diagnostic possi-bilities.