Beware the perianal granuloma! A case report.

Background: Crohn's disease (CD) can often present initially with extraintestinal manifestations and/or perianal disease. Cytology of such a lesion helps arrive at the diagnosis.

Case: A 27-year-old woman presented 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 suppurative background. The possibility of tuberculosis vs. extraintestinal manifestation of CD was considered. Endoscopic 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 revealed chronic inflammation, aphthous ulcers and microgranulomas, 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 possibilities.