A 37-year-old Iranian male patient was admitted to the Shohadaye Ashayer Hospital, Khorramabad, Iran, in 2016 with the complaints of weakness, anorexia, fatigue, weight loss along with fever and chills. The fever was dramatically exacerbated at nights and it was accompanied with sweating, dyspnea, and nonbloody sputum. The patient had been bothered by anal pain and discharge. The symptoms had started 7 days prior to his referral to the hospital. The patient added that all of the above-mentioned symptoms emerged a week (2 weeks before his referral to the hospital) after he had undergone anal fistula surgery and pilonidal sinus surgery due to rectal bleeding that had lasted for 9 months. He had also lost weight up to 12 kg over the previous 5 months. He had received antimicrobials and analgesia in the aftermath of his anal surgery, including metronidazole, ciprofloxacin and acetaminophen. The patient had a history of smoking, opium use and IV drug injection. Historically, he was not known to be immunocompromised and had no close contact with a case of tuberculosis.
On physical examination, he was fully alert and conscious and could actively participate in a conversation. His vital signs were as follows: temperature: 37.9C, heart rate: 86 beats/min, blood pressure: 100/70 mm/Hg, and respiratory rate: 18 breaths/min. In general, he seemed well. Thoracic and abdominal examinations were completely normal, respiratory and cardiac sound were normal and jugular venous pressure was not raised, nor was any lymphadenopathy detected. On the examination of the anus, anal erythema and swelling as well as discharge near the site of surgery were observed.
Standard blood tests are shown in Table 1. A PPD was negative. He was found be HIV antibody positive as well as anti hepatitis C positive. Chest X-ray did not reveal any abnormalities and the CT of the chest was also negative. The CT scan of the abdomen/pelvis with contrast revealed thickening of the rectum (Fig. 1). A colonoscopy revealed grade 2 internal hemorrhoids, many small aphthous ulcers in the rectum and normal sigmoid and descending colon (Fig. 2, Fig. 3). An AFB stain of the ulcers was negative. The biopsy showed chronic granulomatous proctitis (Fig. 4). Staining was positive for acid fast bacilli. The patient was then begun on standard four drug therapy for TB. The cultures for TB were positive and his symptoms and lesions healed.