A 37-year-old male patient was admitted with a history of perianal discharge and ulceration for the last four months. According to his medical history, he was treated for a perianal abscess which was incised and drained one year ago, yet, despite the initial healing, it recurred two months later.
During the clinical examination at the admission, the patient, with a weight of 40 kg was relatively dehydrated and had tachycardia (pulse rate, 110/min). Physical examination revealed body temperature 38,5 C, and arterial pressure of 09/06 mmhg. No lymphadenopathy was found on palpation; in addition abdominal examination revealed a generalized tenderness. 
The perianal region examination showed large bilateral infected ulcerations followed by pus (Figure 1). The digital rectal one revealed no pathological findings except a slight sphincter hypotonia. Anoscopy was normal and no fistulas were noted. The rectosigmoidoscopy showed no abnormalities as well. 
Laboratory investigations showed a hemoglobin level of 09.3 g/dL, a raised white blood cell count of 12,300/muL in addition to high C-reactive protein and elevated erythrocyte sedimentation rate of 50 mm/h. The other laboratory data were within normal limits.
The abdominal X-ray revealed bilateral nonhomogenous infiltrations and cavitary lesions in the right lung (Figure 2). A contrast-enhanced computed tomography scan of the abdominal and pelvic region showed multiple mesenteric and retroperitoneal necrotic adenopathies (Figure 3). The patient was taken to the operating room where a diagnostic laparoscopy was performed and thus showed a thickened and hyperemic peritoneum with Multiple and yellowish white granulations diffusely distributed on the parietal peritoneum and the omentum. Multiple mesenteric adenopathies were noted too. Multiple biopsies of the peritoneum granulations and a diverting sigmoidostomy were performed. 
The perianal lesion was cured and biopsy material was taken. Histological examination of all biopsies showed epithelioid granulomas and Langhans' type multinucleated giant cells, with the presence of caseous necrosis (Figure 4). Culture swabs from the perianal lesion confirmed mycobacterium tuberculosis. Examination of sputum samples for tuberculosis was performed but no Mycobacterium tuberculosis was found. A tuberculosis skin (PPD test) revealed a positive reaction with 22 mm of induration. The human immunodeficiency virus antibody test was negative.
We made a diagnosis of perianal tuberculosis with pulmonary and peritoneal involvement and started antituberculous treatment that is consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first two months. No side effects occurred. The patient symptoms vanished and the perianal ulcer began to heal within the first month of treatment. Therapy with isoniazid and rifampicin took seven months. After six months of treatment, the lesion had disappeared, and only a bilateral mild granular region remained (Figure 5). Closure of the protective sigmoidostomy was performed. Now the patient is healthy and having no symptoms. Luckily, there is still no recurrence after one year of followup.