ABSTRACT
CHALLENGING CASE A 40-year-old male with poorly controlled HIV infection develops severe anorectal pain with associated fever. On physical examination, an obvious perirectal abscess is present 2 cm from the anal verge, just to the right of the posterior midline. Appropriate incision and drainage is performed and the patient is treated with a short course of oral antibiotics, with resolution of the acute event. Several months later, he presents with purulent discharge from the drainage site as well as a second area in the posterior midline, 4 cm from the anal verge. Exam under anesthesia demonstrates a single primary fistula opening anal canal, in the posterior midline 3 cm proximal to the dentate line, which communicate with both secondary openings. Draining setons are placed, and biopsies from the fistula tracts show no evidence of Crohn’s disease or malignancy. Six weeks later, he presents in septic shock due to worsening perineal infection requiring a diverting colostomy.
