This report describes the diagnosis of hepatocutaneous syndrome in a dog concurrently affected by Ehrlichiosis. A 13-year-old Golden Retriever presented with lethargy, fever, lymphadenopathy, and dermatological lesions on the paws, perianal region, and testes, characterized by hyperkeratosis, erosion, ulceration, crusting, and exudation. Clinicopathological evaluation revealed regenerative anemia, lymphopenia, monocytopenia, basophilia, thrombocytopenia, and increased serum activities of alkaline phosphatase, alanine transaminase, and gamma-glutamyl transferase. After ruling out other vector-borne diseases (e.g., Leishmaniasis, Anaplasmosis, Babesiosis), Ehrlichiosis was diagnosed. Abdominal ultrasonography revealed a honeycomb-like hepatic echotexture, and differential diagnoses for hepatocutaneous syndrome included pemphigus foliaceus/vulgaris, systemic lupus erythematosus, drug eruptions, and zinc-responsive dermatosis. Ultimately, the clinical, laboratory, and ultrasonographic findings supported concurrent diagnoses of hepatocutaneous syndrome and Ehrlichiosis. The dog died, most likely due to severe hepatic dysfunction and associated coagulopathy; disseminated intravascular coagulation was suspected based on the clinical course, although it could not be confirmed due to the absence of coagulation testing, despite receiving combination therapy that included vitamin–amino acid infusion, ursodeoxycholic acid, antioxidant nutraceuticals (S-adenosylmethionine, Silybum marianum, phospholipids, zinc), omega-3 fatty acids, and benzoyl peroxide shampoo for hepatocutaneous syndrome, in addition to doxycycline and prednisolone for ehrlichiosis. This case report highlights the diagnostic complexity of hepatocutaneous syndrome, particularly when concurrent with infectious diseases such as Ehrlichiosis. It demonstrates how overlapping clinical signs can complicate diagnosis and delay appropriate treatment. To the authors’ knowledge, this is the first documented case of hepatocutaneous syndrome in a dog concurrently diagnosed with Ehrlichiosis. By presenting this case, we aim to raise awareness among veterinary clinicians of the importance of a thorough diagnostic workup in dogs exhibiting compatible dermatologic and systemic signs, even in regions endemic for tick- borne diseases.

Background: Fistula-in-ano (Bhagandara), chronic ano-rectal condition usually characterized by constant discharge, recurrence and challenges of sphincter injury following conventional surgical practice. Integrated approach of modern surgical intervention along with Ayurveda Kshara Sutra therapy provides a patient centric sphincter saving approach with better wound healing and less recurrence. Clinical presentation: 34-year-old male presented with chief complaints of pain and purulent discharge from perianal region from last 6 months. Per rectal examination shows 2 external openings at 10 o’clock position in perianal region and secondary subscrotal opening at 11 o’clock position. Internal opening at 12 o’clock position. MRI fistulogram showed low anal inter-sphincteric fistula. Intervention: Comprehensive integrated treatment of fistulectomy with primary threading for the main tract and fistulotomy for the secondary tract followed by weekly Yava Kshara Sutra application was carried out. Postoperative internal Ayurvedic medicines and local wound management were carried out and patient was regularly followed up. Outcomes: There was progressive reduction in main complaints of pain and discharge. Fistulous tract healed completely (secondary intention) in 33 days. Postoperative complications and recurrence did not reported during entire follow up period. There was no impairment of sphincter function. Finally, any adverse effects related to intervention were not seen. Conclusion: Low anal inter-sphincteric fistula-in-ano was successfully treated with integrated approach of fistulectomy, fistulotomy with Yava Kshara Sutra coupled with supportive Ayurvedic management. Therapy provided successful healing, preservation of sphincter function and no side effects with recurrence free recovery noted in subsequent follow up period. Further well-designed clinical studies are required to validate these outcomes and to establish standardized integrative treatment protocols for management of Bhagandara.

Background Horseshoe Fistula in Ano (HSFA) is a type of Fistula in Ano which occurs as a complication of deep postanal space abscess. HSFA presents with higher reoccurrence rate and affects 15% of patients suffering from Fistula in Ano. The protocols for HSFA have multiple risk, complications, including anal incontinence. Ksharasutra (Medicated thread) is a well-accepted procedure having faster recovery and reduced risks of complications. Clinical Findings A 21-year-old female patient presented with complaints of severe pain and swelling in perianal region since past 3 days associated with fever and chills. On examination bilateral perianal swelling with prominent redness and tenderness over right buttock seen. Preoperatively it was observed that the contralateral side perineal spaces were involved anteriorly forming Horseshoe shaped abscess. Intervention Bhedana Karma (incision and drainage) was done over perianal area, followed by partial fistulotomy along with Ksharasutra ligation (KSL) at 12 o’clock position to facilitate proper drainage. K.S was changed weekly with rail-road technique. Regular wound dressing and Ayurvedic medicines were advised. Complete healing of the tract was attained within 12 weeks without any reoccurrence or complications observed till date. (4 years) Outcome The Fistula tracts healed completely with complete closure of wound within 12 weeks. Conclusion This case of HSFA was successfully managed with an integrated approach, which included surgical procedures (incision and drainage of abscess + partial fistulotomy + KSL) and oral Ayurvedic medicines with complete wound healing and no complications.

Epidermoid cysts located in the perianal region are rare benign lesions. This case report presents a 78-year-old male patient with a giant perianal epidermoid cyst measuring 94×59×76 mm, clinically suspected of malignancy. After MRI evaluation, the lesion was surgically excised and histopathologically diagnosed as an infundibular-type epidermoid cyst. Due to its unusual localization and large size, this case contributes to the limited literature on perianal epidermoid cysts.

This study investigated the clinical features, misdiagnosis patterns, and treatment outcomes of vulvar lichen sclerosus (VLS) in girls through a single-center, observational, retrospective cohort analysis of 105 pediatric patients diagnosed at Beijing Children's Hospital between January 2021 and September 2024. The results showed a mean age of onset of (5.47±2.13) years (median: 5 years) and a misdiagnosis rate of 29.52% (31/105), with vitiligo being the most frequent initial misdiagnosis (20.95%, 22/105). Lesions predominantly presented in a "figure-of-8" pattern involving both the vulva and perianal regions (45.71%, 48/105), with symmetrical hypopigmented or depigmented patches observed in most cases (96.19%, 101/105). Subjective symptoms were reported by 49.52% (52/105) of patients, most commonly pruritus (32.40%, 34/105). Dermoscopy revealed whitish to yellowish structureless areas in all examined cases (100%, 30/30) and purpuric globules in 70% (21/30). Histopathological examination consistently demonstrated the characteristic"sandwich-like"pattern of hyperkeratosis, homogenization of dermal collagen, and band-like lymphocytic infiltration. Regarding treatment, the median time to lesion remission was 4 months for topical calcineurin inhibitor monotherapy and 3 months for combination therapy with a topical corticosteroid, while the median time to symptom relief was 2 months and 3 months, respectively. In conclusion, this study indicates that pediatric VLS in this cohort presented at a relatively early age with a high misdiagnosis rate, typically manifesting as symmetrical hypopigmented patches in a vulvo-perianal distribution. Dermoscopy and histopathology are valuable adjuncts for early diagnosis, and standardized treatment effectively alleviates symptoms.

Objective: Fissure in ano is a very painful and bothersome condition. The injury occurs while defecating hard stool or stool having hypertonicity causing pain around anal region sometimes with bleeding is the first feature of anal fissure. Study Design: Randomized Control Trial. Setting: Department of Surgery, Gujranwala Medical College and Teaching Hospital, Gujranwala. Period: August 2021 to January 2022. Methods: Sixty (60) patients with age 20 to 60 were included in the study. These were equally distributed randomly into two groups. 1st group underwent lateral anal sphincterotomy and second group receive 0.2% GTN for chronic anal fissure. All these patients were assessed 6 weeks after the start of treatment and were on the basis of control of symptoms per rectum bleed, constipation and pain around perianal region. Results: A total of 60 patients were enrolled and evenly divided into two groups. After 6 weeks of treatment, 90% of patients in the lateral sphincterotomy group achieved complete healing, compared to 50% in the GTN ointment group. Post-treatment perianal pain persisted in only 10% of the surgical group versus 50% in the GTN group. Similarly, per rectal bleeding and constipation were significantly lower in the sphincterotomy group (6.7% each) compared to the GTN group (30% and 46.7%, respectively). The differences between groups were statistically significant (p < 0.05) across all outcome variables. Conclusion: Lateral anal sphincterotomy is significantly more effective than 0.2% glyceryl trinitrate ointment in the treatment of chronic anal fissure. It provides higher healing rates and better symptomatic relief with minimal residual symptoms. Therefore, it should be considered the treatment of choice, especially in patients who do not respond adequately to conservative management.

IntroductionChronic exogenous exposures related to perianal fistula care may lead to systemic effects in patients with Crohn’s disease and require a multisystemic evaluation. In this case, we aimed to raise awareness by presenting a rarely encountered treatment-related complication in a patient with Crohn’s diseaseClinical CaseA 22year-old female with history of ileocolonic, fistulizing Crohn’s disease had previously undergone right hemicolectomy and enterovesical fistula repair. The patient, who had prior exposure to adalimumab and ustekinumab, was most recently on upadacitinib, which had been discontinued 2 months earlier due to the development of a perianal fistula under treatment. Because of recurrent perianal fistulas, she had been under follow-up by general surgery. She was admitted to the gastroenterology clinic for further evaluation due to anal pain and elevated acute phase reactants.On admission, physical examination revealed complaints of hot flashes, sweating, and hand tremors. Tenderness in the perianal region and an active fistula tract were observed. Laboratory tests showed CRP 124 mg/L, TSH <0.01 mIU/L, fT3 >30.80 pmol/L, and fT4 >154.80 pmol/L. Thyroid ultrasonography(USG) was normal, while Tc-99m pertechnetate uptake was measured at 0.15% with a scintigraphic pattern reported as “compatible with exogenous iodine exposure/thyroiditis.” Thyroid antibody profile was negative. Spot urine iodine was 57 µg/L. Upon re-evaluating the history, it was learned that the fistula tract had been irrigated regularly with povidone-iodine for the past three months. With elevated urinary iodine levels and regular povidone-iodine exposure, the patient was diagnosed with iodine-induced thyrotoxicosis.Endocrinology consultation recommended initiation of methimazole 30 mg/day and propranolol 20 mg twice daily, with beta-blocker dose titrated according to symptoms. The patient was monitored daily for thyroid storm.Corticosteroid therapy was not initiated due to the presence of active perianal fistula and abscess. During this period, infection control was achieved with parenteral antibiotics, surgical drainage and seton placement, as well as initiation of infliximab therapy.The patient achieved control of the perianal infection, and Infliximab treatment was given for Crohn's. With antithyroid and symptomatic treatment, thyrotoxic manifestations were stabilized.ConclusionThis case demonstrates that chronic exogenous iodine exposure during perianal fistula care in Crohn’s disease may lead to systemic thyroid dysfunction. In the literature, iodine toxicity has been reported to cause various thyroid disorders. For the diagnosis; thyroid function tests, spot urinary iodine measurement, and thyroid scintigraphy are of particular importance. In conclusion, systemic effects of iodine-containing antiseptics used during perianal fistula care in Crohn’s patients should be carefully considered, and thyroid functions should be monitored regularlyTable 1:Follow-up of the patient's thyroid function test results

Introduction Extramammary Paget disease (EMPD) is a rare intraepithelial adenocarcinoma that predominantly affects areas rich in apocrine glands. Its chronic and nonspecific clinical presentation frequently leads to misdiagnosis and delayed treatment. Objective The primary objective is to describe the clinical, epidemiological, histopathological, and therapeutic characteristics of patients with EMPD treated at a dermatology referral center. The secondary outcome is to propose a diagnostic and therapeutic algorithm based on institutional experience. Methods A single-center, retrospective, observational case series was conducted at the Instituto Dermatológico de Jalisco. All patients with histopathologically confirmed EMPD diagnosed between 2011 and 2025 were included. Demographic, clinical, histopathological, immunohistochemical, and therapeutic data were analyzed. Immunohistochemistry and staging studies were performed selectively based on clinical suspicion of secondary disease. Result Ten cases were identified (N = 10). There was a marked female predominance (90%), with a median age of 69 years (range: 57-86). Lesions were primarily located on the vulva (70%), followed by the perianal region (20%) and scrotum (10%). All patients presented with chronic, well-demarcated erythematous plaques. The median diagnostic delay was 20 months (range: 2-60). Immunohistochemistry was performed in six patients (60%), all demonstrating a CK7-positive/CK20-negative profile, confirming primary EMPD in all cases. No associated internal malignancies were identified. All patients underwent wide-margin surgical excision. Conclusions EMPD requires high clinical suspicion and early biopsy of persistent genital or perianal lesions. All cases in this series corresponded to primary EMPD with no associated malignancy. Surgical excision remains the standard of care. The proposed algorithm provides a practical, experience-based framework to guide diagnostic evaluation and management in referral centers.

Multidrug-resistant (MDR) anal and perianal tuberculosis constitutes an exceptionally rare form of extrapulmonary tuberculosis. We report a case of MDR anal and perianal tuberculosis diagnosed and managed in the Pneumo-Phthisiology Department of Ignace Deen University Hospital in Conakry, Guinea. Mrs. M.B., a 33-year-old housewife residing in Tombolia (Conakry), with no notable medical history, presented to the General Surgery Department of Ignace Deen University Hospital on 24 February 2023 with fever, abdominal pain, constipation, and painful swelling of the anal and perianal region. Following a hemorrhoidectomy, histopathological examination of the surgical specimen initially suggested a diagnosis of diffuse large B-cell lymphoma of the anal region. Consequently, CHOP chemotherapy (Adriamycin, cyclophosphamide, vincristine, and prednisolone) was initiated on 10 March 2023 in the Hematology Department. After three cycles of chemotherapy, the patient showed no clinical improvement, with persistent anal lesions and recurrent fever. A strongly positive tuberculin skin test (15 mm) prompted referral to the Pneumo-Phthisiology Department for suspected anal tuberculosis. GeneXpert MTB/RIF testing performed on stool samples confirmed the presence of MDR Mycobacterium tuberculosis. A 9-month short-course second-line antituberculosis regimen was initiated. After 1 month of treatment, the patient developed abdominal pain, semiliquid diarrhea, anorexia, and abdominal distension with a positive fluid-thrill sign. The anal and perianal lesions, however, showed significant improvement. MDR anal and perianal tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis. In regions with high tuberculosis endemicity, it should be considered in the differential diagnosis of chronic ulcerative cutaneous or mucosal lesions. Management relies primarily on second-line antituberculosis therapy to prevent complications and ensure complete recovery.

Background: Toxic epidermal necrolysis (TEN) is a rare, life-threatening mucocutaneous adverse drug reaction, most commonly triggered by medications. While antibiotics such as penicillins and sulfonamides are well-known culprits, cephalosporins are infrequently implicated, and reports of cefpodoxime-induced TEN, particularly in infants, are exceedingly rare. Clinical Description: We present the case of a 3-month-old male infant who developed TEN following the administration of oral cefpodoxime proxetil prescribed for fever and cough. Within 48 h of initiating therapy, the infant manifested extensive epidermal detachment involving over 30% of the body surface area, including the face, neck, trunk, and extremities. Mucosal involvement was prominent, with conjunctivitis and erosions affecting the oral cavity and perianal region. The clinical diagnosis of TEN was established based on characteristic skin detachment, mucosal involvement, and temporal association with recent drug exposure. Management and Outcome: Cefpodoxime was withdrawn. The infant was managed with intravenous dexamethasone, antihistamines, and meticulous supportive care, including fluid and electrolyte management, infection prevention, and topical wound care. Re-epithelialization progressed steadily, and the patient achieved complete recovery within 2 weeks, with no subsequent complications. Conclusion: This case creates the awareness that even benign drugs such as cefpodoxime proxetil, usually considered safe, have the potential to cause hypersensitivity reactions such as TEN, especially in young infants. Pediatricians should be cautious in the use of such drugs.

ChordoEpidermoid cysts, also known as a sebaceous cyst, are encapsulated subepidermal nodules filled with keratin.

Enterobius vermicularis is the most common intestinal helminth in paediatric population. While often considered a benign condition, infestation may occasionally be complicated by extraintestinal inflammatory or infectious manifestations, especially in the presence of skin micro-trauma or predisposing factors. The paper reports the case of a 3-year-old boy who presented with left scrotal swelling initially attributed to a bicycle-related contusion. After a first diagnosis of scrotal trauma treated with corticosteroids and antibiotics, the child presented with widespread pruritus and a painful perianal swelling. Physical examination confirmed the presence of E. vermicularis in the perianal region and in the stool. Treatment with high-dose amoxicillin/clavulanate and mebendazole led to rapid resolution of the clinical picture. The prompt response to antiparasitic and antibiotic therapy, along with supporting literature, suggests an active role of E. vermicularis in the pathogenesis of the perianal abscess-likely through chronic scratching, cutaneous injury and secondary bacterial infection. This case emphasizes the importance of considering enterobiasis in the differential diagnosis of atypical perianal inflammation in children. A thorough environmental history, integrated therapeutic approach and close follow-up are essential for effective management and recurrence prevention.

Objective: Fournier’s gangrene is a severe, rapidly progressing form of necrotizing fas ciitis affecting the external genitalia, perineum, and perianal regions. It is associated with high rates of morbidity and mortality, even with modern sepsis management. While negative pressure wound therapy (NPWT) has emerged as a promising method to accelerate wound healing, its effectiveness in the Indonesian clinical setting remains underexplored. This study aimed to compare the outcomes of conventional wound care and NPWT in patients with Fournier’s gangrene. Methods: This prospective cohort study enrolled 36 patients with Fournier’s gangrene. The primary outcomes were assessed based on several clinical parameters: pain, mea sured using the Visual Analog Scale; length of hospital stay; mortality; frequency of re-debridement; and the cost of wound care materials. Results: The NPWT group demonstrated significantly better outcomes in several key areas. Patients treated with NPWT reported lower pain scores (4.06 ± 0.66) compared to those receiving conventional care (6.33 ± 0.84), a statistically significant difference (P = .001). Negative pressure wound therapy also resulted in a shorter average hospi tal stay (15.12 ± 4.86 days) compared to conventional care (20.06 ± 4.39 days), with a P-value of .049. Furthermore, wound care costs were significantly lower in the NPWT group ($570.24 ± $1761.74) than in the conventional care group ($985.71 ± $1213.42), with a P-value of .001. Conclusion: Negative pressure wound therapy serves as an effective adjunct to con ventional care for Fournier’s gangrene. The findings suggest that NPWT significantly reduces pain, shortens hospital stays, and lowers treatment costs without increasing mortality or the need for additional surgical debridement. Cite this article as: Ramadhan MS, Siregar S, Mustafa A. Comparison between conventional wound care procedures and negative pressure wound therapy in Fournier’s gangrene patients. Urol Res Pract. 2025;51(5):203-207.

To develop Australian anal cancer screening guidelines for people living with HIV. In 2023, ASHM Health assembled a committee to create guidelines, based on existing international guidelines and utilizing data from the Study of the Prevention of Anal Cancer (SPANC). SPANC provided Australian-specific data on different screening methodologies for the detection of anal high-grade squamous intraepithelial lesions. The guidelines were released in March 2025. They recommend primary high-risk human papillomavirus (HRHPV) testing with cytology triage for high-resolution anoscopy. Gay, bisexual and other men who have sex with men (GBM) and trans-women living with HIV should be offered screening from 35 years of age. Cis-women, trans-men and other cis-men (not GBM) living with HIV should be offered screening from 45 years of age. All anal cancer screening should include annual digital ano-rectal examination, examination of the peri-anal region and a thorough medical history. Screening should be repeated every 3 years for those who screen negative. Screening should be discontinued, with shared decision-making, at age 75 years and/or in individuals with two consecutive negative screening visits who are not currently sexually active. These are the first guidelines to recommend primary HRHPV testing with cytology triage as the screening modality. They will assist clinicians in identifying and screening people living with HIV at higher risk of anal cancer and will enable screening and referral of people living with HIV at highest risk for high-resolution anoscopy, while screening and treatment services capacity are expanded in Australia.

Background: Fournier’s gangrene (FG) is a rapidly progressive, life-threatening necrotizing fasciitis primarily affecting the perineal, genital, and perianal regions. Despite advances in medical care, it remains associated with high morbidity and mortality, especially in resource-limited settings. This study evaluates the clinical characteristics, management strategies, and outcomes of FG at a tertiary care facility in South-South Nigeria using Narayan’s Grading System for severity assessment. Methods: A retrospective review was conducted on 32 male patients treated for FG at the University of Port Harcourt Teaching Hospital between 2013 and 2022. Data on demographics, predisposing factors, disease extent, treatment modalities, and outcomes were collected. Narayan’s Grading System was applied to assess disease severity. Statistical analysis evaluated associations between clinical variables and outcomes. Results: The mean age was 49.7 years. About 25% had predisposing factors, including diabetes and HIV infection. Disease involvement ranged from localized scrotal gangrene to extensive perineal and abdominal wall involvement. All patients received broad-spectrum antibiotics and surgical debridement. The overall mortality rate was 18.8%. Delayed presentation and higher Narayan wound grades were significantly associated with longer healing times. No statistically significant correlation between wound grade and mortality was observed. Conclusions: Early diagnosis and aggressive management, guided by Narayan’s Grading System, are crucial in improving outcomes in Fournier’s gangrene, particularly in low-resource settings where delayed presentation is common. Increased awareness and prompt intervention may reduce the morbidity and mortality associated with this severe condition.

This study aimed to evaluate the effects of Epidermal Growth Factor (EGF) on wound healing, inflammation, and apoptosis markers in a rat perianal fistula model and to compare these effects with conventional seton placement, Tarantula cubensis venom (Theranekron® D6), or a combination (S + T). We hypothesized that EGF could enhance epithelial and granulation tissue repair while limiting local inflammatory damage. A total of 28 male Wistar rats were randomly allocated to four groups (n = 7 each). Perianal fistulas were experimentally induced, and interventions were administered as follows: Group S (loose seton only), Group T (Tarantula venom subcutaneously, weekly), Group S + T (seton plus tarantula venom), and EGF (two doses of 15µg EGF near the fistula tract). After a 30-day follow-up, the animals were euthanized and the perianal regions were excised. Re-epithelialization, granulation tissue, inflammatory cell infiltration, and Caspase-3 immunostaining were analyzed. Data were statistically assessed using Kruskal-Wallis and post-hoc tests (p < 0.05). The EGF group showed markedly higher re-epithelialization scores than did the seton alone (S) and tarantula venom (T) groups. Granulation tissue was predominantly absent or immature in EGF compared to the mature or overly fibrotic profiles in the S and T groups. Inflammatory cell infiltration was significantly lower in EGF, whereas T demonstrated increased inflammation and highest Caspase-3 activity (74%). EGF maintained a minimal apoptotic response (~ 8.6% Caspase-3). EGF administration promoted favorable wound healing parameters, including enhanced re-epithelialization, reduced inflammatory infiltration, and minimal apoptotic injury in a rat perianal fistula model. Tarantula venom contributed to greater tissue damage, and seton placement alone achieved moderate outcomes. These findings suggest that EGF shows promise as an adjunctive treatment for perianal fistulas. However, its translational potential requires further investigation in clinical practice.

Dermatitis in the diapered area (DDA) is the most common skin condition in infants and can cause significant pain and discomfort, leading to disturbed sleep, changes in temperament, and heightened concern and anxiety for caregivers. This study investigates the relationship between skin pH, microbiome composition, and DDA severity in 158 infants from China, the US, and Germany, focusing on the buttocks, perianal, and thigh regions. Significant variations in DNA biomass and microbiota profiles were noted. Escherichia coli and Veillonella atypica were linked to higher rash scores and elevated skin pH, while Bifidobacterium longum showed a negative correlation with buttocks pH and rash severity but not with perianal rash. Correlation patterns emerged for other species, like Enterococcus faecalis, between perianal and buttocks rashes. Functional analysis identified key categories, including lipid and fatty acid metabolism, cofactor, amino acid, and carbohydrate metabolism, homeostasis and osmolarity stress, and microbial virulence and oxidative stress response, which are vital for skin health, DDA, and pH regulation in infants. These findings underscore the importance of maintaining a mildly acidic skin pH and minimizing fecal and urine residues for optimal infant skin health, suggesting that microbiota significantly influence DDA development, and provide insights for future preventive strategies and therapeutic interventions.

Background: Arshas (Haemorrhoids) is a commonly prevalent anorectal disease. Thrombosis is acute complication that occurs in haemorrhoids due to increased venous pressure, causing venous rupture and clot formation which requires immediate treatment, but there is a problem in selecting conservative or surgical management as both have their drawbacks. Raktaavsechana (bloodletting) is a procedure mentioned by Acharya Vagbhata for managing Arshas with this complication. Case report: A 38 year old patient came to our OPD having complaints of severe pain in anal region along with tender mass and discomfort in anal region. He was unable to pass flatus for the past 3 days. A local examination of perianal region showed a single purple, dark, congested, tender and firm mass extending from 6 to 7 o’clock position. Intervention: After the examination and history, the case was diagnosed as Raktaj Arsha (EE-3.7) as per Ayurveda and Thrombosed External Haemorrhoids (THE) according to modern science. Patient was managed by Jalaukaavcharan (Leech therapy), followed by Haridra churna (Curcuma longa powder) bandaging. Outcomes: Clinically patient showed significant reduction in VAS, VDS pain Scores levels to 0/10 by the 3rd day, and biomarker i.e, IL6 levels from 15.462 pg/ml to 0 pg/ml. Conclusion: In the present case, Jalukaavcharan has shown crucial outcomes as it exhibited analgesic and anti-inflammatory activity which are observed as clinical symptoms were resolved as well as biomarker IL6 levels reduced, offering a robust evidence and its relevance in the current anorectal care as a potential noninvasive procedure for the integration in the treatment of painful anorectal disease (TEH).

Rationale:Anal fistulas typically result from infected anal glands, presenting with symptoms like recurrent purulent discharge, pain, and itching around the anus. Infections are commonly located in the skin, soft tissues, or spaces surrounding the rectum and anal canal. Notably, extensive subcutaneous tissue infections in the buttocks are exceedingly uncommon. Distinguishing this condition from anal fistulas associated with Crohn disease poses a significant diagnostic challenge.Patient concerns:A 27-year-old female patient presented with pain, swelling, and purulent discharge in the buttocks persisting for 6 months, with a recent exacerbation over the last 2 days.Diagnoses:The diagnoses were established through a comprehensive medical history assessment, physical examination, enhanced magnetic resonance imaging of the anal canal, and electronic colonoscopy, revealing: complex anal fistula, infected sinus in the buttock area, constipation, and mild anemia.Interventions:The surgical intervention involving complete fistula dissection, excision of the affected area’s apex in the buttocks, removal of necrotic material, fibrous tissue debridement, and thread-draped drainage facilitated fistula tract healing and markedly enhanced patients’ quality of life.Outcomes:After treatment, the patient showed no purulent discharge, swelling, or pain in the buttocks, and there was no bleeding or fluid leakage. The patient was followed up for 18 months after the treatment, and the wound healed well, with a satisfactory treatment outcome.Lessons:In the context of diagnosing and treating anal fistulas, it is crucial to abandon the notion that infection is limited to the perianal region. Utilizing advanced magnetic resonance imaging of the anal canal is essential for precise localization, while employing a combination of diagnostic examinations is warranted for accurate differential diagnosis. Postsurgical follow-up of anal fistula patients for a minimum of 1 year is advisable to monitor recurrence and address predisposing factors like constipation. In instances of uncommon variants, it is advisable to engage in multidisciplinary cooperation to synthesize insights from various specialties, thereby enhancing the scientific rigor of diagnostic and therapeutic approaches.

Abstract Introduction/Objective Anogenital mammary-like glands (AGMLGs) are specialized adnexal structures located in the perineal and perianal regions. Once considered vestigial remnants of the embryonic milk line, they are now recognized—based on embryologic and histopathologic evidence—as a distinct and normal component of anogenital skin. With the capability for both eccrine and apocrine differentiation, along with features resembling mammary glands, AGMLGs are now regarded as a unique type of sweat gland native to the anogenital region, rather than ectopic breast tissue. Due to their pluripotent differentiation potential, AGMLGs can give rise to a wide spectrum of neoplasms, many of which closely resemble breast lesions. Among benign AGMLG-associated neoplasms, hidradenoma papilliferum (HP), fibroadenomas, and phyllode tumors are well documented. Hydrocystomas, typically seen in the periocular area, are rare in the perianal region. Even more uncommon are composite lesions exhibiting mixed glandular differentiation within a single mass. Recent literature highlights the increasing recognition of tumors with overlapping eccrine and apocrine features, especially in anogenital skin where AGMLGs are concentrated. Within this context, we report a rare composite benign perianal neoplasm, composed of hidradenoma papilliferum, hydrocystoma, and proliferative apocrine-eccrine glandular elements, along with ductal and glandular structures resembling normal mammary tissue. Methods/Case Report A 61-year-old woman with a history of Hurthle cell thyroid carcinoma presented for evaluation of a long-standing, asymptomatic perianal mass, initially identified during colonoscopy in 2017. In 2024, a 4 cm soft, mobile, cystic mass located in the left lateral perianal region was excised without complication. Histologic evaluation revealed a composite morphology. One component demonstrated classic features of hidradenoma papilliferum (HP) with complex papillary and glandular architecture. Adjacent areas showed hydrocystoma-like morphology, consisting of multilocular cystic spaces lined by flattened to cuboidal epithelium. Additional regions exhibited proliferative apocrine and eccrine glandular elements, including foci of AGMLGs—coiled ducts and acini embedded in fibromyxoid stroma, some demonstrating apocrine metaplasia. Immunohistochemical stains revealed strong CK7 and BRST2 positivity in the HP and AGMLG components. Myoepithelial cells of all components were highlighted by p63 and CK5/6. Estrogen and progesterone receptors were diffusely positive in the luminal cells of both HP and AGMLGs, but negative in the hydrocystoma-like, apocrine, and eccrine components. Markers CK20, CDX2, PAX8, and TTF1 were negative throughout. The final diagnosis was a composite benign perianal tumor composed of HP, hydrocystoma, and AGMLG elements. The patient recovered uneventfully with a well-healed surgical site. Results NA Conclusion Tumors arising from anogenital mammary-like glands (AGMLGs) present a unique diagnostic challenge due to their overlapping histologic features with breast, apocrine, and eccrine adnexal structures. A broad spectrum of AGMLG-derived lesions has been described in the literature, including hidradenoma papilliferum, fibroadenomas, phyllodes-like tumors, apocrine cystadenomas, adenosis-like hyperplasia, and adenomas. These lesions often demonstrate dual-layered epithelium, apocrine metaplasia, and hormone receptor expression, reflecting the mammary-like differentiation potential of AGMLGs. While prior reports have described individual AGMLG-derived lesions, few document coexisting morphologically distinct components within one mass. Notably, hydrocystoma is rarely reported in the anogenital region and has not been previously observed alongside HP and AGMLG components in a single lesion. Immunohistochemistry played a pivotal role in confirming lineage: ER/PR and BRST2 positivity in HP and AGMLG components supported mammary-like differentiation, while the negative expression of CK20, CDX2, PAX8, and TTF1 effectively excluded gastrointestinal, Müllerian, and thyroid origins. This case expands the spectrum of AGMLG-derived tumors, demonstrating their pluripotent differentiation and capacity to form composite benign neoplasms. Awareness of such complexity is essential to avoid misclassification and unnecessary aggressive management.