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Chronic perianal abscess due to ingested fishbone in a child

  • Chia-Hsuan Chiu
    Affiliations
    Clerk Medical Student, School of Post-Baccalaureate Medicine, College of Medical School, Kaohsiung Medical University, Kaohsiung, Taiwan
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  • Yu-Tang Chang
    Correspondence
    Corresponding author. Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Tzyou 1st Road, Kaohsiung, 80708, Taiwan.
    Affiliations
    Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Open AccessPublished:May 20, 2022DOI:https://doi.org/10.1016/j.pedneo.2022.04.007
      To the Editor:
      A 30-month-old boy without significant history presented with a 6-month history of intermittent anal pain when sitting. Careful inspection of his perianal region showed a 1 cm induration outside the external anal sphincter at the 11 o'clock position, without external skin and internal anal openings, but with minimal discomfort during palpation. No signs of local heat or skin redness (erythema) were detected, although a digital rectal examination revealed a tender swelling at the same position. The total white blood cell count was 5720/μL and the C-reactive protein was within normal ranges, while sonography showed an 11-mm long, linear, and echogenic foreign body surrounded by a halo of hypo-echogenicity (Fig. 1a). The abdominal computed tomography (CT) with contrast confirmed a high-density straight structure in the perianal space (Fig. 1b), with a perianal abscess impression due to an impacted foreign body. Intraoperatively, a piece of the 1 cm fishbone was found inside the perianal abscess cavity (Fig. 1c). Histopathological examination reported bony ossification with necrosis and inflammatory infiltration, but with negative anaerobic and aerobic bacteria culturing of the abscess. The patient was then discharged without complications 2 days postoperatively.
      Figure 1
      Figure 1a. Sonography revealed a linear and echogenic foreign body. b. Abdominal computed tomography showed a straight, high-density structure at the perianal area. c. A part of fishbone (1 cm) was discovered.
      A perianal abscess is a superficial, inflamed mass near the anus. Most cases are caused by cryptoglandular infection, especially for infants younger than 1 year.
      • Ding W.
      • Sun Y.R.
      • Wu Z.J.
      Treatment of perianal abscess and fistula in infants and young children: from basic etiology to clinical features.
      An impacted foreign body in the anal canal by ingestion is an extremely rare cause of perianal abscess and subsequent fistula formation; therefore, paying attention to children with age older than 2 years without a medical history of perianal abscess or fistula is crucial. Fortunately, sonography is an easily accessible and effective tool for diagnosis.
      In Asia, fishbones are the most commonly ingested foreign body in children with a peak incidence from 6 months to 3 years. The most common site for fishbone impaction is the mesopharynx with 87.4% of fishbone foreign bodies.
      • Shishido T.
      • Suzuki J.
      • Ikeda R.
      • Kobayashi Y.
      • Katori Y.
      Characteristics of fish-bone foreign bodies in the upper aero-digestive tract: the importance of identifying the species of fish.
      However, for a piece of a sharp fish bone to pass through the gastrointestinal tract without complications and eventually puncture the anal canal wall, is unusual.
      • Eroğlu H.
      • Çalt T.
      • Sarıkaya M.S.
      • Kuzu R.
      • Başbuğ M.
      • Derici H.
      A rare case of anorectal abscess due to foreign ingested foreign body.
      Risk factors in adults for impacted ingested foreign bodies include the presence of dentures or previous anal surgery complicated by anal stenosis, as well as alcohol intoxication.
      • Eroğlu H.
      • Çalt T.
      • Sarıkaya M.S.
      • Kuzu R.
      • Başbuğ M.
      • Derici H.
      A rare case of anorectal abscess due to foreign ingested foreign body.
      As in our pediatric patient, obscure complaints and slight symptoms might be associated with parental neglect or unawareness of prolonged impaction leading to abscess formation. The exertion by the anal sphincter during defecation appears most to push the piece of fishbone through the anal canal wall, eventually causing the perianal abscess.
      • Eroğlu H.
      • Çalt T.
      • Sarıkaya M.S.
      • Kuzu R.
      • Başbuğ M.
      • Derici H.
      A rare case of anorectal abscess due to foreign ingested foreign body.

      Declaration of competing interest

      None Declared.

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        Treatment of perianal abscess and fistula in infants and young children: from basic etiology to clinical features.
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