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Case 276

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A 24-year-old male patient sought medical attention complaining of a vegetative lesion, with nodular appearance, reddish and continuously painful in a sacrococcygeal region of onset a month ago. He reports a discrete increase in size and spontaneous drainage of small amount of purulent secretion in the last week. Denies previous trauma, pruritus, fever or use of medications.

Based on the clinical history and the image (injury picture) presented, what is the most likely diagnosis?

a) Hidradenitis suppurativa

25%

b) Ostial folliculitis

25%

c) Pilonidal disease

25%

d) Furuncle (Boil)

25%
   

Image Analysis

Image 1: Photograph of sacrococcygeal region showing an nodular erythematous lesion near the midline (red circle), with approximately 1cm in diameter, firm consistency and defined borders, as well as mild erythema in the surroundings. Presence of hairs in adjacent region.

Highlights

- Pilonidal disease is the inflammatory lesion due to the presence of hair in the subcutaneous tissue, commonly located in the sacrococcygeal region;

- The clinical picture involves erythematous and swollen cystic lesion, and may be accompanied by pain;

- Manifests itself as an abscess in 50% of the cases;

- It affects men in the proportion of 4:1 especially between 20 and 40 years;

- Risk factors: obesity, prolonged sitting, poor hygiene and family history;

- The diagnosis is clinical and the treatment is usually surgical - preferably incision and curettage with or without marsupialization;

References

- Speranzini MB, Deutsch CB, Yagi OK. Manual de Diagnóstico e Tratamento para Residente de Cirurgia. ATHENEU EDITORA, 2013

- Rohde L, Osvaldt AB. Rotinas em Cirurgia Digestiva, 2a edição, ARTMED, 2011

- Azulay RD, Azulay DR, Azulay L. Dermatologia – Azulay, 6a edição, GUANABARA KOOGAN, 2013.

- Sullivan DJ, Brooks DC, Breen E. Intergluteal pilonidal disease: Clinical manifestation and diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. [Accessed in January 2017]. Available in URL: http://www.uptodate.com/contents/intergluteal-pilonidal-disease-clinical-manifestations-and-diagnosis?source=search_result&search=cisto+pilonidal&selectedTitle=1%7E20

- Silveira MCR, Miranda FLS, Aguiar SR, Andrade LM. Endoscopic pilonidal sinus treatment (E.P.Si.T.): a minimally invasive approach . J. Coloproctol. (Rio J.) [Internet]. 2015 Mar [Accessed in July 2017] ; 35(1): 72-75. Available in URL:: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2237-93632015000100072&lng=en. http://dx.doi.org/10.1016/j.jcol.2015.01.007.

Authors

Luísa Bernardino Valério,  6th year medical student at Universidade Federal de Minas Gerais.

E-mail: luisabernardino[at]gmail.com

Supervisors

Dr. Antônio Carlos Martins Guedes, dermatologist and professor of the Department of Clinical Medicine at UFMG Medical School.

E-mail: guedesacm[at]gmail.com

Reviewers

André Naback, Rafael Valério, Bruno Campos, Joice Prodígios and professor Viviane Parisotto.

Translated by

Lucas Augusto Carvalho Raso, 6th year medical student at Universidade Federal de Minas Gerais.

Email: lucasraso[at]hotmail.com

Test question

(SISE-SUS) Regarding the pilonidal cyst, it is INCORRECT to state:

a) Consists of a fistula near the anus usually containing hairs.

25%

b) Infection is usually the first manifestation of the disease.

25%

c) In the evidence of abscess, local drainage should be performed.

25%

d) Drainage of the abscess is shown to be a definitive technique.

25%

e) The most used surgical technique is the total resection of the cyst.

25%
   

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