Pakistan Journal of Medical Sciences


ISSN 1681-715X





Volume 23

January - March 2007

Number 1


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Multiple fistula in ANO in an HIV Seropositive Patient
(The danger of stigmatisation)

Elusoji S.O.1, Osime O.C.2


A 45-year-old man presented with a nine-month history of recurrent discharge from the anal region. He also had a history of weight loss. Examination revealed multiple fistulas-in-ano. The patient initially refused an HIV screening test; but later agreed. The result revealed HIV positive. As a result of the stigmatization associated with the diagnosis, the patient bluntly refused to bring the wife for screening and that he was not going to inform the wife of his diagnosis. The patient discharged himself against advise and went to seek traditional ‘doctors’ herb. However, we were reliably informed that he died few months afterwards. The aim of this presentation is to highlight the degree to which stigmatization can influence patients’ decision regarding HIV/AIDS and to emphasize the role of adequate health education to create more awareness. This will minimize the morbidity and mortality associated with HIV/AIDS.

KEYWORDS: HIV seropositivity, stigmatization, multiple fistulas in ano.

Pak J Med Sci January - March 2007 Vol. 23 No.1  122-123

1. Dr, Elusoji S.O
2. Dr. Osime O.C

1-2: Department of Surgery
University of Benin Teaching Hospital
UBTH Benin City,

Dr. Osime O.C.

* Received for Publication: May 26, 2006
* Accepted: September 14, 2006


There is an increasing incidence of HIV seropositivity in Nigeria and most of these patients are diagnosed for the first time when they develop the symptoms of full blown AIDS.1-5 This is because most ‘healthy’ Nigerians and even the symptomatic patients are reluctant to undergo HIV screening. The primary reason for this reluctance is the stigmatization associated with HIV/AIDS.

Multiple fistulas in ano was not listed among the HIV/AIDS defining illnesses or indicator diseases.6 HIV screening has been recommended in any medical setting in which people with high risk behaviour are encountered.7 HIV seropositive individuals who are ignorant of their status constitute grave risk to the populace and the surgeons in particular. The aim of this study is to present an HIV seropositive patient with multiple fistula in ano highlighting the importance of screening all surgical patients especially those with multiple fistula in ano.


A forty five year old businessman presented with a 9-month history of perianal discharge. He was apparently well until 9 months before presentation when he had severe perianal pain and fever. He took some antibiotics and analgesics and the pain subsided. About two weeks after the onset of the symptoms, he noticed discharging purulent fluid from the perianal region. Initially, the discharge was only purulent but later became faeculent. There was no associated weight loss. He had gone to many clinics and taken a lot of antibiotics to no avail. Examination revealed a healthy looking middle-aged man. The only significant finding was on rectal examination that revealed five perianal fistulous tracts with external openings at position 2,4,5,7 and 8 O’clock. Investigations advised were full blood count, HIV screening and barium enema. The patient initially refused to carry out HIV screening because of the fear of stigmatization in case he is found to be HIV positive. A lot of time was spent in counseling him before he finally agreed. He was found HIV positive. All attempt at convincing him to bring his wife for treatment failed. He was most scared of the stigma and rather preferred to be discharged against medical advice to attend traditional doctor’s clinic. The patient refused to have photographs of the lesions taken. Two years later, we were reliably informed that the patient finally died despite the management by the traditional doctor’s.


Acquired immune deficiency syndrome (AIDS) is caused by human immunodeficiency virus, which was first isolated in the Institute Pasteur in Paris by Luc Montagnier in 1983.8 It is characterized by a range of immune dysfunction. Following infection with the virus there is rapid and wide spread dissemination of the virus that attacks T lymphocyte cell leading to a drop in the CD4 lymphocyte counts and thus immunodeficiency and proneness to the development of opportunistic and other infections.9-11

Multiple fistulas in ano are not very common, while single fistula in ano is common in clinical practice. Essentially fistula in ano is a track lined by granulation tissue connecting the anal or rectal mucosa and the skin around the anus. Most fistulas in ano originate as pyogenic infection of the anal crypts. Other causative factors include badly drained anorectal abscesses, tuberculosis, amoebiasis, actinomycosis, lymphogranuloma, ulcerative colitis, crohn’s disease and carcinoma of the anus.12 The human immunodeficiency virus depresses the immune system. Consequently, the individual’s ability to control these pathological conditions would be adversely affected. This must have been responsible for the multiple fistulas in ano in this patient.

Unfortunately AIDS patients are stigmatized in our community. People therefore hesitate to carry out HIV screening. This would obviously encourage the spread of HIV virus. Unfortunately even some of those who are HIV seropositive still engage in indiscriminate sexual activities. This was the case in our patient who was not ready to disclose his status to his partner and thought his partner would become suspicious if he refused to have sexual intercourse with her.

In conclusion, we recommend HIV screening for all surgical patients especially for those with multiple fistulas in ano. We discourage in strong terms the stigmatization of HIV seropositive individuals. They should be counseled and encouraged to come with their partners for management, which is now very cheap in most teaching hospitals in Nigeria.


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