Multidrug-Resistant Perianal Pilonidal Sinus: A Rare Presentation and Surgical Management Approach

Abstract

Aim: This case report aims to describe the clinical presentation, diagnostic approach, and surgical management of a perianal pilonidal sinus complicated by multidrug-resistant bacterial infection, emphasizing the importance of microbiological profiling and individualized treatment. Presentation of Case: A 27-year-old male presented with a progressively enlarging, tender perianal swelling with purulent discharge and foul smelling. Physical examination revealed a ruptured sinus with seropurulent discharge. Microbiological culture identified Klebsiella species resistant to beta-lactams and fluoroquinolones, while sensitive to aminoglycosides and carbapenems. High-resolution ultrasonography (HRUS) confirmed a sinus tract extending to the presacral fascia with hair fragments. The patient underwent wide local excision with methylene blue tract delineation followed by secondary wound closure due to postoperative reinfection. Pharmacological therapy included intravenous gentamicin and meropenem for infection control, along with analgesics for pain management. During follow up, the patient’s condition was improved and further he was managed conservatively. Discussion: Pilonidal sinus disease (PSD) is a chronic inflammatory condition, typically affecting the sacrococcygeal region, with rare perianal involvement. The condition is often complicated by secondary bacterial infections, emphasizing the need for culture-guided antibiotic therapy. Wide local excision with elliptical incision and tension-free secondary closure remains the preferred treatment for recurrent or complicated cases. Postoperative strategies, including wound hygiene and negative pressure wound therapy (NPWT), can further minimize recurrence risk. Conclusion: This case underscores the significance of early diagnosis, culture-directed antimicrobial therapy, and definitive surgical excision in the management of perianal pilonidal sinus complicated by multidrug-resistant infection. A multidisciplinary approach with precise surgical planning can ensure optimal patient outcomes with minimal recurrence.