Abstract As it is an infrequent etiology, the diagnosis of perianal tuberculosis is challenging, especially in the absence of a pulmonary focus. TB should be considered in the differential diagnosis of perianal ulcers, fistulas, abscesses, mainly in non-healing and recurrent anal lesions. Treatment with anti-TB agents can provide complete recovery. Furthermore, these lesions are often diagnosed later after complete histopathological and mycobacterial results, where the benefit of avoiding morbid multiple surgeries by effective anti-TB treatment is lost. We reported a rare case of an immuno-competent patient with perianal TB, which was the first manifestation of the disease. A fit-and-well man in his 20s presented a large perianal abscess. Unexpectedly, his chest X-ray showed a rounded hyper-transparency in the left lung. The abscess was drained. Posterior investigation with culture analysis from pus swabs and sputum revealed the presence of Mycobacterium tuberculosis complex infection. After completing the 6 months of oral administration of anti-TB drugs, the patient was asymptomatic. By highlighting this unusual manifestation, we aim to improve clinicians' awareness of perianal TB, facilitating early recognition and appropriate management. etiology challenging focus ulcers fistulas abscesses nonhealing non healing antiTB anti recovery Furthermore results lost immunocompetent immuno competent disease fitandwell fit well s Unexpectedly Xray X ray hypertransparency hyper transparency lung drained infection drugs asymptomatic clinicians management

Introdução: O angioedema intestinal é um efeito adverso raro dos inibidores da enzima de conversão da angiotensina. Caso clínico: Sexo feminino, 42 anos, recorreu ao Serviço de Urgência por dor abdominal difusa predominante nos quadrantes direitos, sem outra sintomatologia. Tinha iniciado perindopril e indapamida 72 horas antes por hipertensão arterial. Sem outros antecedentes de relevo. Ao exame objetivo salientava-se apenas sinais de irritação peritoneal à palpação da fossa ilíaca e flanco direitos. Analiticamente evidenciava discreta leucocitose, sem outras alterações. A ecografia e tomografia computorizada contrastada abdominal revelaram líquido moderado na escavação pélvica e espessamento das paredes do delgado. Foi internada para vigilância. Admitindo-se angioedema intestinal, o inibidor da enzima de conversão da angiotensina foi suspenso e não foi instituída qualquer outra terapêutica dirigida. Em 24 horas, verificou-se melhoria clínica, analítica e imagiológica, corroborando a hipótese de diagnóstico. Conclusão: O diagnóstico de angioedema intestinal por inibidor da enzima de conversão da angiotensina é, por vezes, difícil e moroso pela sua raridade e inespecificidade dos sintomas, podendo conduzir ao subdiagnóstico desta entidade.

Introduction: Intestinal angioedema is a rare adverse effect of angiotensin converting enzyme inhibitors. Clinical case: A 42-year old woman presented to the Emergency Department complaining of diffuse abdominal pain, predominantly in the right quadrants, with no other associated symptoms. She had been started on perindopril plus indapamide 72 h before the admission for arterial hypertension. There was no other relevant background. Physical examination suggested peritoneal irritation on the lower quadrants of the abdomen and right flank. Laboratory tests were relevant for mild leukocytosis. Abdomen ultrasound and contrast-enhanced computed tomography scan showed moderate amount of fluid in the pelvic excavation and small intestine wall thickening. She was admitted for observation. Once the hypothesis of intestinal angioedema was admitted, angiotensin converting enzyme inhibitor was withheld and no other-directed therapy was instituted. Within 24 h she showed clinical, analytic and imaging improvement, thus supporting this diagnosis. Conclusion: The diagnosis of intestinal angioedema induced by angiotensin converting enzyme inhibitor can be challenging and time consuming due to its rarity and nonspecific symptoms, which may lead to underdiagnosis of this entity.