A 25-year-old man comes to the office with pain over the intergluteal region. The pain has been present for several weeks and makes him uncomfortable when he sits at his desk at work. He has also noticed intermittent swelling with mucoid discharge, which recently became blood-tinged. The patient has no fever or chills. Bowel movements are regular and he has no urinary symptoms. His medical history is significant for an appendectomy 2 years ago. He works as a computer programmer. The patient is sexually active with a female partner. Temperature is 37 C (98.6 F), blood pressure is 123/79 mm Hg, and pulse is 78/min. BMI is 34 kg/m². Examination shows a tender mass near the tip of the coccyx that drains mucoid fluid with pressure. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

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This patient with subacute pain over the midline sacrococcygeal with mucoid and bloody drainage most likely has pilonidal disease (PD). PD most frequently affects individuals age 15-30, particularly young males, obese individuals, those with sedentary lifestyles or occupations, and those with deep gluteal clefts. The most common presenting manifestations include a painful, fluctuant mass 4-5 cm cephalad to the anus in the intergluteal region with associated mucoid, purulent, or bloody drainage. Pain is frequently worsened by activities that stretch the overlying skin (eg, bending down). cephalad to the anus PD develops when an edematous, infected hair follicle in the intergluteal region becomes occluded. The infection spreads subcutaneously and forms an abscess, which can rupture and create a pilonidal sinus tract. As the patient sits or stands, hair and debris are forced into the sinus tract, resulting in recurrent infections and foreign-body reactions. Treatment is drainage of abscesses and collected debris followed by excision of sinus tracts. Despite longer healing times, open closure is preferred due to decreased recurrence rates. (Choice A) Although folliculitis is part of the initial pathophysiology of PD, it most frequently presents with multiple small, pruritic pustules, not a fluctuant, tender mass. multiple small, pruritic pustules (Choice B) Hidradenitis suppurativa (HS), PD, dissecting folliculitis of the scalp, and acne conglobata are members of the follicular occlusion tetrad. Patients with HS typically have multiple, recurrent, painful nodules in the axillae, inguinal folds, and perineal areas as opposed to a single, fluctuant mass. Moreover, the lesions of PD are usually midline in the gluteal clefts, whereas HS can occur at any location in intertriginous areas. painful nodules (Choice C) A perianal abscess presents with fever, malaise, anal pain, and a tender, erythematous bulge at the anal verge. This patient is afebrile, and his pain and swelling are located superior to the anus over the coccyx (4-5 cm cephalad to the anus). (Choice D) Perianal Crohn disease commonly presents with fistulas, fissures, or abscesses. However, fistulas, which are the result of abscesses spreading into the soft tissues, are typically located closer to the anus and present as single or multiple openings draining purulent material. Fissures usually manifest as painful ulcers, which are exacerbated by defecation. (Choice F) Squamous cell carcinoma may present as a thin, erythematous plaque with well-defined irregular borders and an overlying scale or as firm, indurated nodules. Drainage of purulent or bloody material is not common. Educational objective: Pilonidal disease most frequently affects males age 15-30, particularly obese individuals, those with sedentary lifestyles or occupations, and those with deep gluteal clefts. The most common presenting symptoms include a painful, fluctuant mass 4-5 cm cephalad to the anus in the intergluteal region with associated mucoid, purulent, or bloody drainage. References: Pilonidal disease. (http://www.ncbi.nlm.nih.gov/pubmed/22379405) Pilonidal sinus: a comparative study of treatment methods. (http://www.ncbi.nlm.nih.gov/pubmed/24653753)

A 25-Year-Old Man Comes to the Office with Pain Over