記住我
Vinod Hanumanthu1, Vishal Sharma2, Thammannagowda Prarthana1, Rahul Mahajan1
1 From the Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
2 Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
Correspondence Address:
Rahul Mahajan
From the Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijd.ijd_573_22
How to cite this article:Sir,
A 23-year-old, Bacillus Calmette-Guerin vaccinated, ill-appearing emaciated male presented to emergency with complaints of spasmodic abdominal pain associated with diarrhoea, low-grade fever and significant weight loss of nine months duration. After 10 days of receiving an intramuscular analgesic injection for abdominal pain over the left arm, attendants noticed an asymptomatic necrotic ulceration at the injection site which prompted for dermatology consultation. His viral markers such as human immunodeficiency virus (HIV), Hepatitis B surface antigen (HbsAg) and antibody against hepatitis C virus (anti-HCV) were negative. There was no personal or family history of tuberculosis (TB) in the past and association with other comorbidities such as diabetes, mellitus, etc. On general physical examination, the patient looked pale and asthenic, and had bilateral cervical lymphadenopathy. On mucocutaneous examination, a solitary, large, ill-defined, non-tender ulcer of about 5 × 5 × 0.5 cm in size with undermined edges and erythematous, oedematous, border covered with black haemorrhagic adherent eschar over the lateral aspect of the left upper arm [Figure 1]a. Histopathological examination from the lesion was unyielding, Gene Xpert Ultra of the skin biopsy specimen showed Mycobacterium tuberculosis (MTB) with indeterminate rifampicin resistance. A frozen section of tissue was negative for fungal hyphae, ruling out mucormycosis or aspergillosis.
Figure 1: (a) A solitary, ill-defined, non-tender, soft swelling of about 5 cm × 5 cm × 3 mm in size, present over the lateral aspect of the middle one-third of the left arm. Surface shows ulceration with undermined edges and erythematous border covered with black haemorrhagic eschar in the centre (b) Significant improvement in the cutaneous lesion, healing with a hyperpigmented scar with surrounding hypo/depigmentation noted within four weeks of commencing anti-tubercular therapyHis laboratory examinations revealed pancytopenia, and sputum for acid-fast bacilli (AFB) was positive. His Mantoux test was positive (12 × 10 millimetres), and his chest X-ray showed inconspicuous features. On further evaluation, contrast-enhanced computed tomography (CECT) chest showed areas of consolidation with nodules in both lungs [Figure 2]a. Contrast-enhanced computed tomography abdomen showed asymmetrical circumferential mural thickening involving the terminal ileum, caecum and ascending colon, necrotic mesenteric lymphadenopathy and mild ascites [Figure 2]b. Gene Xpert Ultra from colonoscopy specimen was also positive for MTB. Based on clinical, mycobacteriological and radiological features, a diagnosis of disseminated TB was made. He was started on a combination of isoniazid 150 mg OD (30 mg/kg), rifampicin 300 mg (10 mg/kg), pyrazinamide 750 mg (25 mg/kg) and ethambutol (600 mg 20 mg/kg). Significant improvement in the cutaneous lesion was noted within four weeks of starting first-line anti-tubercular treatment (ATT) [Figure 1]b.
Figure 2: (a) Contrast-enhanced computed tomography chest showed areas of consolidation (blue arrows) with nodules (red arrows) in both lungs (b) Contrast-enhanced computed tomography abdomen showed asymmetrical circumferential mural thickening involving the large intestine (blue arrow), necrotic mesenteric lymphadenopathy (red arrow)Cutaneous manifestations of disseminated TB are rarely reported in the literature with atypical presentations. It is imperative to recognise such rare presentations, especially in an endemic country like India to avoid mismanagement, complications of the disease and mortality. Morphologically, it can have a myriad of presentations like cellulitis, non-healing ulcers, verrucous lesions, miliary lesions and maybe the first clue towards underlying disseminated TB.[1],[2] It may also present with vesiculopustules, which rapidly become necrotic to form ulcers due to acute hematogenous dissemination of MTB to the skin. Macules, follicular papules, purpura, indurated plaques and subcutaneous nodules have also been described in the literature.[3],[4]
Our case manifested with painless, necrotic ulceration at the injection site made us to think of typical/atypical cutaneous mycobacterial infection, deep fungal infection and pyoderma gangrenosum (PG). Deep fungal infections and PG were ruled out based on systemic features and laboratory reports including a negative smear for fungal hyphae and negative histopathological findings for PG. Diagnosis of cutaneous TB was confirmed by positive polymerase chain reaction test (PCR) for MTB. Though dissemination of military TB to the skin has been reported frequently in immunocompromised patients, there are only a few cases presented with cutaneous TB in an immunocompetent patient with TB of internal organs have been reported.[5]
Diagnosis of cutaneous TB can be challenging in the view of atypical presentation and needs correlation of clinical findings and laboratory tests. In addition to traditional testing like smear for AFB and culture, rapid testing by PCR may be required for early diagnosis and initiation of treatment, especially in cases of negative histology and tissue culture. Thus, GeneXpert Ultra along with other investigations guided us to arrive final diagnosis and further management with good clinical response. Since, the bacillary load in cutaneous TB is usually less than in pulmonary TB and most cutaneous TB, are a manifestation of systemic TB, treatment regimens are similar to that of TB in general.[6] However, in places of poor resource settings, commencement of ATT is essential when the index of suspicion is high and rapid response to it confirms the clinical diagnosis.
Acknowledgement
We thank the patient for granting permission for clinical photography.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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