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CASE SNIPPET
Year : 2023 | Volume
: 69
| Issue : 4 | Page : 241-242
An unusual case of facial cutaneous tuberculosis
X Liao, G Zhou, H Liu, F Zhang
Correspondence Address:
Dr. H Liu
Shandong Provincial Hospital for Skin Diseases and Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong
China
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpgm.jpgm_100_23
How to cite this article:A 49-year-old Chinese female presented with facial erythema and papules since the last 2 years and which had aggravated since 1 month. The patient received treatment for “facial hormone-dependent dermatitis” without improvement. She had no other illnesses or any known contact with tuberculosis. Dermatology examination revealed reddish and well-marginated plaques and nodules, which were symmetrically distributed on the nose, cheeks, forehead, and mandible [Figure 1]a. The rest of the systemic findings and vitals were normal.
Figure 1: (a) reddish and well-marginated plaques and nodules in the middle of the face; (b) significant improvement of the lesions after 6 months of standard anti-tuberculosis regimenLaboratory results revealed a normal complete blood count, liver and kidney function tests, and erythrocyte sedimentation rate. Chest X-ray was normal. The skin biopsy displayed a slight thickening of the facial epidermis and epithelioid granulomas in the superficial and deep dermis [Figure 2]. The purified protein derivative (PPD) skin and the T-cell spot test (T-SPOT.TB) were both positive. Polymerase chain reaction (PCR) from tissue was positive for M. tuberculosis. The final diagnosis was cutaneous tuberculosis and the patient was given quadruple antitubercular therapy with rifampin 600 mg twice weekly, isoniazid 300 mg daily, ethambutol 750 mg daily, and pyrazinamide 1500 mg daily for 1 month. Subsequently pyrazinamide was omitted and triple therapy was continued for another 6 months in the same dose. The lesions improved within 1 month and healed completely after 6 months leaving a slight pigmentation [Figure 1]b. A 2-year post-treatment follow-up showed no recurrences.
Figure 2: The histopathology showed granulomas in the dermis consisting of epithelioid cells without caseous necrosis in the center. (arrows, a: H and E, ×40; b: H and E, ×100)Cutaneous tuberculosis (CTB) is a chronic dermatosis mainly caused by the Mycobacterium tuberculosis complex and can be found in 0.1%–2% of dermatology patients.[1] The clinical morphology varies from erythema, papules, and verrucous hyperplasia to infiltrated plaques that can be extremely deformative. The manifestation of the clinical morphology depends on bacterial virulence, the site of infection, and host's immunity.[1] In China, the most commonly involved site is the face, and it is usually unilateral. Bilateral symmetric lesions in Chinese patients have rarely been reported. Previously, Chaaboun et al.[2] have reported a middle-aged woman with facial cutaneous tuberculosis who had presented with facial erythema symmetrically distributed on both sides of the cheek, nose, and upper lip. The present patient presented with red infiltrating plaques and nodules involving the entire midface, forehead and mandible. Other causes of symmetrical inflammatory dermatoses which tend to occur in the midface, such as facial corticosteroid-dependent dermatitis, rosacea, and lupus miliaris disseminatus faciei were close differential diagnoses.[3]
According to the WHO Global Tuberculosis Report 2022, China accounts for 7.4% of the total infected population worldwide, just behind India and Indonesia.[4] Tuberculosis infection remains a major health problem in China. Due to polymorphous clinical presentations and negative detection of M. tuberculosis, CTB remains one of the most difficult diseases to diagnose, with misdiagnosis rates ranging from 33% to 50%.[5] It should be diagnosed and treated early to avoid the involvement of other facial organs and subsequent complications such as disfigurement, skin cancer, and the spread of the infection. In conclusion, owing to the diversity in clinical presentations, of which some are unusual, clinicians should recognize all types of CTB and be highly suspicious of it when a skin lesion is refractory to treatment.
Declaration of patient consent
The authors certify that appropriate patient consent was obtained.
Financial support and sponsorship
This work was supported by grants from the Academic promotion program of Shandong First Medical University (2019LJ002, 2019RC007), the Youth Technology Innovation Support Project of Shandong Colleges and Universities (2019KJL003), and the Key Research and development program of Shandong Province (2021LCZX07).
Conflicts of interest
There are no conflicts of interest.
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