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 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 85-88

A polymorphous cutaneous tuberculosis

1 Department of Dermatology, CHU Ibn Sina, Mohamed V University of Rabat, Rabat, Morocco
2 Department of Anatomopathology, CHU Ibn Sina, Mohamed V University of Rabat, Rabat, Morocco

Date of Submission27-Nov-2020
Date of Acceptance13-Jan-2021
Date of Web Publication28-Feb-2021

Correspondence Address:
Hasna Azendour
Department of Dermatology, CHU Ibn Sina, Rabat 10100
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_224_20

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Cutaneous tuberculosis is uncommon, comprising 1%–2% of all extrapulmonary manifestations. It has a wide clinical spectrum. The clinical presentation depends on the route of the infection, the pathogenicity of the bacteria, and the immune status of the host. Association of multiple forms in a same patient is uncommon. We report a case of disseminated tuberculosis with polymorphous cutaneous lesions in an immunocompetent woman, combining scrofuloderma, gummas, and sporotrichoid lesions, along with tuberculous adenitis and bone tuberculosis.

Keywords: Cutaneous tuberculosis, multifocal tuberculosis, scrofuloderma, sporotrichoid tuberculosis, tuberculous gumma

How to cite this article:
Azendour H, Meziane M, Znati K, Benzekri L, Senouci K. A polymorphous cutaneous tuberculosis. Int J Mycobacteriol 2021;10:85-8

How to cite this URL:
Azendour H, Meziane M, Znati K, Benzekri L, Senouci K. A polymorphous cutaneous tuberculosis. Int J Mycobacteriol [serial online] 2021 [cited 2022 Jul 4];10:85-8. Available from: https://www.ijmyco.org/text.asp?2021/10/1/85/310510

  Introduction Top

Tuberculosis is an infectious disease due to Mycobacterium tuberculosis. It remains a major global health problem, especially in developing countries. Lung is the organ involved the most often so far. Tuberculosis manifests only as an extrapulmonary disease in 8.4%–13.7% of cases.[1]

Cutaneous tuberculosis is uncommon, comprising 1%–2% of all extrapulmonary manifestations.[2] It has a wide clinical spectrum. Association of multiple forms in a same patient is uncommon. We herein report a case of disseminated tuberculosis with polymorphous cutaneous lesions in an immunocompetent woman, combining scrofuloderma, gummas, and sporotrichoid lesions, along with tuberculous adenitis and bone tuberculosis.

  Case Report Top

A 45-year-old woman was admitted to our hospital with painful warm nodules of various sizes on his body which had been present for 2 years. The patient received various courses of antibiotics, without any improvement. She had no previous history of immunosuppressive therapy. There was a history of progressive weight loss, and the family history revealed a past occurrence of treated pleural tuberculosis in her husband.

Dermatologic examination revealed eroded erythematous nodules ranging from 1 to 3 cm of diameter on her left third finger and both right and left medial malleolar areas. The lesions were fluctuating, without redness or local warmth on the overlying skin [Figure 1] and [Figure 2].
Figure 1: Tuberculous gummas of the left third finger

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Figure 2: Tuberculous gumma of the right medial malleolar area

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Two ulcertations with retractil borders were seen on the right palm and the anterior wrist, along with multiple erythematous subcutaneous ulcerated nodules along the right upper limb, in a sporotrichoid pattern, with an enlarged ipsilateral axillary lymph node [Figure 3].
Figure 3: Sporotrichoid tuberculosis of the right upper limb, with tuberculous gumma of the left hand, and scrofulodermas of the groins

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Further examination revealed enlarged left axillary and inguinal lymph nodes. The overlying skin was scaly and dusky violaceous, and the patient reported a previous purulent discharge at inguinal areas. The other physical findings were normal.

A Mantoux test was positive with 28 mm × 30 mm of induration after 72 h, with an indeterminate result of QuantiFERON-TB Gold test.

Erythrocyte sedimentation rate was 80 mm/h. Blood count revealed reduced hemoglobin (8.8 gr/dl), with thrombocytosis (624,000/mm3). C-reactive protein was 106 mg/dl. Serology for antibodies to HIV was negative.

Aspiration cytology from the unguinal abscess was negative for acid-fast bacilli, and polymerase chain reaction was positive for M. tuberculosis.

Skin biopsy taken from a malleolar gumma and an axillary node showed epithelioid granulomas with Langhans giant cells and a mixed inflammatory infiltrate [Figure 4]. Acid-fast bacilli were not seen using Ziehl–Neelsen stain.
Figure 4: Epithelioid granuloma with Langhans giant cells and a mixed inflammatory infiltrate

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Chest X-ray was normal. X-ray of the extremities showed osteolysis of the left third metacarpal bone, without any other skeletal location. A magnetic resonance imaging of her left hand was suggestive of osteoarthritis of the proximal interphalangeal joint of the left third finger, underlying to the cutaneous lesion.

On the basis of clinical, pathological, bacteriological, and radiological findings, a final diagnosis of disseminated tuberculosis was made. The patient had multiple bilateral gummas of the malleolar areas, scrofuloderma of the left third finger overlying a tuberculosis osteoarthritis, and scrofuloderma of inguinal and left axillary areas overlying tuberculous adenitis, along with sporotrichoid tuberculosis of the right upper limb.

Treatment with isoniazid 5 mg/kg/day, rifampicin 10 mg/kg/day, ethambutol 20 mg/kg/day, and pyrazinamide 25 mg/kg/day was started.

  Discussion Top

Cutaneous tuberculosis has many different manifestations. The clinical presentation depends on the route of the infection, the pathogenicity of the bacteria, and the immune status of the host. Extension from underlying tuberculous infection results in scrofuloderma. Hematogenous spread leads to tuberculous gummas, lupus vulgaris, or acute miliary tuberculosis in immunocompromised patients. Direct inoculation into the skin results in tuberculous chancre if the patient had no previous history of tuberculous infection, and in tuberculosis verrucosa cutis in previously infected hosts. Autoinoculation from body fluids leads to tuberculosis cutis orificialis.[3]

Aside from bone and adenitis involvement, our patient presented with scrofuloderma, gummas, and sporotrichoid tuberculosis at different anatomic areas of her body.

Scrofuloderma and gumma are the most frequently encountered types of cutaneous tuberculosis in Morocco, in contrast to other series from Europe, the USA, and India where lupus vulgaris has been more commonly seen.[4]

Scrofuloderma originates from contiguous spread of a tuberculous focus to the overlying skin leading to local tissue destruction. This results in the formation of a painless subcutaneous nodule that breaks down and expresses purulent discharge. Scrofuloderma most often affects the supraclavicular, axilla, and both sides of the neck. Inguinal scrofuloderma and multiple simultaneous scrofulodermas are less common.[5]

Tuberculous gumma can occur in a large profile of patients, whether with good cellular immunity status or not. Associated locations are present in third-fourth of cases. Lung, nodes, and musculoskeletal apparatus are the most frequent associated locations.[6] The lesions generally start as cold, subcutaneous nodules, which liquefy into nontender abscesses and eventually perforate the skin, forming ulcers and sinus tracts and making them sometimes hardly distinguishable from scrofuloderma.

Sporotrichoid tuberculosis is a rare form of cutaneous tuberculosis, not mentioned in the classical classification, which was described for the first time by Premalatha et al. in 1987.[7] It consists of a linear arrangement of nodules along the lymphatic vessels, representing a lymphatic spread of the infection. Sporotrichoid pattern has been reported with various forms of cutaneous tuberculosis: gummas, tuberculosis verrucosa cutis, or lupus vulgaris.[8],[9] This form of tuberculosis is more common in children and young adults, because of the efficient lymphatic drainage, and their high physical activity which makes them more prone to trauma.[10]

The presence of two or more lesions in extrapulmonary sites, with or without pulmonary involvement, defines multifocal systemic tuberculosis. Few observations were reported in immunocompetent individuals in the literature, and skin involvement was even rarer.[11]

Cutaneous tuberculosis is present in about 3.5% of patients with organ tuberculosis as reported by Kivanç-Altunay et al. in a series of 370 patients with tuberculosis.[12] Tuberculous adenitis is the form most frequently associated to cutaneous involvement. Our patient had at the same time nodal and joint involvement. Association of various forms of cutaneous tuberculosis in a same patient is very rare. In the series reported by Kivanç-Altunay et al., this concern was present only in one patient. It was an association of scrofuloderma and lupus vulgaris.

Amraoui et al. reported 7 cases of multifocal tuberculosis with cutaneous localization in immunocompetent patients. Cutaneous forms of tuberculosis included gummas, scrofuloderma, vasculitis tuberculosis, and lupus tuberculosis. None had an association of more than one type of cutaneous tuberculosis.[11]

Panda et al. reported the association of multiple clinical types of cutaneous tuberculosis in 7 out of 44 children with cutaneous tuberculosis but without precision of the nature of the lesions.[3]

Scrofuloderma and tuberculous gumma are both multibacillary tuberculoses. Sporotrichoid tuberculosis was reported by Pau et al. as paucibacillary form,[13] but we believe that it can be pauci- or multibacillary depending on the initial lesion from which tuberculosis spread. Histologic and bacteriologic analyses are usually done on the initial lesion. Hence, it is difficult to confirm this concern.

  Conclusion Top

The three cutaneous forms of tuberculosis we report herein have different routes of inoculation – contiguous for scrofuloderma, hematogenous for gummas, and lymphatic for sporotrichoid tuberculosis – which make this case special.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

van Zyl L, du Plessis J, Viljoen J. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb) 2015;95:629-38.  Back to cited text no. 1
Franco-Paredes C, Marcos LA, Henao-Martínez AF, Rodríguez-Morales AJ, Villamil-Gómez WE, Gotuzzo E, et al. Cutaneous mycobacterial infections. Clin Microbiol Rev 2018;32:e00069-e18.  Back to cited text no. 2
Panda M, Patro N, Dash M, Mohapatro S, Jena M. Clinical profile of childhood cutaneous tuberculosis in eastern India – A prospective study. Pediatr Infect Dis J 2015;7:92-6.  Back to cited text no. 3
Zouhair K, Akhdari N, Nejjam F, Ouazzani T, Lakhdar H. Cutaneous tuberculosis in Morocco. Int J Infect Dis 2007;11:209-12.  Back to cited text no. 4
Gunawan H, Achdiat PA, Hindritiani R, Essary ED, Ningtias LD, Siregar EP, et al. Various cutaneous tuberculosis with rare clinical manifestations: A case series. Int J Mycobacteriol 2018;7:288-91.  Back to cited text no. 5
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Machan A, Hanafi T, Hjira N, Boui M. Tuberculous gummas: Epidemiological, clinical, bacteriological, immunological, and therapeutic features. Int J Mycobacteriol 2018;7:203-11.  Back to cited text no. 6
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Premalatha S, Rao NR, Somasundaram V, Abdul Razack EM, Muthuswami TC. Tuberculous gumma in sporotrichoid pattern. Int J Dermatol 1987;26:600-1.  Back to cited text no. 7
Hadj I, Meziane M, Mikou O, Inani K, Harmouch T, Mernissi FZ. Tuberculous gummas with sporotrichoid pattern in a 57-year-old female: A case report and review of the literature. Int J Mycobacteriol 2014;3:66-70.  Back to cited text no. 8
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Ramesh V. Sporotrichoid cutaneous tuberculosis. Clin Exp Dermatol 2007;32:680-2.  Back to cited text no. 10
Amraoui N, Krich S, Meziane M, Gallouj S, Abid H, Elmrini A, et al. Cutaneous tuberculosis revealing multifocal tuberculosis in immunocompetent patients. Int J Mycobacteriol 2015;4:255-7.  Back to cited text no. 11
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Kivanç-Altunay I, Baysal Z, Ekmekçi TR, Köslü A. Incidence of cutaneous tuberculosis in patients with organ tuberculosis. Int J Dermatol 2003;42:197-200.  Back to cited text no. 12
Pau WS, AlSaffar H, Weinstein M, Kitai I. Sporotrichoid-like tuberculosis. Pediatr Infect Dis J 2009;28:1135-6.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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