|Year : 2022 | Volume
| Issue : 3 | Page : 329-331
Multifocal cutaneous tuberculosis coexisting with pulmonary tuberculosis
Anjali Srikanth Mannava1, Chris Alex Wesley Garapati1, Satyaki Ganguly1, Kranti Chandan Jaykar2
1 Department and Dermatology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Skin and VD, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||23-May-2022|
|Date of Decision||17-Jun-2022|
|Date of Acceptance||01-Aug-2022|
|Date of Web Publication||12-Sep-2022|
Department of Dermatology, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) is caused by Mycobacterium tuberculosis and it can affect multiple organ systems. Cutaneous TB, a less common type of extrapulmonary TB can coexist with TB of other organs. Here, we describe a case of multifocal cutaneous TB suggestive of two different morphological types with concomitant miliary pulmonary TB.
Keywords: Cutaneous tuberculosis, lupus vulgaris, multifocal, pulmonary tuberculosis, scrofuloderma
|How to cite this article:|
Mannava AS, Wesley Garapati CA, Ganguly S, Jaykar KC. Multifocal cutaneous tuberculosis coexisting with pulmonary tuberculosis. Int J Mycobacteriol 2022;11:329-31
|How to cite this URL:|
Mannava AS, Wesley Garapati CA, Ganguly S, Jaykar KC. Multifocal cutaneous tuberculosis coexisting with pulmonary tuberculosis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Nov 26];11:329-31. Available from: https://www.ijmyco.org/text.asp?2022/11/3/329/355923
| Introduction|| |
Tuberculosis (TB) is an infection most commonly caused by Mycobacterium tuberculosis. It commonly causes pulmonary TB. Among the less common extrapulmonary manifestations is cutaneous TB. The most common type of cutaneous TB is lupus vulgaris. The mode of infection of cutaneous TB is from contiguous spread or hematogenous dissemination to the skin from endogenous focus of infection. Inoculation from an exogenous source also occasionally results in localized infection. Risk factors include age and gender of the host and the immune status.
| Case Report|| |
A 13-year-old girl presented with a chronic asymptomatic growing elevated lesion that started as a small lesion over the left buttock and gradually expanded over to the right buttock and gluteal cleft to attain the present size in 2 years [Figure 1]. She developed similar smaller lesions on the dorsum of the left foot, tip of the nose, and medial side of the right thigh, in that order over the past 1.5 years [Figure 2]. She complained of watery discharge from two other chronic painless discharging lesions one in the right preauricular area and the other just below the right medial canthus for the past 6 months [Figure 2]. The lesions did not respond to treatment given previously. The skin changes were associated with chronic cough and evening rise in temperature over the past 2 years. She gave no history of dyspnea, chest pain, or hemoptysis. Bacillus Calmette-Guerin (BCG) scar was absent. Her parents could not recall the vaccine being given. There was no history of TB among family members and no history of contact with TB-infected individuals. She was not on any chronic medications.
|Figure 1: The plaque on the left buttock and extending to the gluteal cleft and right buttock|
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|Figure 2: Plaques on the dorsum of the left foot, tip of the nose and alae nasi, medial side of right thigh, and two discharging sinuses in the right preauricular area and medial canthus of the right eye (clockwise from bottom left)|
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On examination, there was a large exophytic brownish-black irregular plaque measuring 10 cm × 12 cm distributed predominantly over the left buttock and extending over to the gluteal cleft and right buttock [Figure 1]. There was another smaller irregular well to ill-defined plaque with depigmentation at the center and peripheral hypopigmentation present over the left forefoot extending onto the dorsum of great toe and second toe [Figure 2]. Two similar smaller hyperpigmented plaques with areas of depigmentation were seen over the right inguinal area and tip of the nose and alae nasi [Figure 2]. Two skin-colored sinuses with visible serous discharge were seen on the right preauricular area and inner canthus of the right eye [Figure 2].
Based on the clinical features, a clinical diagnosis of lupus vulgaris was made for the lesions on the left foot, nose, and buttocks and the lesions in the right preauricular area and right medial canthus were thought to be scrofuloderma. Laboratory studies showed anemia, erythrocyte sedimentation rate was 110 mm/h. Sputum was positive for acid-fast bacilli in Ziehl–Neelsen staining. Biopsy was taken from the lesion on the buttock which showed acanthosis, papillomatosis of epidermis with TB granuloma in the reticular dermis with dense lymphocytes infiltration, consistent with lupus vulgaris [Figure 3]. Chest radiograph showed miliary deposits that appeared as 1–3 mm diameter nodules, uniform in size and uniformly distributed all over the lungs. Mantoux test was negative. She was nonreactive for HIV.
|Figure 3: Histopathology of the lesion on the buttock showing acanthosis, papillomatosis, and tubercular granuloma (H and E, ×20)|
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A diagnosis of lupus vulgaris with scrofuloderma and miliary pulmonary TB was made. Following diagnosis, she was started on antitubercular therapy. Lesions showed improvement in 2 months and completely healed in 6 months.
| Discussion|| |
Cutaneous TB accounts for only 1%–2% of TB cases, although the incidence may be more significant in high prevalence areas such as India, Pakistan, and South Africa.
Multifocal systemic TB is defined as the presence of two or more lesions caused by M. tuberculosis in extrapulmonary sites, with or without pulmonary involvement. Risk factors for multifocal TB are HIV, immunosuppression due to other causes, smoking, malnutrition, diabetes, and stress. All of them can cause latent TB to reactivate and lead to extrapulmonary TB as well.
Multifocal tuberculous osteomyelitis in a nonimmunocompromised 9-year-old patient of pulmonary TB has been reported from Indonesia. A report of multifocal cutaneous TB with pulmonary involvement in a 14-year-old immunocompetent immigrant girl from the Indian subcontinent has been described from Italy. Seven immunocompetent patients of cutaneous TB with extracutaneous involvement have been described from Morocco, pulmonary and musculoskeletal being the common involved extracutaneous sites. Lupus vulgaris accompanied by multifocal skeletal TB has been reported from Indonesia. There are reports of multifocal tuberculosis verrucosa cutis from India in the absence of pulmonary involvement and immunosuppression.,
Our patient had lesions suggestive of two different morphological types of cutaneous TB, lupus vulgaris and scrofuloderma, possibly due to hematogenous spread from lungs and contiguous spread from lymph node. She had concomitant miliary pulmonary TB in the absence of immunosuppression and a negative Mantoux test, features which are unusual. Hence, disseminated TB presenting as cutaneous TB can occur even in immunocompetent individuals with coexisting pulmonary TB and can present with multiple lesions of different morphologies. Lesions respond well to antitubercular therapy and lead to good outcomes in immunocompetent individuals. Therefore it is important to suspect cutaneous TB and look for other pulmonary and extrapulmonary focus in diagnosed cases of cutaneous TB.
Declaration of patient consent
The authors certify that they have obtained the appropriate patient consent form. In the form, the patient and her guardian have given their assent and consent for her images and other clinical information to be reported in the journal. They understand that her name and initials will not be published and due efforts will be made to conceal her identity. Further, there is no ethical concern raised in the present case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]