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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 472-474

Large nonhealing cutaneous tubercular neck ulcer as a presenting feature of undiagnosed pulmonary tuberculosis: An atypical presentation


1 Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
2 Department of Pathology, Command Hospital, Lucknow, Uttar Pradesh, India
3 Department of Radiodiagnosis and Imaging, Command Hospital, Lucknow, Uttar Pradesh, India

Date of Submission15-Aug-2022
Date of Decision29-Oct-2022
Date of Acceptance03-Nov-2022
Date of Web Publication10-Dec-2022

Correspondence Address:
Preema Sinha
Department of Dermatology, Base Hospital, Lucknow - 226 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_180_22

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How to cite this article:
Sinha P, Kamboj P, Vashisht D, Sinha A, Bhattacharjee S, Vij V, Raj CS. Large nonhealing cutaneous tubercular neck ulcer as a presenting feature of undiagnosed pulmonary tuberculosis: An atypical presentation. Int J Mycobacteriol 2022;11:472-4

How to cite this URL:
Sinha P, Kamboj P, Vashisht D, Sinha A, Bhattacharjee S, Vij V, Raj CS. Large nonhealing cutaneous tubercular neck ulcer as a presenting feature of undiagnosed pulmonary tuberculosis: An atypical presentation. Int J Mycobacteriol [serial online] 2022 [cited 2023 Feb 4];11:472-4. Available from: https://www.ijmyco.org/text.asp?2022/11/4/472/363167



Dear Editor,

A 62-year-old male with no known comorbidities presented with chief complaints of multiple dark-colored itchy lesions over the right side of the neck of 9 months duration, which ulcerated to form a large nonhealing ulcer. There was no history of weight loss, chronic cough, breathlessness, fever, or night sweats. There was no history of photosensitivity or oral ulcers. There was no past or family history of tuberculosis (TB).

Dermatological examination revealed a well-defined large tender indurated ulcer with undermined edges of size 6 cm × 10 cm with mild serous, nonfoul smelling discharge. Surrounding skin showed erythematous to violaceous hue [Figure 1]. The patient was evaluated in detail. Positive findings included erythrocyte sedimentation rate – 21 mm fall and Staphylococcus aureus Scientific Name Search  isolated in pus swab culture. C-reactive protein was negative, and viral markers (HIV, hepatitis B virus surface antigen, anti-HCV Ab) were negative.
Figure 1: A well-defined ulcer of size 10 cm × 6 cm with undermined edges and surrounding skin showing a violaceous hue over the nape of the neck extending till the upper back

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Skin biopsy revealed granulomas comprising epithelioid cells and Langhans giant cells surrounded by lymphocytes and plasma cells with central necrosis [Figure 2] and [Figure 3]. Immunohistochemistry showed a mixture of CD20 and CD3-positive lymphoid cells around the granulomas. Ziehl-Neelsen stain from ulcer base showed acid-fast bacilli (AFB).
Figure 2: Multiple epithelioid granulomas seen in the dermis (H and E, ×100)

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Figure 3: Dermal granuloma comprising Langhans giant cell, epithelioid cells, and a cuff of lymphocytes and plasma cells (H and E, ×400)

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Chest X-ray showed few fibronodular opacities. Mantoux test showed erythema with an induration of size of 12 mm. Gene Xpert was positive for mycobacterial TB, sensitive to rifampicin. Sputum for AFB was negative. Contrast-enhanced computed tomography of the chest revealed features of active pulmonary TB with consolidations and endobronchial nodules [Figure 4]. Based on the clinical picture, histopathological findings, and radiological correlation, the patient was started on antitubercular therapy (ATT). Ulcer healed with atrophic scarring within 4 weeks of ATT administration [Figure 5].
Figure 4: CECT chest revealed active pulmonary tuberculosis with consolidations and endobronchial nodules (arrow showing centrilobular nodules with tree-in-bud pattern). CECT: Contrast-enhanced computed tomography

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Figure 5: Ulcer healing well with reepithelization and central atrophic scaring after 4 weeks of antitubercular treatment

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TB is a disease caused by Mycobacterium TB that affects various organs. One of the most infected organs is the lung.[1] The number of extrapulmonary TB is nearly 14%, and 1%–2% out of them are cutaneous TB.[2] Cutaneous TB is found worldwide, especially in tropical countries.[3]

As we move into the 21st century, cutaneous TB has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary TB. Cutaneous TB was a major problem in the late 19th and early 20th centuries. The incidence of cutaneous TB declined with the decline of pulmonary TB. Pulmonary TB declined because of improved hygiene, improved living standards, the use of BCG immunization, and the introduction of effective chemotherapy.[4] In developed countries, cutaneous TB has typically been observed in those patients with immunosuppression from malnutrition, cancer, chronic corticosteroid therapy, or immunosuppressive therapy, whereas in developing countries, it occurs more often in the healthy population.[1] Our patient is from a developing country without any evidence of immunosuppression.

Variants of cutaneous TB generally associated with active pulmonary TB include scrofuloderma, orificial TB, and miliary TB. Orificial TB, which occurs via self-inoculation from mucosa or skin, is rare and usually affects middle-aged men. The lesions can be located anywhere in the buccal mucosa, around the anus, vulva, or penis. It is generally associated with active internal TB infection.[2],[3] Scrofuloderma appears as firm subcutaneous nodules that ulcerate and develop sinus tracts in overlying skin. The most commonly affected areas are the neck, axillae, chest wall, and groin. The patient may have the active pulmonary or pleural disease and systemic symptoms. Scrofuloderma has been most commonly associated with active pulmonary TB and lymphadenitis.

Acute miliary TB occurs via hematogenous spread from a primary pulmonary focus. It is usually seen in children and adolescents.[4],[5] Our case did not fit into any of the above variants of cutaneous TB.

A case report by Fragoso et al. has described a case similar to our case where TB of the oral cavity was the primary presentation of the disease and the patient was later found to have pulmonary involvement.[5] Tekbas et al. and Arora et al., in their reports, have stated that in patients with chronic, recurrent, and nonhealing ulcers, TB should be considered, especially in endemic areas.[6],[7]

In conclusion, cutaneous TB continues to be an important cause of morbidity, and there is a high likelihood of internal involvement, especially pulmonary involvement. Our case is unique as the patient initially presented with a large chronic nonhealing ulcer over the neck, and active pulmonary TB was discovered only on detailed evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient's identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Santos JB, Figueiredo AR, Ferraz CE, Oliveira MH, Silva PG, Medeiros VL. Cutaneous tuberculosis: Epidemiologic, etiopathogenic and clinical aspects – Part I. An Bras Dermatol. 2014;89:219-28.  Back to cited text no. 1
    
2.
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. 2
[PUBMED]  [Full text]  
3.
Mannava AS, Wesley Garapati CA, Ganguly S, Jaykar KC. Multifocal cutaneous tuberculosis coexisting with pulmonary tuberculosis. Int J Mycobacteriol 2022;11:329-31.  Back to cited text no. 3
  [Full text]  
4.
Semaan R, Traboulsi R, Kanj S. Primary Mycobacterium tuberculosis complex cutaneous infection: Report of two cases and literature review. Int J Infect Dis 2008;12:472-7.  Back to cited text no. 4
    
5.
Fragoso J, Oliveira MM, Gonçalves C, Méndez J, Sarmento-Castro R. Oral ulcer as presentation of cavitating pulmonary tuberculosis. IDCases 2020;22:e00976.  Back to cited text no. 5
    
6.
Tekbas G, Abakay A, Tanrikulu AC, Firat U, Ekici F, Dostbil Z, et al. Skin ulcers: A sign of disseminated tuberculosis. Respir Care 2011;56:1853-6.  Back to cited text no. 6
    
7.
Arora S, Kaur T, Gandhi G. Chronic foot ulcers – Rule out cutaneous tuberculosis! Indian J Paediatr Dermatol 2021;22:363-6.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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