Cutaneous tuberculosis: diagnostic challenges

Abstract

Introduction: Despite of a high incidence of pulmonary tuberculosis (114,3/100.000) the nail of extrapulmonary TB rests very low (1,3%). Cutaneous TB is often misdiagnosed due to clinical picture and none relevant bacteriological tools for detection of M. tuberculosis. Purpose and Objectives: To find out the diagnostic challenges o f cutaneous tuberculosis. Material and methods: Two patients, a 40 years old female patient and a 6 years old boy with C utaneous TB were studied. Results: The 40 years old patient with alopecia areata since the age of 9, presented nodular hypodermitis on the posterior aspect of both legs for 17 years without any treatment, complaining it steadily progression in cold seasons. It was performed an esthetic intervention on the nasal pyramid after a facial traumatism. The post-intervention lesion failed to heal extended to brownish-red plaque covered by a scale with red borders, on both cheeks, with more evident extension in cold seasons. There were taken 2 biopsies from the face and left leg showing tubercle granulom as with wide areas of caseation, foreign body and giant cells Langerhans. No acid-fast bacilli were found on Ziehl-N eelson staning, classic culture on solid medium was negative for M.Tuberculosis (MTB), but PCR detected specific fragment for M TB DNA from facial lesions. The patient had TB contact in childhood, multiple post-primary quiescent lesions in both hills and pulmonary parenchym as on chest XRay and a peripheral adenopathy. Diagnosis of Lupus vulgaris for facial lesions and indurated Erythem a Basin for nodular hypodermitis was established. The antiTB treatment for new case was started with no evident clinical improvement. The second clinical case presents a 6 years old boy with an unestablished immune disorder with reduced immunity and sensitivity to MTB antigenes proved by a hyperergic Mantoux reaction. He complains a large deep brownish plaque, on the nose and both cheeks with steadily progression and contraction of nasal fossaes, with polycyclic outlines and smooth surface, alopecia areata, dorsal kyphoscoliosis, drummer fingers and abdominal distention. It was revealed 2 groups of multiple papules and macules with squamous surface on the left part of hem ithorax and abdomen. From the anamnesis it was revealed a surgical intervention for adenopathy in the left axilla at the 4 months age. The cutaneous byopsia revealed tubercle granulom as with wide areas of caseation and giant Langerhans cells. No one specimen at ZiehlN eelson staining, solid and liquid cultures and PCR was positive. Lupus vulgaris was established for facial lesion and papula necrotic tuberculides for abdominal lesions, as focal post-BCG com plication. The antiTB treatment according DOTS standard was started with local application with Rifampicin ointment that contributes to a slow regression. Conclusion: Lupus vulgaris is chronic, mutilating extrapulmonary TB, appearing in moderate immunity and previously sensitive individual, often very late detected due to absence of a proper diagnosis and without specific appearance. Pathogenetically is a feature of a quiescent post-primary sequelae showed in first case, or follows after BCG inoculation, as in child case. Innovative value: This study increases awareness of the re-emergence of cutaneous tuberculosis imposing the using of the proper diagnosis tools for a early diagnosis and case management.