Q J Med 2014; 107:1043–1044 doi:10.1093/qjmed/hcu090 Advance Access Publication 23 April 2014
Clinical picture Primary cutaneous tuberculosis in an elderly man for the following 9 months. There was no sign of recurrence after 1 year of follow-up. Tuberculosis remains one of the leading cause of death in infectious diseases worldwide. It is one of the most notorious highly contagious disease, especially in crowded developing countries and urban area. The cutaneous tuberculosis (TB) is relatively rare, accounting for merely 2% of the disease.1 The diagnosis of cutaneous TB is challenging because the clinical presentations vary greatly. Primary cutaneous TB resulted from direct inoculation of the bacilli, and is more common in children or health care workers. The patients were naive, never having being exposed to the pathogen previously.1 Clinically, it usually started as small papules progressing to non-healing ulcers covered with granulomatous or necrotic tissue in 2–4 weeks after inoculation. Associated regional lymphadenopathy may be found in weeks after infection. In our case, we have conducted thorough survey for any possible tuberculosis asides from the skin. However, the cutaneous ulcer remained the only finding of tuberculosis. Taiwan is a developing country with high incidence of tuberculosis. The presentation of the primary inoculation tuberculosis in this old man
Figure 1. A. The ulcerative plaque on left chest. B. Acid-fast stain highlighted the tuberculosis bacilli. (AFS 400).
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
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A 95-year-old man presented with a 1-month history of enlarging painful ulcerative plaque on the left chest wall. Skin examination showed a 5 3 cm ulcer with central necrosis and purulent discharge. The ulcer was neither warm nor swollen at periphery (Figure 1A). He recalled that initially it was a tiny papule that subsequently enlarged and became ulcer. He had been otherwise healthy and there were no associated constitutional symptoms such as fever, malaise, cough, lymphadenopathy or recent weight loss. Initial bacterial culture yielded no growth. Skin biopsy showed granulomatous inflammation with positive acid-fast bacilli (Figure 1B). Chest X-ray did not show evidence of pulmonary tuberculosis. A few weeks after excision, the healed wound ulcerated gradually again. Wide excision was done. Pathology still showed granulomatous inflammation with positive polymerase chain reaction (PCR) to Mycobacterium tuberculosis. Further tissue culture of skin confirmed M. tuberculosis. No M. tuberculosis were identified in three sets of sputum culture. Systemic survey for genitourinary, spine and gastrointestinal systems did not show any evidence of M. tuberculosis infections. He was treated with standard anti-TB regimen
1044
Clinical picture
is exceptional. The management may require excision and traditional medical anti-tuberculosis regimen.2 For clinicians, any poor-healing ulcer, refractory to common antibiotics, without vascular compromise should warrant the suspicion of atypical infections, including tuberculosis, especially in the patients living in or with a recent travel history to endemic region of tuberculosis. Photographs and text from: H.-C. Tseng, C.-H. Lee and Y.-W. Cheng, Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College
of Medicine, Kaohsiung, Taiwan. email: yuwen@ cgmh.org.tw Conflict of interest: None declared.
References 1. Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol 2007; 25:173–80. 2. Liang G, Rooney JA, Rhodes KH, Calobrisi SD. Cutaneous inoculation tuberculosis in a child. J Am Acad Dermatol 1999; 41:860–2.
Downloaded from by guest on November 15, 2015
Clinical picture Primary cutaneous tuberculosis in an elderly man for the following 9 months. There was no sign of recurrence after 1 year of follow-up. Tuberculosis remains one of the leading cause of death in infectious diseases worldwide. It is one of the most notorious highly contagious disease, especially in crowded developing countries and urban area. The cutaneous tuberculosis (TB) is relatively rare, accounting for merely 2% of the disease.1 The diagnosis of cutaneous TB is challenging because the clinical presentations vary greatly. Primary cutaneous TB resulted from direct inoculation of the bacilli, and is more common in children or health care workers. The patients were naive, never having being exposed to the pathogen previously.1 Clinically, it usually started as small papules progressing to non-healing ulcers covered with granulomatous or necrotic tissue in 2–4 weeks after inoculation. Associated regional lymphadenopathy may be found in weeks after infection. In our case, we have conducted thorough survey for any possible tuberculosis asides from the skin. However, the cutaneous ulcer remained the only finding of tuberculosis. Taiwan is a developing country with high incidence of tuberculosis. The presentation of the primary inoculation tuberculosis in this old man
Figure 1. A. The ulcerative plaque on left chest. B. Acid-fast stain highlighted the tuberculosis bacilli. (AFS 400).
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on November 15, 2015
A 95-year-old man presented with a 1-month history of enlarging painful ulcerative plaque on the left chest wall. Skin examination showed a 5 3 cm ulcer with central necrosis and purulent discharge. The ulcer was neither warm nor swollen at periphery (Figure 1A). He recalled that initially it was a tiny papule that subsequently enlarged and became ulcer. He had been otherwise healthy and there were no associated constitutional symptoms such as fever, malaise, cough, lymphadenopathy or recent weight loss. Initial bacterial culture yielded no growth. Skin biopsy showed granulomatous inflammation with positive acid-fast bacilli (Figure 1B). Chest X-ray did not show evidence of pulmonary tuberculosis. A few weeks after excision, the healed wound ulcerated gradually again. Wide excision was done. Pathology still showed granulomatous inflammation with positive polymerase chain reaction (PCR) to Mycobacterium tuberculosis. Further tissue culture of skin confirmed M. tuberculosis. No M. tuberculosis were identified in three sets of sputum culture. Systemic survey for genitourinary, spine and gastrointestinal systems did not show any evidence of M. tuberculosis infections. He was treated with standard anti-TB regimen
1044
Clinical picture
is exceptional. The management may require excision and traditional medical anti-tuberculosis regimen.2 For clinicians, any poor-healing ulcer, refractory to common antibiotics, without vascular compromise should warrant the suspicion of atypical infections, including tuberculosis, especially in the patients living in or with a recent travel history to endemic region of tuberculosis. Photographs and text from: H.-C. Tseng, C.-H. Lee and Y.-W. Cheng, Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College
of Medicine, Kaohsiung, Taiwan. email: yuwen@ cgmh.org.tw Conflict of interest: None declared.
References 1. Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol 2007; 25:173–80. 2. Liang G, Rooney JA, Rhodes KH, Calobrisi SD. Cutaneous inoculation tuberculosis in a child. J Am Acad Dermatol 1999; 41:860–2.
Downloaded from by guest on November 15, 2015
