Am. J. Trop. Med. Hyg., 79(6), 2008, pp. 817-818
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene
Cutaneous Mycobacterium tuberculosis Infection
David Pace*,
Noel Gatt, AND
Simon Attard-Montalto
Department of Paediatrics and Department of Pathology, Mater Dei Hospital, Msida, Malta
A 20-month-old boy from Sierra Leone had a three-month history of painless cutaneous ulcers above and below the right clavicle (Figure 1
) and on the left cheek (Figure 2). The three ulcers had smooth, raised, indurated, violaceous edges with a central, dry, adherent crust and were associated with regional lymphadenopathy. His chest radiograph was unremarkable. A tuberculin skin test showed an induration of 17 mm, and the result of a quantiFERON-TB gold assay (Cellestis GmbH, Darmstadt, Germany) was positive. Histologic analysis of biopsy specimens from shoulder lesions showed caseating granulomas with giant cells (Figure 3) but no acid-fast bacilli were seen by Ziehl-Neelsen staining. A diagnosis of scrofuloderma was made. Treatment was initiated with daily isoniazid, rifampicin, ethambutol, and pyrazinamide.
View larger version (118K):
[in this window]
[in a new window]
|
FIGURE 1. Cutaneous Mycobacterium tuberculosis infection in the patient involving the right supra-clavicular and infra-clavicular regions. This figure appears in color at www.ajtmh.org.
|
|
View larger version (145K):
[in this window]
[in a new window]
|
FIGURE 3. Histologic analysis of a shoulder lesion biopsy specimen from the patient. A, Caseating granuloma with palisading epithelioid histiocytes. Part of a hair follicle may be seen on the right of the section (hematoxylin and eosin stain, magnification x100). B, Multiple typical Langhans type giant cells (hematoxylin and eosin stain, magnification x400). This figure appears in color at www.ajtmh.org.
|
|
Mycobacterium tuberculosis sensitive to isoniazid and rifampicin was cultured after eight weeks. Further investigations did not show any underlying immunodeficiency, and no antibodies against human immunodeficiency virus type 1 (HIV-1) and HIV-2 were detected. The lesions resolved after an additional seven months of treatment with isoniazid and rifampicin. Cutaneous tuberculosis constitutes < 1–2% of all cases of tuberculosis. Diagnosis is made by staining and culturing skin biopsy specimens for mycobacteria and histopathologic examination. Polymerase chain reaction may provide a more rapid diagnosis. The risk of retrobulbar neuritis with ethambutol (at a dose of 15 mg/kg/day) in children less than six years of age is < 1%.1 Delaying treatment for tuberculosis until mycobacterial antibiotic sensitivities are known is not recommended in children less than five years of age because of the associated high risk of dissemination.2
Received July 9, 2008.
Accepted for publication August 27, 2008.
Acknowledgments: We thank the parents of the child for giving consent to publish the photographs used in the figures and Dr. J. M. Deguara for interpreting the histology of the skin biopsy specimens.
Disclosure: David Pace and Simon Attard-Montalto were responsible for the overall care of the child. David Pace has received travel grants from GlaxoSmithKline Biologicals and Wyeth to attend scientific meetings. The other authors have no conflicts of interest.
* Address correspondence to David Pace, Department of Paediatrics, Mater Dei Hospital, Tal-Qroqq, Msida, MSD 2090, Malta. E-mail: dpace{at}mail.global.net.mt 
Authors’ addresses: David Pace and Simon Attard-Montalto, Department of Paediatrics, Mater Dei Hospital, Msida, Malta. Noel Gatt, Department of Pathology, Mater Dei Hospital, Msida, Malta.
 |
REFERENCES
|
- Reed MD, Blumer JL, 1983. Clinical pharmacology of antitubercular drugs. Pediatr Clin North Am 30: 177–188.[Medline]
- Pandhi D, Reddy BS, Chowdhary S, Khurana N, 2004. Cutaneous tuberculosis in Indian children: the importance of screening for involvement of internal organs. J Eur Acad Dermatol Venereol 18: 546–551.[Medline]
TOP
REFERENCES
