• View in gallery
    Figure 1.

    Left breast with inflammation, chronic ulcerations, abscesses with purulent discharge, and scars.

  • View in gallery
    Figure 2.

    Histopathology photograph showing granuloma, chronic inflammation.

  • View in gallery
    Figure 3.

    Positive mycobacterial culture on solid media.

  • 1.

    Global Tuberculosis Report 2017. Available at: http://www.sld.cu/noticia/2017/11/07/global-tuberculosis-report-2017. Accessed May 20, 2018.

  • 2.

    Benchikhi H, Chiheb S, 2015. Tuberculosis cutánea. EMC-Dermatología 49: 18.

  • 3.

    Van Zyl L, du Plessis J, Viljoen J, 2015. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb) 95: 629638.

  • 4.

    Fitzgeral DW, Sterling TR, 2018. Mycobacterium tuberculosis. Mandell, Douglas y Bennett. Enfermedades infecciosas. Principios y práctica. Barcelona, Spain: Elsevier, 2977.

  • 5.

    Tappeiner G, 2008. Tuberculosis and infections with atypical mycobacteria. Wolff K, Goldsmith LA, Katz SI et al., eds. Fitzparick’s Dermatology in General Medicine, 7th edition. New York, NY: McGraw Hill Medical, 1768.

  • 6.

    Bravo FG, Gotuzzo E, 2007. Cutaneous tuberculosis. Clin Dermatol 25: 173180.

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Cutaneous Tuberculosis Presenting as Mastitis in a Prepubertal Girl

Catalina Arango-FerreiraDivision of Pediatric Infectious Diseases, Hospital San Vicente Fundación Medellín, Colombia;
Department of Pediatrics, Medical School, University of Antioquia, Medellín, Colombia;

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Claudia M. Zapata-MuñozResident in Pediatrics, Medical School, University of Antioquia, Medelllín, Colombia;

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Eduardo GotuzzoInstituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú

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A 9-year-old girl, from a rural area of Chocó in Colombia, had 10 months of multiple lesions involving the left breast. She denied previous trauma, but often had swum in rural fresh water ponds. The lesions were reported to have started as a single hyperpigmented brown non-painful plaque that became a papule, and then a pustule. Fistulization followed, and then purulent drainage. Similar lesions appeared around the areola with scarring and chronic ulceration. The lesions recurred and were painful. Empiric oral and intravenous antibiotics were prescribed without improvement. Physical examination showed the breast to be swollen and tender. Ten lesions around the areola were seen, a combination of scars, ulcers, abscesses, and cutaneous fistulas (Figure 1). The right breast was unaffected. Chest x-ray and complete blood counts were normal; a fourth-generation test for the human immunodeficiency virus-1 was negative. Three pus samples obtained by digital compression were negative by Ziehl-Neelsen, Kinyoun, and Gomori methenamine–silver stains (Figure 2). A skin biopsy showed giant cell granulomas without caseation and acute inflammation. By the time the patient was reexamined 4 weeks later, all three samples yielded positive mycobacterial cultures on solid media (Figure 3). A rapid lateral flow assay (SD BIOLINE TB Ag MPT64 Rapid TEST) was consistent with Mycobacterium tuberculosis complex, further confirmed by polymerase chain reaction (GenoType Direct mycobacterial assay, Anyplex micobacterium tuberculosis/non tuberculous micobacteria assay). Primary cutaneous tuberculosis (TB) was confirmed. After mycobacteriological sensitivities were confirmed, the patient was started on standard four-drug therapy with isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, and isoniazid and rifampin after that to complete 6 months of therapy. Three household neighbors were diagnosed with pulmonary TB after a home investigation.

Figure 1.
Figure 1.

Left breast with inflammation, chronic ulcerations, abscesses with purulent discharge, and scars.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 6; 10.4269/ajtmh.18-0413

Figure 2.
Figure 2.

Histopathology photograph showing granuloma, chronic inflammation.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 6; 10.4269/ajtmh.18-0413

Figure 3.
Figure 3.

Positive mycobacterial culture on solid media.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 6; 10.4269/ajtmh.18-0413

Tuberculosis affecting children was approximately 7% of all newly reported cases in 2016 worldwide.1 Cutaneous TB is an uncommon form of extrapulmonary TB, representing 1–2% such infections. Skin manifestations can occur through three different mechanisms, which are related to clinical presentation: 1) exogenous inoculation (verrucosa cutis); 2) dissemination of an endogenous infection such as scrofuloderma, osteomyelitis, or TB orificialis by autoinoculation; or 3) hematogenous spread from a distant infection site as miliary TB.24 Differential diagnoses include environmental mycobacteria, leprosy, cutaneous leishmaniasis, Nocardia spp., actinomycosis, deep fungal infections, and idiopathic granulomatous mastitis.5,6 Diagnosis is confirmed through combination of stains, cultures, and molecular tests, which determines treatment.

REFERENCES

  • 1.

    Global Tuberculosis Report 2017. Available at: http://www.sld.cu/noticia/2017/11/07/global-tuberculosis-report-2017. Accessed May 20, 2018.

  • 2.

    Benchikhi H, Chiheb S, 2015. Tuberculosis cutánea. EMC-Dermatología 49: 18.

  • 3.

    Van Zyl L, du Plessis J, Viljoen J, 2015. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb) 95: 629638.

  • 4.

    Fitzgeral DW, Sterling TR, 2018. Mycobacterium tuberculosis. Mandell, Douglas y Bennett. Enfermedades infecciosas. Principios y práctica. Barcelona, Spain: Elsevier, 2977.

  • 5.

    Tappeiner G, 2008. Tuberculosis and infections with atypical mycobacteria. Wolff K, Goldsmith LA, Katz SI et al., eds. Fitzparick’s Dermatology in General Medicine, 7th edition. New York, NY: McGraw Hill Medical, 1768.

  • 6.

    Bravo FG, Gotuzzo E, 2007. Cutaneous tuberculosis. Clin Dermatol 25: 173180.

Author Notes

Address correspondence to Catalina Arango Ferreira, Department of Pediatrics, Medical School, University of Antioquia, Medellín, Colombia. E-mail: catarango52@hotmail.com

Authors’ addresses: Catalina Arango-Ferreira, Department of Pediatrics, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia, and Hospital Universitario San Vicente de Paul, Medellin, Colombia, E-mail: catarango52@hotmail.com. Claudia M. Zapata-Muñoz, Department of Pediatrics, Facultad de Medicina, Universidad de Antioquia, Medellin, Colombia, E-mail: cmaria.zapata@udea.edu.co. Eduardo Gotuzzo, Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú, E-mail: eduardo.gotuzzo@upch.pe.

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