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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 433-435
Hand tuberculous chancre with secondary pulmonary tuberculosis


From the Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China

Date of Web Publication2-Nov-2022

Correspondence Address:
Hong Liu
From the Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_481_22

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How to cite this article:
Peng Y, Sun L, Pan Q, Chen S, Liu H, Zhang F. Hand tuberculous chancre with secondary pulmonary tuberculosis. Indian J Dermatol 2022;67:433-5

How to cite this URL:
Peng Y, Sun L, Pan Q, Chen S, Liu H, Zhang F. Hand tuberculous chancre with secondary pulmonary tuberculosis. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 8];67:433-5. Available from: https://www.e-ijd.org/text.asp?2022/67/4/433/360331




Sir,

Cutaneous tuberculosis (CTB) is a rare infection that represents 1% to 1.5% of extra-pulmonary tuberculosis.[1] We report a case caused by a wood stabbing, leading to chronic non-healing lesion, followed by the development of the secondary pulmonary tuberculosis.

A 42-year-old man presented with multiple irregular plaques with ulcers on his left hand with a history of 8 years. The lesion was initially a flat and asymptomatic nodule caused by a wooden stick stabbing, gradually increasing and slowly developed to ulcers in 3 to 6 months. Antibiotic ointment was used without improvement. The patient reported no systemic symptoms of fever, fatigue, having night sweats, and weight loss. No history of immuno-suppression was reported. Physical examinations revealed dark-red edematous plaques, papules, and nodules on his left hand and wrist as well as eroding and ulcerated lesions [Figure 1]. A skin biopsy showed tuberculoid granuloma with epithelioid cell and Langhans giant cells, and an acid-fast staining did reveal several acid-fast bacilli (AFB) [Figure 2]. The result of T-SPOT.TB test was positive. A polymerase chain reaction (PCR) confirmed the definitive microbiological diagnosis of Mycobacterium tuberculosis (M. tuberculosis). Further examination of chest radiography reported the high-density shadows in the upper lobes of both lungs. The diagnosis of tuberculous chancre and pulmonary tuberculosis was made. After 6 months of treatment with isoniazid, rifamycin, pyrazinamide, and ethambutol, the improvement of the skin lesion was observed.
Figure 1: (a) Irregular shallow ulcer and fissure with an indurated granular base and raised borders. (b) Multiple deep ulcers with a thickened scab or depressed scar on the radial side of the hand

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Figure 2: (a) Histopathology shows tuberculous granuloma infiltrated with epithelioid cells, lymphocytes, and Langhans cells. (Haematoxylin and Eosin, 80×). (b) Acid-fast staining shows acid-fast bacilli. (Acid-fast staining, 400×)

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   Discussion Top


Tuberculous chancre is a rare type of CTB caused by M. tuberculosis with varied clinical features depending on the source of infection, the route of transmission, the amount of bacteria, and the immune state of the host.[2] M. tuberculosis can enter macrophages and induce T-cell immune responses when the skin is broken. Papules, infiltrated plaques, or nodules develop at the site of inoculation 2 to 4 weeks later. Approximately in 3 to 6 months, ulcers, with a granular base, firm edge, and adherent crust, would develop. Bacilli dissemination may occur through the lymphatic flow and eventually reach the circulatory system, leading to haematogenous spread elsewhere.[3] Our patient may be attributed to the entry of the M. tuberculosis from the skin to the lungs.

The differential diagnosis of tuberculous chancre includes non-tuberculous mycobacterial infections, cutaneous mycoses, leprosy, syphilis, sporotrichosis, leishmaniasis, and so on.[4] A medical history, histopathology, screening and culture for AFB, tuberculin skin test, interferon-γ release assays, and PCR to identify the etiological agent could be used in the differential diagnosis.[5] It is remarkable that not all tests show positive results. About 3–12% of patients with cutaneous tuberculosis likely develop pulmonary tuberculosis. Thus, pulmonary tuberculosis should be considered even if the patient is asymptomatic, just like our patient. The anti-tuberculosis drugs isoniazid, rifamycin, pyrazinamide, and ethambutol remain to be the first-line treatment for all types of cutaneous tuberculosis.

This case highlights the importance of submitting samples to pathological and microbiological examinations for a correct diagnosis and appropriate treatment. Efforts to improve patients' care seeking behavior also need to be intensified.

Declaration of patient consent

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

Financial support and sponsorship

The Academic promotion programme of Shandong First Medical University (2019LJ002, 2019RC007), Youth technology the Innovation Support Project of Shandong Colleges and Universities (2019KJL003) and the Shandong Province Taishan Scholar Project (tsqn201812124).

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
van Zyl L, du Plessis J, Viljoen J. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb) 2015;95:629-38.  Back to cited text no. 1
    
2.
Djawad K, Wahab S, Massi N. Coexistence of tuberculous chancre on a chronic nonhealing wound and bilateral submandibular scrofuloderma. Acta dermatovenerologica Alp Pannonica Adriat 2021;30:79-81.  Back to cited text no. 2
    
3.
Fernandez-Nieto D, de Perosanz-Lobo D, Ortega-Quijano D, Jimenez-Cauhe J, Fernandez-Gonzalez P, Bea-Ardebol S. Tuberculous chancre in a foot leading to a disseminated tuberculosis infection. Ital Jo Dermatol Venereol 2021;156:89-91.  Back to cited text no. 3
    
4.
Brito AC, Oliveira CMM, Unger DA, Bittencourt MJS. Cutaneous tuberculosis: Epidemiological, clinical, diagnostic and therapeutic update. An Bras Dermatol 2022;97:129-44.  Back to cited text no. 4
    
5.
Agarwal P, Singh EN, Agarwal US, Meena R, Purohit S, Kumar S. The role of DNA polymerase chain reaction, culture and histopathology in the diagnosis of cutaneous tuberculosis. Int J Dermatol 2017;56:1119-24.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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