Tuberculosis Cutis Orificialis.

A 24-year-old female was referred to the department of plastic surgery with a large, painful, fungating lesion of the upper lip that had gradually enlarged over the preceding 9 months (Figure 1). She reported a 9-month history of chronic cough, together with night sweats and significant weight loss, which she quantified by a drop in 2 clothes sizes. She had no medical history and no recent travel history.

Figure 1. 

Large fungating lesion on the upper lip.

Physical examination was notable for temporal wasting and bilateral cervical lymphadenopathy. Right upper lobe crackles were heard upon auscultation of her chest.

A chest x-ray confirmed the presence of a right upper lobe reticulo-nodular infiltrate, and a complete blood count revealed a normocytic anemia (haemoglobin 10.6 g/dL). Liver and renal function were within normal limits. A test for HIV was negative.

A sputum sample sent for Xpert MTB/RIF assay was positive for Mycobacterium tuberculosis nucleic acid without identification of resistance to rifampicin. Mycobacterium tuberculosis was also cultured from sputum after 14 days using Mycobacteria Growth Indicator Tube (MGIT) liquid culture. The GenoType MTBDRplus assay was used for speciation and to genotypically assess for resistance mutations to rifampicin and isoniazid, of which none were identified.

Two tissue biopsy specimens obtained from the upper lip lesion demonstrated a dense subepithelial inflammatory cell infiltrate and granulomatous inflammation with no features of dysplasia or invasive malignancy. No viral cytopathic changes were noted. Grocott, Alcian blue, and Periodic-acid Schiff stains failed to identify fungal elements. A Ziehl-Neelsen stain highlighted the presence of acid-fast bacilli. Fine needle aspiration of the enlarged cervical lymph nodes demonstrated granulomatous inflammation in keeping with mycobacterial infection.

A diagnosis of pulmonary and cutaneous mycobacterium tuberculosis (specifically, tuberculosis cutis orificialis) was made based on sputum and histopathology results. Cutaneous tuberculosis is uncommon and occurs in 1%–2% of all cases of tuberculosis [1]. Clinical presentations vary widely and are dependent on the mode by which the disease is spread, whether hematogenous, contiguous, or by direct inoculation (Table 1) [1]. Additionally, pauci-bacillary cutaneous hypersensitivity reactions due to mycobacterium tuberculosis may occur in individuals with a high degree of immunity [2].

Table 1.

Classification of Cutaneous Tuberculosis According to Mode of Infection

Direct inoculation

Tuberculosis verrucosa cutis

Primary inoculation tuberculosis (tuberculous chancre)

Contiguous spread

Tuberculosis cutis orificialis

Scrofuloderma

Lupus vulgaris

Hematogenous spread

Acute cutaneous miliary tuberculosis

Metastatic tuberculous abscesses (tuberculous gumma)

Lupus vulgaris

Tuberculids

Papulonecrotic tuberculid

Erythema induratum of Bazin

Lichen scrofulosorum

Tuberculosis cutis orificialis is a rare form of cutaneous tuberculosis and is due to the autoinoculation of mucocutaneous tissues from a visceral site of infection such as the lungs, gastrointestinal tract, or genitourinary tract [3]. It usually presents as a painful oral or anal ulcer, but hypertrophic, verrucous plaques are occasionally seen [1]. Important differential diagnoses for tuberculosis cutis orificialis include cutaneous malignancy, fungal infections (paracoccidiomycosis), viral infections (herpes simplex), and bacterial infections (syphilis) [2].

Treatment of cutaneous tuberculosis can be difficult. It depends on the extent of the disease, the host immune status, or the presence of drug-resistant tuberculosis. Our patient was started on antituberculosis therapy comprising rifampicin, isoniazid, ethambutol, and pyrazinamide with a plan to complete 6 months of treatment. After 2 months of treatment, the skin lesion showed a marked improvement (Figure 2).

Figure 2. 

Photograph of tuberculosis cutis orificialis after 2 months of antituberculosis therapy.

This case highlights the variable ways in which tuberculosis may present. Cutaneous tuberculosis should be considered in any patient with an unexplained ulcer, papule, nodule, warty lesion, or plaque, particularly in patients living in, or traveling from, countries in which tuberculosis is regarded as endemic.