Disseminated Mycobacterium Tuberculosis with Ulceronecrotic Cutaneous Disease Presenting As Cellulitis Kelly L

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Disseminated Mycobacterium Tuberculosis with Ulceronecrotic Cutaneous Disease Presenting as Cellulitis Kelly L. Reed DO Lehigh Valley Health Network, [email protected]

Nektarios I. Lountzis MD Lehigh Valley Health Network, [email protected]

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Published In/Presented At Reed, K., Lountzis, N. (2015, April 24). Disseminated Mycobacterium Tuberculosis with Ulceronecrotic Cutaneous Disease Presenting as Cellulitis. Poster presented at: Atlantic Dermatological Conference, Philadelphia, PA.

This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact [email protected]. Disseminated Mycobacterium Tuberculosis with Ulceronecrotic Cutaneous Disease Presenting as Cellulitis Kelly L. Reed, DO and Nektarios Lountzis, MD Lehigh Valley Health Network, Allentown, Pennsylvania

Case Presentation: Discussion: Patient: 83 year-old Hispanic female Cutaneous tuberculosis (CTB) was first described in the literature in 1826 by Laennec and has since been History of Present Illness: The patient presented to the hospital for chest pain and shortness of breath and was treated for an NSTEMI. She was noted reported to manifest in a variety of clinical presentations. The most common cause is infection with the to have redness and swelling involving the right lower extremity she admitted to having for 5 months, which had not responded to multiple courses of antibiotics. She acid-fast bacillus Mycobacterium tuberculosis via either primary exogenous inoculation (direct implantation resided in Puerto Rico but recently moved to the area to be closer to her children. Our dermatology service was consulted for evaluation of the lesions. Her medical history of mycobacterium into the skin), secondary to endogenous spread (hematogenous or direct extension of was pertinent for chronic low dose systemic corticosteroids for polymyalgia rheumatica. She denied fever, cough, night sweats, fatigue or other systemic symptoms. mycobacterium to the skin from an internal source, typically lung), or as a cutaneous reaction known as a tuberculid (reactive eruption without the presence of mycobacterium in the skin). Occasionally M.bovis Medical History/Surgical History: polymyalgia rheumatica, coronary artery disease, diabetes mellitus type 2, hypertension, atrial fibrillation, asthma, and the bacilli Calmette-Guérin (BCG) vaccine have been reported to cause cutaneous disease. Cutaneous hyperlipidemia tuberculosis accounts for <1-2% of all cases of TB and most often affects immunocompromised hosts due to Social History: >100 pack year smoking history HIV infection or medications, such as TNF-α inhibitors and corticosteroids. Current Medications: prednisone 5mg, quinapril, pravastatin, albuterol inhaler, fluticasone inhaler, aspirin, insulin glargine, diltiazem Clinical presentation is extremely variable and is dependent upon the route of infection and the bacterial load in lesions. Exogenous inoculation often causes a tuberculous chancre or TB verrucosa cutis, while endogenous Physical Examination: Afebrile with multiple red to purple painful indurated plaques associated with pitting edema extending along the right lower extremity spread causes scrofuloderma, miliary TB or lupus vulgaris. Tuberculids are reactive conditions, which include and foot in a geographic distribution. Over the course of two weeks, the lesions became progressively necrotic and ulcerated. The left leg and remainder of skin exam papulonecrotic lesions, lichen scrofulosorum and erythema induratum. Tuberculous cellulitis, as our patient was unremarkable. developed, is an uncommon presentation and does not fit neatly into the aforementioned categories. Laboratory Data: QuantiFERON TB Gold - positive Diagnosis of cutaneous TB is multifaceted and often includes a combination of the following modalities: Biopsy: Health Network Labs (S14-32700, 09/25/14) Right lateral upper leg: “Neutrophilic and focally granulomatous dermatitis.” Acid fast stain- negative PPD, interferon-γ release assay, tissue culture, PCR for mycobacterial DNA and tissue culture and/or biopsy with special staining techniques, such as Auramine-Rhodamine (highly sensitive fluorescent study), Ziehl- Tissue Culture: (09/25/14) Left lateral upper leg: Mycobacterium tuberculosis complex (10/02/14) Bronchial lavage lung left upper lobe: Mycobacterium Neelsen or Wade-Fite stain. The histopathological findings vary depending on the type of infection, however tuberculosis complex CTB is characteristically described as a mixed inflammatory reaction of the dermis and subcutis comprised Imaging: Chest x-ray (09/25/14) Well-circumscribed opaque nodules in bilateral lungs of neutrophils, multinucleate giant cells and epithelioid histiocytic granulomas, which may display some caseation necrosis. Diagnosis: Disseminated Mycobacterium tuberculosis Treatment of CTB is primarily antibiotic therapy, based upon the culture and sensitivities of the isolated strain Treatment: Topical wound care and quadruple antibiotic therapy with rifampin, isoniazid, ethambutol, pyrazinamide of M. tuberculosis due to the rise in multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR- TB). This patient represents an interesting case of cutaneous tuberculosis from endogenous spread, presenting as a recalcitrant “cellulitis” that deteriorated to an uncommon ulceronecrotic form of the disease. Typically ulceronecrotic cases are due to tuberculid reactions, however in this case, the isolation of bacilli on tissue culture favors this to be an active cutaneous infection from hematogenous spread. There are fewer than ten reported cases of tuberculous cellulitis in the literature, seven of which reported systemic corticosteroid use, similar to our patient. Studies estimate approximately 20% of patients with CTB may have concomitant pulmonary TB as in our patient’s case. This case is relevant to dermatologists, because it increases awareness of cutaneous TB as the presenting symptom of disseminated tuberculosis infections in immunocompromised patients. It also serves as a reminder to maintain a high index of suspicion for such opportunistic infections, specifically in cases of resistant cellulitides and to complete a thorough patient work-up.

References: Figure 1: Right lateral thigh with erythematous plaque Figure 2: Right medial foot with erythematous plaque Figure 3: Right dorsal foot with necrotic ulcerated Figure 4: Right lateral foot with large ulcerated plaque 2 and central ulceration developing at site of biopsy. and central stellate purpura and necrosis. plaque. weeks after admission. 1 Taguchi R, Nakanishi T, Imanishi H, et al. A case of tuberculous cellulitis. Clinical Medicine Insights: Case reports. 2015;(8):11-12. 2 Dias M, Quaresma M, Azulay D, et al. Update on cutaneous tuberculosis. An Bras Dermatol. 2014; 89(6):925-938. 3 Daido-Horiuchi Y, Kikuchi Y, Kobayashi S, et al. Tuberculous cellulitis in a patient with chronic kidney disease and polymyalgia rheumatica. Intern Med. 2012; 51:3203-3206. 4 Mahmud T, Paul HK, Zakaria ASM, et al. Study on association of cutaneous tuberculosis with pulmonary tuberculosis. Bangladesh Med Res Counc Bull. 2010;36:57-60. 5 Koba S, Okawa T, Misago N, et al. A case of tuberculous cellulitis lacking epithelioid granuloma. Acta Derm Venereol. 2013;93:596-597.

Figure 5: Chest x-ray with opaque nodules in Figure 6: H&E 4x Punch biopsy right lateral Figure 7: H&E 10x Closer view of histiocytic bilateral lungs. thigh showing neutrophilic and granulomatous epithelioid granuloma. dermatitis.