Lupus Vulgaris of the External Nose in a Paediatric Patient: a Case Report from Muhimbili National Hospital, Tanzania

Global Journal of Otolaryngology ISSN 2474-7556

Lupus Vulgaris of the External Nose in a Paediatric Patient: A Case Report from Muhimbili National Hospital, Tanzania

Zephania Saitabau Abraham1*, Daudi Ntunaguzi2 Enica Richard Massawe2 and Aveline Aloyce Kahinga2 1Department of Surgery, University of Dodoma-College of Health Sciences, Tanzania 2Department of Otorhinolaryngology-Muhimbili University of Health and Allied Sciences, Tanzania Submission: March 07, 2019; Published: March 13, 2019 *Corresponding author: Zephania Saitabau Abraham, Department of Surgery, University of Dodoma-College of Health Sciences, Tanzania

Abstract

histopathologically.Lupus vulgaris isOn the local most examination, common form the ofpatient cutaneous had irregularly tuberculosis bordered, which usually well demarcated, occurs in patients whitish who to reddish have been lesion previously on her external sensitized nose. to Mycobacterium tuberculosis. We present a case of a 4-year-old girl who was diagnosed to have lupus vulgaris clinically and was then confirmed

histopathologicalThe histopathological basis examination so as to avoid showed its destructive many dermal consequences stromal granulomaswhich are mainly of epithelioid erosion of cells, the externalmany multinucleated nose, nasal cavity giant and cells the of face Langhans and in raretype. occasions, This case reportpossible is thereforedevelopment to emphasize of a carcinoma on the of importance squamous cellof early type. diagnosis of Lupus vulgaris of the external nose both clinically and on

Keywords:

Lupus Vulgaris; External Nose

Introduction diagnoses is not an easy task and it should be based on clinical grounds, histopathological or microbiological examinations and cutaneous tuberculosis which occurs in patients who have been By definition, Lupus vulgaris is a progressive form of Otorhinolaryngologists should be involved whenever a patient previously sensitized to Mycobacterium tuberculosis and the has an ulcer on the external nose that does not respond to usual disease is acquired either endogenously by haematogenous or antibiotics given in a local setting [3]. We are reporting a 4-year- exogenously by direct inoculation of the bacilli into the skin old girl who was diagnosed to have lupus vulgaris of the external or lymphatic spread from an underlying infected focus in a nose with emphasis on early clinico-histopathological diagnosis sensitized host with a moderate to high degree of immunity to of the disease so that early treatment is instituted to avoid its Mycobacterium tuberculosis [1]. It’s progressive in nature if no destructive consequences which causes mid-facial erosion any medical intervention is undertaken to control the disease. and possible development of a squamous cell carcinoma of the In developing countries like Tanzania, tuberculosis has kept on external nose in rare occasions. To the best of our knowledge, drawing attention from health care professionals and the society in general because of its multi-systemic effect, the increasing in Tanzania. incidence of multiple drug resistant TB and the surge of HIV/TB this is a first case report of Lupus Vulgaris of the External Nose co-infection which is of concern in many developing countries Case Report including Tanzania [2]. The 4-year old girl presented with a three-month history of a swelling on the external nose with no history of nasal bleeding, if its associated consequences including mid-facial destruction nasal obstruction, or constitutional symptoms of tuberculosis. Early diagnosis of Lupus Vulgaris is of paramount importance and possible development of carcinoma of the external nose The patient had a positive history of open tuberculosis contact are to be avoided and this is through high index of suspicion with her grandmother who had pulmonary tuberculosis about a by all clinicians at all levels of health care provision including year prior to the presentation of the current complaints by the primary health care facilities. Establishment of its differential patient and it was reported that the grandmother was kept on

Glob J Otolaryngol 19(4): GJO.MS.ID.556019 (2019) 0087 Global Journal of Otolaryngology a 6-months course of Anti-tuberculous chemotherapy and was it’s estimated to range from 0.5% to 10.5%. The interval from cured. On local examination the patient had well demarcated, its onset to the occurrence of malignancy ranges from 2 to 79 irregularly bordered, whitish to reddish lesion on her external years [4]. Following exogenous inoculation, lupus vulgaris nose. The patient had neither palpable peripheral lymph nodes may manifest at the site of BCG vaccination and may also be nor systemic examination abnormalities. However, the patient acquired endogenously through reactivation of dormant or has received all immunizations as per the immunization and persistent Mycobacterium tuberculosis after a reduction of vaccine development programme of Tanzania. To investigate the cell-mediated immunity [1,2,7]. Establishing the diagnosis of patient, the following were the results; Complete blood count and Urinalysis which were normal. Erythrocyte sedimentation Otorhinolaryngologists need to have a high index of suspicion. The Lupus vulgaris is not a straightforward task and clinicians and rate was 18mm/hour and HIV screening were negative. The diagnosis should mainly be based on clinico-histopathological patient had no signs or symptoms of pulmonary tuberculosis and Chest radiograph was normal. The patient was referred relying on tissue culture and polymerase chain reaction often is findings and retrospective review of response to treatment [1]; to Tuberculosis Unit and received Anti-tuberculous drugs of no help because of low yield [8]. The diagnosis of the child (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol) for 6 in this case report was established on clinico-histopathological months and was cured (Figure 1). basis following a wedge biopsy. Conclusion The aim of this case report is to emphasize on the role of early diagnosis by having a high index of suspicion of any form of

so that early initiation of anti tuberculous drugs is done so as to cutaneous tuberculosis like Lupus Vulgaris of the external nose nose and nasal cavity, and rarely development of squamous cell avoid its looming consequences like disfiguration of the external carcinoma of the external nose. Ethical consideration: A written informed consent was obtained from her biological father about publication of the case report. Figure 1: A 4-year old child with Lupus Vulgaris of the External Nose diagnosed both clinically and confirmed on References histopathological basis upon taking a wedge biopsy. 1. a pediatric patient: a clinicohistopathological diagnosis. Braz j infect disAfsar 12(2): FS, Afsar 152-154. I, Diniz G, Asilsoy S, Sorguc Y (2008) Lupus vulgaris in Discussion 2. It was once known for cutaneous tuberculosis to be a common al. (2014) Update on cutaneous tuberculosis. A Bras Dermatol 89: 925- disease but has now become rare because of improved living 938.Dias MF, Bernardes Filho F, Quaresma MV, Nascimento LV, Nery JA, et conditions, BCG vaccination and effective anti-tuberculous drugs. 3. If no intervention is promptly taken, then the course of lupus evaluation of the polymerase chain reaction for the rapid diagnosis of Cheng VC, Yam WC, Hung IF, Woo PC, Lau SK, et al. (2004) Clinical vulgaris becomes extremely chronic and thus extending over tuberculosis. J Clin Pathol 57: 281-285. many years and its ultimate consequences becomes unavoidable 4. [4]. There are reported periods of relative inactivity in lupus carcinoma of external nose. Indian J Surg Oncol 2(3): 215-217. Bhat VS, Bhandary SK, Shenoy MS (2011) A rare case of lupus vulgaris but generally it leads to considerable impairment of 5. vulgaris: A variant of extrapulmonary tuberculosis. Indian J Paediatr DermatolArya S, Kushwaha 17(2): 161-163. RK, Bunkar ML, Jain S (2016) Extensive lupus [5]. The most serious complication of untreated lupus vulgaris function and disfiguration because of its progressive nature is the development of carcinoma of the external nose [1,6]. 6. Singal A, Sonthalia S (2010) Cutaneous tuberculosis in children: The With particular emphasis in children, most cases of primary tuberculosis are contracted on the extremities and on the face 7. IndianAfsar FS,perspective. Ozcelik S,Indian Uysal J DermatolSS, Ermete Venereol M, Afsar Leprol I (2015) 76(5): 494-503.Primary inoculation tuberculosis: a report of a rare entity. Rev Soc Bras Med following scratches, bruising, lacerations, pin-pricks, impetigo, Trop 48(1): 112-124. boils piercing, tattoos, and circumcision [1,4]. 8. Malignant transformation of lupus vulgaris to lupus treatment of tuberculosis in infants. Pediatrics 94(1): 1-7. Vallejo JG, Ong LT, Starke JR (1994) Clinical features, diagnosis, and carcinoma has been reported in certain parts of the World and

How to cite this article: Zephania S A, Daudi N, Enica R M, Aveline A K. Lupus Vulgaris of the External Nose in a Paediatric Patient: A Case Report from 0088 Muhimbili National Hospital, Tanzania. Glob J Oto, 2019; 19(4): 556019. DOI: 10.19080/GJO.2019.19.556019. Global Journal of Otolaryngology

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How to cite this article: Zephania S A, Daudi N, Enica R M, Aveline A K. Lupus Vulgaris of the External Nose in a Paediatric Patient: A Case Report from 0089 Muhimbili National Hospital, Tanzania. Glob J Oto, 2019; 19(4): 556019. DOI: 10.19080/GJO.2019.19.556019.