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Year : 2021  |  Volume : 22  |  Issue : 4  |  Page : 363-366

Chronic foot ulcers – Rule out cutaneous tuberculosis!

Department of Dermatology, Government Medical College, Amritsar, Punjab, India

Date of Submission10-Sep-2020
Date of Decision18-May-2021
Date of Acceptance12-Jun-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Tejinder Kaur
Department of Dermatology, Government Medical College, Amritsar, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.ijpd_140_20

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Cutaneous tuberculosis is a form of extrapulmonary tuberculosis and is seen in a small but significant subset of patients seeking dermatology outpatient services. Children constitute a significant proportion of overall cases of cutaneous tuberculosis. We report the case of an 8-year-old boy who presented with multiple discharging ulcers over bilateral feet. High suspicion of cutaneous tuberculosis led to early diagnosis and initiation of therapy. Cutaneous tuberculosis can have a varied clinical presentation. We wish to draw attention to mycetoma-like presentation of cutaneous tuberculosis characterized by chronic discharging foot ulcers.

Keywords: Childhood, cutaneous, diabetic foot, Gram-positive cocci, mycetoma, nucleic acid amplification techniques, sclerosis, tuberculosis, World Health Organization

How to cite this article:
Arora S, Kaur T, Gandhi G. Chronic foot ulcers – Rule out cutaneous tuberculosis!. Indian J Paediatr Dermatol 2021;22:363-6

How to cite this URL:
Arora S, Kaur T, Gandhi G. Chronic foot ulcers – Rule out cutaneous tuberculosis!. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Dec 6];22:363-6. Available from: https://www.ijpd.in/text.asp?2021/22/4/363/327444

  Introduction Top

According to the World Health Organisation (WHO) global tuberculosis report 2019, incidence of tuberculosis in India in 2018 was around 2.7 million (27%) out of global incidence of 10 million.[1] A significant proportion of patients with cutaneous tuberculosis is seen in pediatric age group.[2] Pediatric tuberculosis accounts for 11% of all tuberculosis cases.[3] Extrapulmonary tuberculosis manifests in 8.4%–13.7% of all tuberculosis cases. Out of these extrapulmonary tuberculosis cases, cutaneous tuberculosis is seen in 1%–1.5% cases.[4] Similarly, osteoarticular tuberculosis is seen in 1%–3% of these extrapulmonary cases with 10% of osteoarticular tuberculosis cases affecting the foot.[5] We report the case of an 8-year-old boy with chronic foot ulcers diagnosed to have cutaneous tuberculosis.

  Case Report Top

An eight-year-old boy presented with multiple discharging sinuses and ulcers over left foot and single ulcer over the right foot for 3 months [Figure 1] and [Figure 2]. According to the parents, these started 1 year ago when he developed a painful swelling over the dorsum of the left foot. For this, he underwent a surgical procedure (details unavailable). Histopathological examination of the tissue was reported as nonspecific. Three months before presentation, he developed a single painful erosion spontaneously over the left foot which gradually increased in depth to form an ulcer. Similar lesions developed over both feet, for which he had oral and topical treatment from alternative medicine practitioners. There was no prior history of trauma. Systemic symptoms such as fever, cough, chest pain, breathlessness, abdominal pain, bowel bladder disturbances, and weight loss were absent. There was no history of drug allergy. He was completely vaccinated for his age. His father had taken antitubercular treatment (ATT) for 6 months for a lesion on the neck in his childhood.
Figure 1: Ulcers over the dorsum of left foot with secondary eczematization

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Figure 2: Ulcer over the dorsum of right foot

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The patient was poorly built (body mass index = 12.86 Kg/m2) and malnourished. Although the gait was abnormal, the child had no difficulty in walking. A single nontender, mobile, firm left inguinal lymph node of size 1 cm × 1 cm was present. Systemic examination was unremarkable. Bacillus Calmette–Guérin scar was present over the left deltoid.

Multiple sinuses and ulcers of size varying from 0.5 cm × 0.3 cm to 2 cm × 1.5 cm were present over the dorsum of bilateral feet and near the base of left great toe and first toe webspace. Some of them were oozing serosanguinous to hemorrhagic fluid, some were covered with reddish granulation tissue while others had yellowish slough. The surrounding skin was edematous and had multiple crusted plaques suggestive of secondary eczematization. On palpation, the lesions were tender, indurated, and warm with notable expression of serosanguinous to hemorrhagic material on light touch [Figure 1] and [Figure 2].

The child was anemic with a hemoglobin of 9.5 g/dl, and serum alkaline phosphatase was 602U/L. Rest of the investigations was unremarkable.

X-ray foot anteroposterior and oblique view showed evidence of an expansile lytic lesion involving the first metatarsal with surrounding sclerosis, minimal periosteal reaction, and fusiform enlargement of the medullary cavity of the metatarsal with intact cortical margins. Surrounding soft tissue edema were seen. These changes were suggestive of tubercular osteomyelitis [Figure 3].
Figure 3: X-ray left foot anteroposterior and oblique view; suggestive of tuberculous osteomyelitis

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Considering the diagnostic possibilities of chronic osteomyelitis of tubercular, deep fungal, or bacterial origin, the patient was investigated. Discharge from the ulcer was sent for cartridge-based nucleic acid amplification test (CBNAAT), Ziehl–Neelsen staining, Gram stain, and potassium hydroxide mount (KOH) examination. CBNAAT detected rifampicin-sensitive Mycobacterium tuberculosis. On Gram stain, many pus cells, Gram-positive cocci in clusters, and Gram-positive bacilli were seen. Ziehl–Neelsen staining showed acid-fast bacilli. KOH smear was negative for fungal hyphae.

Mantoux test site at 48 h showed a diffuse erythema with induration and bulla formation.

Guided by radiology and CBNAAT, a diagnosis of scrofuloderma was made and the patient was started on daily 3 fixed drug combination (pediatric) drug regimen of ATT (isoniazid, rifampicin, pyrazinamide, and ethambutol). Improvement was obtained within 3 months of starting the treatment [Figure 4]a and [Figure 4]b. The diagnosis was also supported by this rapid response to ATT.
Figure 4: (a and b) Marked improvement after 3 months of antitubercular therapy

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  Discussion Top

Cutaneous tuberculosis can affect children of all ages; the 10–14-year age group is most commonly affected. The source of childhood cutaneous tuberculosis is often a household contact with either present or past history of tuberculosis. Children are likely to have more lymph node enlargement and systemic involvement as compared to adults. Most of the patients in Indian scenario belong to low socioeconomic status families with poor living conditions.[6]

Cutaneous tuberculosis can have a varied clinical presentation.[7] In a prospective study, Vashisht et al. found scrofuloderma, lichen scrofulosorum, and lupus vulgaris as common patterns of pediatric cutaneous tuberculosis.[8]

Scrofuloderma arises by direct extension of the infection from an underlying tuberculous focus. It usually starts as a subcutaneous swelling or nodule, which ruptures over a period of time to give rise to shallow ulcers and sinuses.

Our patient developed a painful swelling which ruptured to form ulcers and sinuses over dorsum of the feet. CBNAAT of the discharging fluid was positive for rifampicin-sensitive M. tuberculosis. Most probably, the contiguous spread from the underlying infected bone had resulted in cutaneous ulcers and sinuses. As M. tuberculosis was detected on CBNAAT, biopsy was deferred.

Similar presentation has been reported wherein the patient had multiple serosanguinous discharging sinuses with deep nodules and ulcerative lesions over the left leg. The patient was initially treated on the lines of mycetoma with no response. It was only on histopathology and excellent response to ATT that diagnosis of cutaneous tuberculosis could be made.[9]

In a prospective study by Nayak et al., out of 20 ankle-foot tuberculosis cases presenting with nonhealing ulcers/abscess/sinuses for duration ranging from 3 months to 5 years, five cases were initially misdiagnosed and treated on lines of diabetic foot ulcers/rheumatoid arthritis with abscess/calcaneal osteomyelitis/arteriovenous malformation. It was only after repeated biopsies from wound margin/sinus tract/depth of wound or bone that the diagnosis of ankle-foot tuberculosis was established, and the treatment could be initiated.[10]

Another retrospective study done by Agarwal et al. aimed at reporting the manifestations of ankle and foot tuberculosis found that 6 out of 21 cases had discharging sinuses at presentation similar to our case.[11]

There is a similar case report of chronic discharging sinus on the right foot for the past 1 month not responding to antibiotics in a 22-year-old male. Guided by radiography of chest and foot, diagnosis of pulmonary tuberculosis with tubercular osteomyelitis was made. The stage of disease on presentation decides the radiographic appearance. In the initial stages, there may be absence of any radiological change except for mild soft tissue swelling. Tuberculous osteomyelitis on radiography typically presents as an eccentrically located small focus of osteolysis with the presence of local osteopenia.[12],[13]

Sethuraman et al. report a similar case presenting with chronic discharging sinuses on the lateral aspect of bilateral ankles diagnosed as scrofuloderma on skin biopsy from the sinus. Interestingly, this patient had also developed verrucous hyperkeratotic plaques, just anterior to the sinuses; which on skin biopsy were consistent with the diagnosis of tuberculosis verrucosa cutis. The reason for the symmetrical involvement in this case was attributed to local trauma and habit of walking barefoot. It was due to autoinoculation that the patient had gradually developed lesions of tuberculosis verrucosa cutis over a period of time.[14]

A nonhealing wound on the left foot of 3-year duration in a patient with diabetes mellitus was treated as diabetic foot ulcer without any improvement. Bacterial culture and polymerase chain reaction and improvement after ATT helped in diagnosis.[15]

CBNAAT is an automated, semi-quantitative polymerase chain reaction method that detects microorganisms of the M. tuberculosis complex as well as resistance of the agent to rifampicin in samples over a period of 2 h. The WHO has endorsed it as an initial diagnostic test in children suspected of having tuberculosis both in pulmonary and specific forms of extrapulmonary tuberculosis.[16]

  Conclusion Top

The involvement of feet in tuberculosis is rare. Cutaneous tuberculosis should be suspected in cases with long-standing pain/swelling/discharging sinus over the foot.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardian has given the consent for patient's images and other clinical information to be reported in the journal. The guardian understands that patient's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Available from: https://www.who.int/teams/ global tuberculosis programme/tb reports/global report 2019. [Last accessed on 2021 May 05].  Back to cited text no. 1
Kumar B, Kumar S. Pediatric cutaneous tuberculosis: Indian scenario. Indian Jour of Paediatr Dermatol 2018;19:202.  Back to cited text no. 2
Floyd K, Glaziou P, Houben RM, Sumner T, White RG, Raviglione M. Global tuberculosis targets and milestones set for 2016-2035: definition and rationale. Int J Tuberc Lung Dis 2018;22:723-30.  Back to cited text no. 3
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. 4
Dhillon MS, Nagi ON. Tuberculosis of the foot and ankle. Clin Orthop Relat Res 2002;398:107-13.  Back to cited text no. 5
Singal A, Sonthalia S. Cutaneous tuberculosis in children: The Indian perspective. Indian J Dermatol Venereol Leprol 2010;76:494-503.  Back to cited text no. 6
[PUBMED]  [Full text]  
Chen Q, Chen W, Hao F. Cutaneous tuberculosis: A great imitator. Clin Dermatol 2019;37:192-9.  Back to cited text no. 7
Vashisht P, Sahoo B, Khurana N, Reddy BS. Cutaneous tuberculosis in children and adolescents: A clinicohistological study. J Eur Acad Dermatol Venereol 2007;21:40-7.  Back to cited text no. 8
Vora RV, Diwan NG, Singhal RR. Cutaneous tuberculosis mimicking a mycetoma. J Postgrad Med 2018;64:174-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
Nayak B, Dash RR, Mohapatra KC, Panda G. Ankle and foot tuberculosis: A diagnostic dilemma. J Fam Med Prim Care 2014;3:129.  Back to cited text no. 10
Agarwal A, Qureshi NA, Khan SA, Kumar P, Samaiya S. Tuberculosis of the foot and ankle in children. J Orthop Surg (Hong Kong) 2011;19:213-7.  Back to cited text no. 11
Yuen MC, Tung WK. An uncommon cause of foot ulcer: Tuberculosis osteomyelitis. Emerg Med J 2001;18:140-1.  Back to cited text no. 12
Vohra R, Kang HS, Dogra S, Saggar RR, Sharma R. Tuberculous osteomyelitis. J Bone Joint Surg Br 1997;79:562-6.  Back to cited text no. 13
Sethuraman G, Kaur J, Nag HL, Khaitan BK, Sharma VK, Singh MK. Symmetrical scrofuloderma with tuberculosis verrucosa cutis. Clin Exp Dermatol 2006;31:475-7.  Back to cited text no. 14
Baveja CP, Gumma VN, Jain M, Jha H. Foot ulcer caused by multidrug-resistant Mycobacterium tuberculosis in a diabetic patient. J Med Microbiol 2010;59:1247-9.  Back to cited text no. 15
Sahana KS, Prabhu AS, Saldanha PR. Usage of Cartridge Based Nucleic Acid Amplification Test (CB-NAAT/GeneXpert) test as diagnostic modality for pediatric tuberculosis; case series from Mangalore, South India. J Clin Tuberc Other Mycobact Dis 2018;11:7-9.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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