|Year : 2021 | Volume
| Issue : 4 | Page : 363-366
Chronic foot ulcers – Rule out cutaneous tuberculosis!
Sunita Arora, Tejinder Kaur, Guneet Gandhi
Department of Dermatology, Government Medical College, Amritsar, Punjab, India
|Date of Submission||10-Sep-2020|
|Date of Decision||18-May-2021|
|Date of Acceptance||12-Jun-2021|
|Date of Web Publication||01-Oct-2021|
Department of Dermatology, Government Medical College, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
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|| |
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. A significant proportion of patients with cutaneous tuberculosis is seen in pediatric age group. Pediatric tuberculosis accounts for 11% of all tuberculosis cases. 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. Similarly, osteoarticular tuberculosis is seen in 1%–3% of these extrapulmonary cases with 10% of osteoarticular tuberculosis cases affecting the foot. We report the case of an 8-year-old boy with chronic foot ulcers diagnosed to have cutaneous tuberculosis.
| Case Report|| |
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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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|| |
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.
Cutaneous tuberculosis can have a varied clinical presentation. In a prospective study, Vashisht et al. found scrofuloderma, lichen scrofulosorum, and lupus vulgaris as common patterns of pediatric cutaneous tuberculosis.
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.
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.
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.
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.,
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.
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.
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.
| Conclusion|| |
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]