Summary Eosinophilic granulomatosis with polyangiitis (EGPA), or Churg-Strauss Syndrome (CSS) is a rare granulomatous necrotizing vasculitic disease characterized by the presence of asthma, sinusitis, and hypereosinophilia. We describe a patient who was initially diagnosed with tuberculous lymphadenitis and later diagnosed with EGPA.
Granulomatosis with Polyangiitis ; Tuberculosis, Cutaneous ; Tuberculosis, Lymph Node

INTRODUCTION: Cutaneous involvement is relatively uncommon representing a small fraction (1-2%) of the localizations of extrapulmonary tuberculosis. Cutaneous TB presents with several clinical forms, wherein one of the most common is scrofuloderma resulting from the direct extension of a tuberculous focus from a deeper structure such as the lymph node into the overlying skin. Tuberculous gumma is a rare form which occurs due to hematogenous spread of the TB bacilli. Although presenting with a wide clinical spectrum, it is believed that the association of different morphologies as well as numerous lesions and sites of cutaneous TB in a same patient is very rare.

CASE REPORT: This is a case of a 20-year-old Filipino male presented with a fi ve-month history of several progressive cutaneous lesions initially presenting as subcutaneous nodules evolving into well-demarcated suppurative painless ulcers which were unresponsive to topical antibiotic. Skin punch biopsy from the medial malleolar area of the right foot revealed dilated blood vessels with a diffuse inflammatory infiltrate of lymphocytes, histiocytes, and few multinucleated giant cells. Clinical and laboratory findings were consistent with cutaneous tuberculosis. Patient was started on anti-Koch's treatment regimen and presented an excellent response to treatment showing resolution of the skin lesions on the neck and forearms and notable regression of the lesions on the right foot within four (4) months.

CONCLUSION: This case serves as a reminder that cutaneous tuberculosis can manifest with a wide spectrum of clinical presentation which can mimic diverse dermatological conditions and may present with high rates of negative or equivocal diagnostic testing results. This report highlights the importance of a high index of suspicion in the timely diagnosis and management of tuberculosis in countries wherein tuberculosis remains a significant health burden such as the Philippines.

KEYWORDS: Cutaneous tuberculosis, Scrofuloderma, Tuberculous gumma, Metastatic tuberculous abscess

Summary Tuberculosis (TB) is a serious communicable disease of major concern in endemic regions. Cutaneous tuberculosis (CTB), which accounts for less than 1% of all cases, can cause severe infection in susceptible patients. The diagnosis of CTB is challenging as it can present with a multitude of clinical presentations. The diagnosis must be supported by highly sensitive and specific investigations. This paper highlights the susceptibility of immunocompromised patients to the development of CTB and the challenges in making a diagnosis.
Tuberculosis, Cutaneous ; HIV Infections

No abstract available.
DNA* ; Mycobacterium tuberculosis* ; Mycobacterium* ; Polymerase Chain Reaction* ; Tuberculosis* ; Tuberculosis, Cutaneous

A 33-year-old male had a 22-year history of generalized xanthogranulomas but had a normal lipid profile. He also developed ulcerating plaques on his arm and back that were consistent with cutaneous tuberculosis on histopathologic and polymerase chain reaction PCR studies. In a normolipemic patient with generalized xanthogranulomas, a reactive granulomatous response of histiocytes to infection is explored since these share a common CD 14+ precursor with the macrophages that are vital in tuberculosis.

A 52-year-old woman presented with erythematous nodules and swelling on both upper eyelids. She had a surgical history of blepharoplasty about 10 years previously. Skin biopsy revealed non-caseating granulomas in the dermis. Mycobacterium tuberculosis (MTB) polymerase chain reaction (PCR) testing of the tissue sample was positive. In addition, the serum interferon gamma release assay (IGRAs) result was positive. Based on the positive result of MTB PCR and IGRAs, a diagnosis of tuberculosis was made. Despite a 2-month treatment with anti-tuberculosis medication, the skin lesions worsened. An additional skin biopsy was taken and AFB stain, AFB culture, and MTB PCR of the tissue were all negative. Four months after systemic corticosteroid treatment, the skin lesion had almost cleared. Considering that there have been many reports of positive results of MTB PCR in sarcoidosis tissue and IGRAs, a diagnosis of tuberculosis based on the results of PCR and IGRAs needs to be interpreted with caution. Also, evaluation of other organ involvement including the lungs can be helpful in making a correct diagnosis.
Biopsy ; Blepharoplasty ; Dermis ; Diagnosis ; Eyelids* ; Female ; Granuloma ; Humans ; Interferons ; Lung ; Middle Aged ; Mycobacterium tuberculosis ; Polymerase Chain Reaction ; Sarcoidosis* ; Skin ; Tuberculosis ; Tuberculosis, Cutaneous*

Perforating granuloma annulare (PGA), a rare variant of granuloma annulare, is characterized by transepidermal elimination of altered collagen that clinically manifests an umbilicated papule with a central crust. It can be confused with papulonecrotic tuberculid (PNT) because of their similar appearance. Unlike PGA, PNT is usually related to tuberculosis infection with a typical histologic finding of wedge-shaped dermal necrosis. Here, we report the first Korean case of PGA mimicking PNT both clinically and histologically. A 43-year-old Korean woman presented with erythematous papules localized on the extensor surface of her limbs for one year. Some of these papules had a central umbilication or a crust. Regarding comorbidity, she had latent tuberculosis diagnosed with QuantiFERON®-TB Gold test about five months ago. She was on antituberculous medication. Initially, a diagnosis of papulonecrotic tuberculid accompanied by latent tuberculosis was considered. However, despite taking the antituberculous medication for five months, her skin lesions were not improved. Biopsy specimen from her arm lesion showed wedge-shaped area of necrosis in the dermis. Additionally, there were multiple focal mucin depositions and palisading granulomatous inflammation throughout the dermis. A diagnosis of PGA was made and she was treated with topical corticosteroid. After two weeks of applying topical corticosteroid, most of her skin lesions disappeared, leaving some hyperpigmented scars.
Adult ; Arm ; Biopsy ; Cicatrix ; Collagen ; Comorbidity ; Dermis ; Diagnosis ; Extremities ; Female ; Granuloma Annulare* ; Granuloma* ; Humans ; Inflammation ; Latent Tuberculosis ; Mucins ; Necrosis ; Skin ; Tuberculosis ; Tuberculosis, Cutaneous*

Tuberculosis verrucosa cutis is a warty form of cutaneous tuberculosis. It is a paucibacillary disorder caused by external reinfection of mycobacteria into the skin of previously sensitized individuals with moderate to strong cell-mediated immunity. Inoculation arises at sites of minor wounds, or rarely from the patient's sputum. Tuberculosis verrucosa cutis begins as a small papule and grows slowly by peripheral expansion, sometimes reaching a size of several centimeters or more in diameter. For definitive diagnosis of cutaneous tuberculosis, the demonstration of Mycobacterium tuberculosis is essential. However, the laboratory diagnosis of paucibacillary cutaneous tuberculosis is very difficult owing to the poor sensitivity of routine available methods. Herein, we report two cases of tuberculosis verrucosa cutis definitively confirmed by mycobacterial culture in Korean patients who had received bacille Calmette-Guerin vaccination earlier in life.
Clinical Laboratory Techniques ; Diagnosis ; Humans ; Immunity, Cellular ; Mycobacterium tuberculosis ; Skin ; Sputum ; Tuberculosis* ; Tuberculosis, Cutaneous ; Vaccination ; Wounds and Injuries

Nodular tuberculid (NT) was originally described by Jordaan et al. in 2000 in 4 patients from South Africa. It appeared as nodules on the legs; the pathologic changes were situated in the deep dermis and adjacent subcutaneous fat. A 34-year-old woman visited our hospital with subcutaneous skin-colored or slightly erythematous round to oval nodules. Skin biopsies revealed granulomatous inflammation at the dermo-subcutaneous junction with vasculitis. Chest X-ray, tuberculosus (TB)-polymerase chain reaction and TB culture of the skin specimen were normal. A QuantiFERON®-TB Gold test (QUIAGEN, Germany) was positive, which suggested a diagnosis of latent TB infection. The patient was treated with anti-TB medication and her condition has not recurred. Herein, we report a case of a patient with latent TB diagnosed by a positive QuantiFERON®-TB Gold test whose skin lesions had the clinical and histopathologic features of NT.
Adult ; Biopsy ; Dermis ; Diagnosis ; Female ; Humans ; Inflammation ; Leg* ; Skin Pigmentation* ; Skin* ; South Africa ; Subcutaneous Fat ; Thorax ; Tuberculosis, Cutaneous ; Vasculitis

Nodular tuberculid (NT) was originally described by Jordaan et al. in 2000 in 4 patients from South Africa. It appeared as nodules on the legs; the pathologic changes were situated in the deep dermis and adjacent subcutaneous fat. A 34-year-old woman visited our hospital with subcutaneous skin-colored or slightly erythematous round to oval nodules. Skin biopsies revealed granulomatous inflammation at the dermo-subcutaneous junction with vasculitis. Chest X-ray, tuberculosus (TB)-polymerase chain reaction and TB culture of the skin specimen were normal. A QuantiFERON®-TB Gold test (QUIAGEN, Germany) was positive, which suggested a diagnosis of latent TB infection. The patient was treated with anti-TB medication and her condition has not recurred. Herein, we report a case of a patient with latent TB diagnosed by a positive QuantiFERON®-TB Gold test whose skin lesions had the clinical and histopathologic features of NT.
Adult ; Biopsy ; Dermis ; Diagnosis ; Female ; Humans ; Inflammation ; Leg* ; Skin Pigmentation* ; Skin* ; South Africa ; Subcutaneous Fat ; Thorax ; Tuberculosis, Cutaneous ; Vasculitis