Multi focal tuberculosis

Introduction

Cutaneous tuberculosis makes up a small proportion of all cases of extra-pulmonary tuberculosis. Tuberculous gumma is the result of haematogenous dissemination from a primary focus. It presents either as a firm subcutaneous nodule which slowly softens or as an ill-defined fluctuant swelling. The extremities are more often affected than the trunk. Tubercular dactilitis constitutes 2. 5% of skeletal tuberculosis and is uncommon after the age of 6 year. The hand is more frequently involved than foot.[1]

Case Report

A 19-year-old salesman first noticed a swelling over the left ankle which gradully increased in size and burst to form a discharging sinus. Later, he developed similar swellings and sinuses over the right index finger, base of right thumb, back of elbow, dorsum of left hand left little finger, base of middle three toes, the right foot and great and little toes of the left foot. The swellings were associated with pain. Examination revealed swellings distributed over dorsum of left hand and middle phalanx of left index finger and base of left little finger. The swellings were fusiform, fluctuant, non-tender, varying from 1 cm to 3 cm. in length. Multiple sinuses few discharging purulent material were noted over base of right thumb, base of left little finger, lateral aspect of left heel and base of left little toe, and point of right elbow. There was hyperpigmentation and oedema surrounding the sinuses. Purulent discharge could be expressed from few sinuses. Puckered scars were present over the base of III/ IV toes and over great toe of left foot, and lateral aspect of right thenar eminence. The scars were fixed to the underlying tissue. Hair, nail, mucous membranes and genitalia were normal. Systemic examination did not reveal any abnormality.

He was provisionally diagnosed as a case of tubercular gumma. ESR was 51 mm, X-ray chest showed apical cavity and infiltration suggestive of tuberculosis sputum for AFB was negative. Mantoux test was positive. X-ray both hands showed irregular osteolytic lesions with pathological fracture. Smear taken from the pus was negative for AFB Pus for AFB. culture on Lowenstein Jensen medium was positive. VDRL was non-reactive. HIV test I & II was negative. Biopsy taken from the swelling on the dorsum of left hand showed tubercular granulation tissue. The patient was started on antituberculosis treatment. With treatment the patient stopped developing new lesions and old lesions healed.

Discussion

The patient had multiple tubercular gummata, pulmonary tuberculosis and dactilitis which led to pathological fracture. The occurrence of the gumma is uncommon. Farine et al had reported 2 cases of tubercular gumma in their study of 11 cases of cutaneous tuberculosis.[2] Tubercular infection involving multiple systems like skin, lungs and bones as in our case is also rare. Bard et al had reported a case of cutaneous tuberculosis caused by Mycobaterium africanum, which was associated with bilateral nodular scleritis, nasal septal perforation and pulmonary tuberculosis.[3] In recent years, cutaneous infections with Mycobacterium tuberculosis with an atypical clinical appearance have become more common because of increased number of immunocom-promised patients. Corbett et al had reported 4 cases of disseminated cutaneous tuberculosis in HIV positive patients all of whom also had pulmonary tuberculosis.[4] However the reported case had multisystem involvement even though he was HIV negative.