Metastatic tuberculous abscesses in an immunocompetent patient

Abstract

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.

Tuberculosis extrapulmonar, una revisión

“…Metastatic tuberculous abscesses also known as tuberculous gummas usually arise as a consequence of hematogenous spread of the bacillus from a primary focus of infection to the subcutaneous tissue during a state of reduced cell-mediated immunity 34 . These lesions typically occur in malnourished children and immunosuppressed adults, although cases have also been reported in immunocompetent individuals 32,35 . This form of the disease is more typically observed in highly endemic regions, however we have been observing an upturn in developed countries due to the expansion of HIV infection and to a progressive increase of immunosuppressive treatments.…”

Musculoskeletal Tuberculosis Presenting as Isolated Tuberculous Gumma in an Immunocompetent Patient

“…In musculoskeletal tuberculosis, metastatic tuberculous abscesses, also called tuberculous gummas, are the result of a subcutaneous tuberculous process that leads to cold abscess formation and secondary breakdown of the overlying skin, resulting in skin ulceration (2). The physiopathological mechanism is that it is actually a consequence of metastatic spreading via the blood, of latent mycobacteria, which form abscesses most frequently in the limbs or trunk, usually sparing deeper tissue (7).…”

“…However, it is a rare disease in immunocompetent patients and it is also very rare that isolated gumma is the first clinical presentation of TB in immunocompetent patients (1)(2)(3). Radiologic findings of tuberculous gumma, especially in immunocompetent patients have not been reported (4)(5)(6).…”

Una causa inusual de absceso cutáneo a tener en cuenta

“…La tuberculosis gomosa o colicuativa (abscesos metastásicos tuberculosos) es una variante rara de la tuberculosis cutánea generalmente producida por la diseminación hematógena de M. tuberculosis desde un foco primario o en el seno de una tuberculosis miliar [1][2][3][4] . A diferencia del escrofuloderma, no existe contigüidad con ningún foco de tuberculosis ósea o ganglionar subyacente [2][3][4] .…”

“…Suele afectar a niños malnutridos y pacientes inmunodeprimidos (ID) aunque de forma excepcional se describen casos en huéspedes inmunocompetentes (IC) 1,5,6 . Clínicamente se caracteriza por la formación de nódulos subcutáneos indoloros de lento crecimiento o abscesos fríos con edema fluctuante, localizados principalmente en el tronco y las extremidades, que tienden a ulcerarse dando lesiones de bordes abruptos violáceos con supuración típicamente caseificada 1,5 . A diferencia del caso que presentamos, las lesiones cutáneas aisladas son características de pacientes IC mientras que una afectación cutánea múltiple en localizaciones atí-picas debería orientar hacia el estudio de inmunosupresión 1,5,7,8 .…”