Letter to the Editor
Perianal cutaneous tuberculosis: A case study
Tuberculosis cutánea perianal: estudio de un caso
José Juan Parra García
, Marta Segado Sánchez, Miguel Lova Navarro
Corresponding author
Servicio de Dermatología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Perianal ulcer with well-defined borders, predominantly on the left side with mucopurulent exudate. B) Chest X-ray. Severe pulmonary emphysema with multiple bilateral apical fibrotic opacities. C) Haematoxylin-eosin staining, 40×: granulomatous necrotising and suppurative dermatitis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis has emerged as a pressing health concern, with a global incidence rate of 132 cases per 100,000 individuals in 2019.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> This increase is largely due to immunosuppressive factors, which predispose to more disseminated presentations with vague clinical features and high mortality rates.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Extrapulmonary tuberculosis refers to infections caused by <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> that affect tissues and organs beyond the lung parenchyma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,5</span></a> Cutaneous tuberculosis, which constitutes only 1%–4% of cases, commonly manifests as scrofuloderma and lupus vulgaris.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,5</span></a> Periorificial cutaneous tuberculosis, which accounts for 2% of cutaneous TB cases, arises from local autoinoculation of the bacillus, resulting in ulcerative lesions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Unconventional clinical presentations, such as the one discussed here, can hinder timely diagnosis, potentially leading to delays in initiating treatment and high morbidity and mortality rates.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A 45-year-old male with an unremarkable medical history, except for asthma controlled by the allergology department, was referred to the dermatology department from general surgery due to painful erosive lesions in the perianal region that persisted for 9 months. Despite extensive topical treatment (rectal ointment with lidocaine, triamcinolone acetonide and pentosan polysulphate sodium), the ulcerative lesion showed no signs of improvement. Close examination revealed a well-defined perianal ulcer with mucopurulent exudate (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Despite a change in treatment (drying hot packs with septomida), no clinical improvement was observed after four weeks, which led to extensive investigations and blood tests with CBC, biochemistry and serology for HIV and syphilis, with no relevant results. The medical history was reviewed, which showed a chest X-ray with no report, requested 2 years earlier, showing severe pulmonary emphysema with multiple bilateral apical fibrotic opacities. In view of these findings, a new chest X-ray was requested, which showed findings compatible with pulmonary tuberculosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Sputum was collected from the patient for Ziehl–Neelsen (Z–N) staining, which was positive for acid fast bacilli (AFB).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was extended by taking a biopsy (necrotising granulomas), but with negative Z–N staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), QuantiFERON-TB Gold In-Tube® (negative) and mycobacterial culture (positive), confirming the diagnosis of tuberculosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A more detailed study of the QuantiFERON-TB Gold In-Tube® result showed an anergy, which required the determination of the lymphocyte populations (T, B, NK), revealing a decrease in CD8+ T lymphocytes, which is currently being investigated by the Immunology Department. Treatment was started with isoniazid, rifampicin, pyrazinamide and ethambutol, and, after a negative sputum smear test for AFB and resolution of the perianal ulcer 4 months after treatment, the patient was considered cured.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although periorificial cutaneous tuberculosis is uncommon, it should be considered in the differential diagnosis of recalcitrant perianal ulcers. Thorough review of the patient’s medical history and prior diagnostic evaluations are imperative. Direct identification of <span class="elsevierStyleItalic">M. tuberculosis</span> is of paramount importance.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case highlights the critical importance of X-ray interpretation by radiology specialists to avoid overlooking diagnostically relevant information (a pathological chest X-ray had been overlooked 2 years before the onset of the ulcer).</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">This article was written in accordance with the ethical guidelines of the World Medical Association (Declaration of Helsinki) and the ethics committee of the hospital concerned. The anonymity of the person whose imaging is used is guaranteed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">No funding was received for this article.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest in relation to the publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1243 "Ancho" => 1750 "Tamanyo" => 311052 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Pre-treatment image. Perianal ulcer with well-defined borders, predominantly on the left side with mucopurulent exudate. B) Chest X-ray. Severe pulmonary emphysema with multiple bilateral apical fibrotic opacities. C) Haematoxylin-eosin staining, 40×: granulomatous necrotising and suppurative dermatitis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unusual case of cutaneous tuberculosis due to <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> in a patient with acquired immunodeficiency syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.M. Mederos Cuervo" 1 => "M.A. Acosta Suárez" 2 => "V. Cálas Echevarría" 3 => "A. Cárdenas García" 4 => "M. 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