MYCOBACTERIUM TUBERCULOSIS INFECTION PRESENTING WITH CUTANEOUS ABSCESS, CALCANEAL ABSCESS, AND PULMONARY NODULES: A CASE REPORT AND REVIEW OF THE LITERATURE
A 21 year old Hispanic male immigrant presented to his internist with a 2x3 cm right axillary abscess , which had been present for one week. Purulent material was recovered from an incision and drainage. A course of cephalexin for 10 days was followed by trimethroprim- sulfamethoxazole with minimal improvement. Two weeks later, the patient presented to the emergency room with a chest wall nodular mass extending 3 cm medially from the right axillary line. Past medical history was noncontributory, including negative history of smoking or illicit drug use. Review of systems was negative except for the skin lesions. Vital signs were normal.
On physical examination, an open draining sinus was observed within a nontender,
erythematous fixed nodule in the right chest wall. Laboratory revealed normal complete
blood count (CBC), chemistry, hepatic function panel, and urine analysis. Computerized
tomography scan of the chest demonstrated a superficial solid mass defect in the right anterior chest wall measuring 3.0 x 5.2 cm with central low density, suggestive of necrosis. Unsuspected findings included circumferential right pleural thickening and diffuse pleural enhancement, worrisome for a neoplastic process, primary or metastatic. Multiple right anterior cervical, axillary, supraclavicular, infraclavicular, hilar, and anterior diaphragmatic lymph nodes were observed. Four enhancing parenchymal nodules in the subcarinal and juxta-diaphragmatic regions, ranging from 2.6 cm to 1.1 cm in diameter, were also visualized. There were no left sided hilar or mediastinal lymph nodes or pulmonary nodules.
The patient was admitted and initiated on levaquin and clindamycin for the chest wall
abscess. Differential diagnosis was for an infectious versus neoplastic process. Abdominal and pelvic CT for metastatic workup demonstrated multiple enlarged retroperitoneal and mesenteric lymph nodes. Bone scan revealed increased uptake in the right calcaneous, and a followup CT scan of the right lower extremity demonstrated a 1.8 cm ovoid lucency with posterior nodule of the calcaneous , which was suggestive of a possible bone neoplasm versus abscess. Human immunodeficiency virus (HIV) testing, blood cultures, and purified protein derivative (PPD) were negative. Alpha-fetoprotein, human chorionic gonadotropin, and carcinoembryonic antigen levels were normal. Fiberoptic bronchoscopy revealed normal cytology, negative bacterial and fungal cultures, and negative acid fast bacilli (AFB) staining.
Necrotic tissue consisting of eosinophilic, granular hypocellular material was obtained from a fine needle aspiration of the chest wall mass. Fungal culture and gram stains were negative, but AFB staining was positive. CT guided needle aspiration of the calcaneous yielded purulent material that was also AFB positive. Repeat PPD was positive at 12 mm. The patient responded favorably to standard antituberculous regimen. Cultures confirmed M. tuberculosis infection.
Mycobacterium tuberculosis is a multi-systemic infection. A resurgence of cases of M
tuberculosis infection and extrapulmonary involvement has occurred in parallel with the
HIV epidemic.1 Lymphadenopathy is the most frequent extrapulmonary manifestation and pleural tuberculosis occurs in 5% of tuberculosis. 1
Clues that suggest possible extrapulmonary
tuberculosis include chronic lymphadenopathy, pleural effusion and thickening , HIV infection,
monoarticular joint inflammation with negative bacterial cultures, immigration from endemic regions, and osteomyelitis of the thoracic vertebra.1
M tuberculosis is rarely associated with cutaneous or osteoarticular infection.2
This case report illustrates an unusual case of tuberculosis presenting with concurrent
cutaneous abscess, occult calcaneal abscess, and pulmonary parenchymal nodules. We
postulate that the soft tissue abscess of the chest wall occurred by direct extension from the underlying right axillary lymphatics. The final diagnosis was confounded by radiographic findings that were more suggestive of a neoplastic process.
Overall cutaneous tuberculosis accounts for .14% of all cases of tuberculosis.2,3
Cutaneous tuberculosis can arise from direct inocculation from an exogenous source,
contiguous, or hematogenous spread from an endogenous focus. Most often,
cutaneous tuberculosis arises from hematogenous dissemination of tubercle bacilli from
the lung.2,3 Clinical appearances of cutaneous tuberculosis may include papulovesicles,
pustules, macules, or nodules.2 Although the diagnosis of cutaneous tuberculosis may be
confirmed by acid fast staining from cutaneous biopsy, results are often negative because skin lesions are typically paucibacillary.4,5,6 Polymerase chain reaction (PCR) for detection of M tuberculosis improves the probability of diagnosis, especially in cases where there is high clinical suspicion.7,8
The classifications of cutaneous tuberculosis include lupus vulgaris, miliary tuberculosis,
scrofuloderma, and tuberculous gumma.2,3 Our patient had the scrofuloderma type. This skin lesion occurs by direct extension into the skin from an underlying tuberculous focus, which was the axillae in our case.2 The initial lesion is a firm subcutaneous nodule that suppurates into an ulcer, fistula, sinus or abscess.2 Ulcers tend to have blue, undermined edges with soft granulation. Other common sites for scrofuloderma are the neck, supraclavicular fossae, and groin.2,3 In contrast, the classic morphologic appearance of lupus vulgaris is a red-brown plaque with “apple jelly” color on diascopy. Common sites of infection are the head and neck, arms, legs, and trunk.2,3 Tuberculous gumma appear as single or multiple cold subcutaneous nodules, or abscesses with sinuses and ulcers.2,3 Miliary tuberculosis is characterized by discrete
pinhead blue to red macules or papules with a predilection for the trunk, thighs, buttocks, and genitalia.
Osteoarticular tuberculosis is a rare manifestation of extrapulmonary tuberculosis.9 Foot
involvement accounts for less than 10% of cases of osteoarticular tuberculosis.10 Osteoarticular tuberculosis arises from hematogenous, lymphatic, or direct contiguous spread from visceral tuberculosis. Most commonly, osteoarticular tuberculosis originates from a foci of bacilli lodged hematogenously during primary mycobacteremia.9,10 Osteoarticular infection may also occur from lymphatic drainage from paraortic lymph nodes.9,10
The symptoms of osteoarticular tuberculosis are nonspecific and often indolent , including pain, joint swelling, or reduced range of motion. Subsequently, there may be delays in diagnosis and therapy, with progression to bone and joint destruction and deformities.12,13,14,15
A high index of suspicion for osteoarticular tuberculosis should be maintained in populations at risk including immigrants and immunosupressed patients.9,11 Our patient never complained of foot pain, which examplifies the difficulty in diagnosing early stages of osteoarticular infection.
Radiographic signs of osteoarticular tuberculosis are nonspecific as well, including soft tissue swelling, osteopenia, joint space narrowing, and subchondral erosions.9,11 Nonspecific changes such as radiolucency or sclerotic changes such as observed in our patient, may mimic signs of malignancy.16 Computerized tomography (CT), magnetic resonance imaging (MRI), or ultrasound may facilitate diagnosis.9,11,16 Osteoarticular infection may be confirmed by AFB staining or isolation of M tuberculosis from bone biopsy.
In conclusion, cutaneous tuberculosis should be included in the differential
diagnosis of patients with cutaneous abscesses or musculoskeletal complaints, particularly in high risk populations such as immigrants from endemic regions and immunosupressed patients. Further, this case is a reminder to clinicians that extrapulmonary manifestations may serve as the initial clues to the diagnosis of M tuberculosis infection. Antibiotic therapy and duration for cutaneous and skeletal tuberculosis are the same as for pulmonary tuberculosis.11
Hien Nguyen, MD
Internal Medicine Department, Kaiser Permanente-Mid Atlantic
Connie Le, MD
Internal Medicine Department, Kaiser Permanente-Mid Atlantic
Hanh Nguyen, medical student
Medical College of Virginia School of Medicine
(Corresponding address: Kaiser Permanente, Mid-Atlantic, 3808 Daniel’s Run Court, Fairfax, VA, 22030,)
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First Published April 2007
Copyright Priory Lodge Ediucation Ltd. 2007