Facial cutaneous tuberculosis: an unusual presentation

The puzzle of the evolutionary natural history of tuberculosis

Several pieces of the puzzle of the natural history of tuberculosis are assembled in this review to illustrate the potential reservoirs and sources of the Mycobacterium tuberculosis complex (MTBC) mycobacteria, their transmission to animals and humans, and their fate in populations, in a co-evolutionary perspective. Millennia-old companions of mammalian and human populations, MTBC are detected in the soil, in which they infect and survive within vegetative amoebae and cysts, except for Mycobacterium canettii. Never detected in the sphere of plants, they are transmissible by transcutaneous, digestive and respiratory routes and cause an infection of the lymphatic system with secondary dissemination in most tissues, in which they determine a specific and non-pathognomonic granulomatous inflammatory reaction; in which MTBC survives in dormant form irrespective of MTBC species and mammalian species; indicating that the current epidemiology in mammalian populations is essentially governed by the probabilities of contact between mammalian species and MTBC species. Individual variabilities in clinical expression of tuberculosis are related to MTBC species, strain and inoculum; host genetic factors; acquired modulations of the inflammatory response; and probably human microbiota. This review of the literature suggests an evolutionary natural history of telluric environmental mycobacteria, satellites of unicellular eukaryotes, transmissible to mammals via the digestive and then respiratory tracts, in which they determine a fatal contagious infection that is primarily lymphatic and a quiescence-mimicking encysted form. This review opens perspectives for microbiological and translational medical research.

Multifocal tuberculosis verrucosa cutis

Tuberculosis has been a well-known affliction of human kind, since antiquity. Cutaneous tuberculosis constitutes only a small proportion of extra pulmonary tuberculosis and multifocal involvement of cutaneous tuberculosis is an even rarer manifestation. We report one such case of multifocal tuberculosis verrucosa cutis in a 17-year old male patient in the absence of any primary tuberculous focus.

Presumed localized tuberculous inflammation after periocular procedures

PURPOSE

To report 4 rare cases of periocular presumed tuberculosis that developed after eyelid and lacrimal drainage surgery.

METHODS

Retrospective, interventional case series. Review of clinical, laboratory, photographic, and radiologic records of patients with presumed tuberculous inflammation after periocular procedures.

RESULTS

Four patients had periocular presumed tuberculosis after blepharoplasty, dacryocystorhinostomy, and intracanalicular lacrimal plug insertion. Diagnosis was made by characteristic histopathologic findings, acid-fast bacilli staining, polymerase chain reaction results, or response to therapeutic trial. All of the patients underwent antituberculosis chemotherapy for a minimum of 9 months and all recovered. Ectropion and eyelid retraction complicated 2 cases.

CONCLUSIONS

Unresponsiveness of chronic inflammation to conventional treatment after periocular procedures should arouse the clinical suspicion of localized tuberculosis, particularly in endemic areas or in patients who have a tuberculosis history or recent exposure. For presumed eyelid tuberculosis without evidence of Mycobacterium tuberculosis, the clinical diagnosis and therapeutic trials could be considered cautiously especially in countries with an intermediate or high tuberculosis burden. Early diagnosis and appropriate treatment can prevent the sequelae of tuberculosis infection.

[Primary palpebral tuberculosis]

INTRODUCTION

Isolated-eyelid tuberculosis is exceptional. Its clinical polymorphism explains the delayed diagnosis.

OBSERVATION

A 36-year-old male nurse, with no specific history, presented with a lower-eyelid nodule. The treatment was not effective and the lesion-exeresis biopsy proved the diagnosis of tuberculosis. Follow-up did not reveal any other tuberculosis focus and the patient's evolution was good under antibacilli treatment.

DISCUSSION

Eyelid tuberculosis is exceptional. Unlike in our case, it is usually secondary to pulmonary tuberculosis. The eyelid contamination may be hematogenic or secondary to trauma.

Delayed diagnosis in a case of lupus vulgaris with unusual localization

Lupus vulgaris is the most common form of cutaneous tuberculosis, and the usual sites of involvement are the head and neck. We present a forty-six-year-old woman with lupus vulgaris on the external surface of the left leg and foot, an unusual site. Based on histopathological and clinical features, this case was diagnosed as lupus vulgaris with unusual localization.

Lupus vulgaris: unusual presentations over the face

Lupus vulgaris (LV) is the most common morphological variant of cutaneous tuberculosis. However, the occurrence of bizarre clinical presentations over atypical sites often leads to misdiagnosis and inappropriate treatment causing significant morbidity. This report seeks to highlight two unusual cases of lupus vulgaris occurring on the face of immunocompetent women and remarkably mimicking periorbital cellulitis and basal cell carcinoma, respectively. The diagnosis was confirmed by histopathology, an enzyme-linked immunosorbent assay (ELISA) test for Mycobacterium tuberculosis and polymerase chain reaction (PCR). With four-drug antitubercular therapy, both patients had a dramatic response.