Acknowledgements:
I would like to express my very great appreciation to Dr Dharmendra Karn for his valuable and constructive suggestions during the planning and development of this research work. His willingness to give time so generously has been very much appreciated.
I would also like to thank the Department of Pathology and Microbiology of Dhulikhel Hospital for their constant support.
CASE REPORT
BACKGROUND
With the rise in the prevalence of immunocompromised patients, tuberculosis with unusual manifestations is more observable1. Cutaneous miliary tuberculosis is a less common manifestation of extrapulmonary tuberculosis resulting from a hematogenous spread1. Due to the non specific clinical features and high transmissibility, it is important to recognize the disease early on its course2. Here, we present a case of a 67 years female with non healing cutaneous ulcers secondary to miliary tuberculosis with Potts spine and improvement of clinical features following a month of anti-tubercular drugs.
OBSERVATION
We present a case of a 67 year old female who presented to our dermatology OPD with the chief complaints of multiple painful non healing ulcers with yellowish discharge over mons pubis and perivulvar area for 6 months with single ulcer over left upper arm from 5 months (fig 1, 2, 3). The lesions started as firm tender swellings which ruptured spontaneously to form ulcers. She was admitted in a different department and was treated with multiple courses of IV antibiotics without any improvement. On physical examination, she was thinly built weighing around only 38kg. Ulcers were well defined, painful, with a firm edge and yellowish discharge. These were 4-5 in number over perivulvar area measuring around 1x2 cm, and a single ulcer over left upper arm measuring around 4x5 cm. A punch biopsy specimen of the edge of the ulcer showed poorly formed granulomas consisting of epitheloid cells (fig 4, 5). Mantoux test was negative. However, acid fast bacilli were seen in tissue gene xpert, sample taken from ulcer over left upper arm. There were no lymphadenopathies. Her chest x-ray showed numerous nodules scattered throughout the both lung fields. For further investigation, we added a CT scan of the chest which was suggestive of miliary tuberculosis. She was also complaining of low back pain, so we performed x-ray of dorso-lumbar spine with MRI which showed features of Pott’s spine. After one month of treatment with multi drug therapy including Isoniazid, Rifampicin, Ethambutol and Pyrazinamide, her symptoms were gradually improving with marked reduction in size of ulcers.