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.