Primary Cutaneous Tuberculosis in a 27 year old medical intern from needlestick injury: a case report
Karoney M J1*, Kaumbuki E K2, Koech M K3, Lelei L K4
1
Mercy Jelagat Karoney , Medical Officer, Moi University Clinical Research Center AMPATH,
Nandi Road PO Box 4606-30100, Eldoret, Kenya
2
Erastus Kaumbuki Kanake, Medical officer, Ministry of Medical Services, Afya House,
Cathedral Road, PO Box 30016-00100, Nairobi, Kenya
3
Mathew Kiptonui Koech, Consultant Physician, Division of Medicine, Moi Teaching and
Referral Hospital, Nandi Road, PO Box 3-30100, Eldoret, Kenya
4
Lectary Kibor Lelei, Senior lecturer, Department of Orthopedic Surgery, Moi University School
of Medicine, Nandi Road, PO Box 4606-30100, Eldoret, Kenya
*correspondence to Karoney M J, karoneymercy@gmail.com
Words in text -1878; Figures 4
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ABSTRACT
Introduction: Primary cutaneous tuberculosis is a rare presentation of tuberculosis and the skin
barrier must be breached for infection to take place.
Case presentation: The authors report a case of cutaneous tuberculosis in a 27 year old African
male medical intern who sustained a needle-stick injury to his right little finger. He suffered
several months of persistent swelling of the finger and developed constitutional symptoms such
as low grade fever, night sweats and weight loss. The intern also developed painless axillary
lymphadenopathy 6 weeks after inoculation. He underwent several debridements weeks apart
and different regimens of antibiotics with no improvement of symptoms. Cultures of pus
aspirated from the finger initially grew Staphylococcus aureus. This led to a delay in the
diagnosis and several months of morbidity. The diagnosis of tuberculosis was made by histology.
Conclusion: This case is presented to draw attention to the direct inoculation transmission of
tuberculosis. Few cases of needle-stick transmission of Mycobacterium tuberculosis from
patients with AIDS have been documented. Early management should be initiated to minimize
morbidity.
Key words: primary, cutaneous, tuberculosis
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INTRODUCTION
Primary inoculation tuberculosis results from the direct introduction of Mycobacterium
tuberculosis into the skin of a person with no previous tuberculosis infection. Skin is resistant to
tuberculosis and a break in the skin barrier must be present for the infection[1]. Once the
traumatized skin of a previously uninfected person is inoculated with M. tuberculosis, a
tuberculous chancre develops at that site within 3 weeks. A painless regional lymphadenopathy
becomes prominent 3 to 6 weeks after inoculation, and a previously negative, intradermal,
intermediate-strength purified protein derivative (PPD) test converts to a positive test[1].
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CASE PRESENTATION
A 27 year old previously healthy African male medical intern sustained a needle-stick injury
from a wide bore needle (gauge 18) to his little finger while performing a lumbar puncture on a
HIV-infected patient. He sustained a small lesion that oozed a few drops of blood and
immediately washed it with water and soap. He was immediately started on post exposure
prophylaxis Anti Retroviral drugs (ARVs): Zidovudine, Lamivudine and Kaletra for 28 days as
per the Kenya National AIDS Control Program protocol. His initial rapid HIV test (Determine)
test was negative and so was a PCR done on completion of the ARVs. He had no significant past
medical history.
The patient source, an African Female, was WHO clinical stage 4, not on ARVs and was being
investigated for meningitis died soon the lumbar puncture and her results were not followed up
until several months later.
Two weeks after the injury, the intern had swelling of the little finger associated with a persistent
dull ache for which he sought surgical intervention. Pus was aspirated from the finger and
incision and drainage was done under local anesthesia. Culture of the pus grew Staphylococcus
aureus sensitive to flucloxacillin on which he was started.
His little finger now had an open wound that persisted for several months despite debridement
and different antibiotic regimens: levofloxacin, clindamycin, ceftriaxone and vancomycin. The
intern continued to clean and dress his wound daily.
He developed painless axillary lymphadenopathy 6 weeks after the injury. For the next 6 months
there was persistent swelling of the little finger which seemed to be spreading to the hand (Figure
1). This was associated with low grade fever, night sweats and subjective weight loss. He
underwent a surgical debridement 6 months after the injury and was started on levofloxacin.
Intraoperatively necrotic debris was found.
Radiographic examinations done during the course of illness showed no bone involvement.
Serial blood counts done in the course of illness showed persistently elevated lymphocytes and a
raised ESR. Liver function test and renal tests were normal.
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Ten months later and with no improvement of symptoms, he underwent yet another surgical
debridement. Histological examination of the tissue taken revealed a chronic inflammatory
process (Figure 2), granulomatous tubercles with epithelioid cells (Figure 3), giant cells of
langerhans (Figure 4), and a mononuclear infiltrate but no Acid Fast Bacilli (AFB) were
demonstrated on Ziehl Nelson stain.
He was started on rifampicin, isoniazid, pyrazinamide and ethambutol for duration of two
months to be followed by a four-month course of rifampicin and isoniazid. The intern had
complete recovery by the end of the 6 months.
DISCUSSION
This case shows an example of primary cutaneous tuberculosis, a rare presentation of
tuberculosis. Tuberculosis continues to pose a significant public health problem and kills about 3
million people annually [2]. It is largely an airborne infection, but skin manifestations may be
caused by hematogenous spread or contiguity from foci of infection which may be active or
latent. Primary inoculation, another mode of transmission [3], results from direct inoculation of
Mycobacterium tuberculosis into the skin of a person who has no natural of artificially acquired
immunity to the organism[4]. Cutaneous tuberculosis infection is rare, accounting for 0.1% of all
cases seen in a dermatology service [5] and constitutes 1.5% of all cases of extra pulmonary
tuberculosis[6]
Cutaneous tuberculosis is more commonly seen in young adults because of their likelihood to
sustain work related injuries and inoculation of tubercle bacilli[7]. It is also common among
hospital personnel[8, 9].
The diagnosis of tuberculosis in this case was masked by an initial culture growth of
Staphylococcus aureus which led to a delay in diagnosis and several months of morbidity for the
medical intern. This is comparable to a case report by Opara T.N et al 2007 on tuberculous
arthritis of the knee with staphylococcus superinfection in which a delay in the diagnosis led to
adverse outcome[10]. Cutaneous tuberculosis continues to be one of the most elusive and more
difficult diagnoses to make in developing countries due to wide differential diagnosis e.g fungal
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infections, leishmaniasis and also because of difficulty in obtaining microbiological confirmation
[11].
Diagnosis requires correlation of clinical and histopathologic findings and diagnostic testing with
mycobacterial culture remaining the most reliable method in determining presence of live
mycobacteria and monitoring treatment response. An absolute diagnosis consists in the
demonstration of AFB on Ziehl-Nelson’s staining of the smear, prepared from material from
lesions [12]. Cutaneous tuberculosis that occurs by direct inoculation is a paucibacillary disease,
sparse bacilli seen on histology and microorganisms are difficult to isolate [11]. Smears, ZiehlNelson staining and mycobacterial cultures in Lowenstein-Jensen and BACTEC media are
frequently negative [13]. The most prominent features of a tuberculous chancre of tuberculosis
at histology are typical granulomatous tubercles with epithelioid cells, Langerhans giant cells,
and a mononuclear infiltrate [14]. Histopathologic findings and isolation of M. tuberculosis in
cultures of biopsy material or by polymerase chain reaction are the most useful diagnostic tools
in cutaneous tuberculosis [15].
Chemotherapy still remains the treatment of choice. The management of cutaneous tuberculosis
follows the same guidelines as that of tuberculosis of other organs, which can be treated with a
short course four-agent chemotherapeutic regimen given for 2 months followed by a two-drug
regimen for the next 4 months [12].
CONCLUSION
Primary cutaneous tuberculosis is rare and should be suspected in immuno-competent as well as
immunosuppressed patients who present with skin lesions failing to improve on antibacterial
treatment. Healthcare workers are at risk of direct inoculation of tuberculosis. Manifestation of
Cutaneous tuberculosis is so variable that a high index of suspicion is required for its diagnosis.
Current diagnostic methods are far from perfect leading to a delay in starting the appropriate
therapy. Complete microbiological tests should be carried out for any persistent non healing
wound or ulcer. Early management should be initiated to minimize morbidity.
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CONSENT
Written informed consent was obtained from the patient for publication of this case report and
accompanying images. A copy of the written consent is available for review by the Editor-inChief of this journal.
AUTHORS CONTRIBUTIONS
MJK was the primary researcher, collected the patient’s details upon consent from both the
institution and the patient, drafted and finalized the manuscript for publication. MKK assisted in
interpreting the histology results and took photos for the manuscript. EKK and LKL assisted in
gathering patient information and reviewed initial and final drafts of this manuscript. All authors
read and approved the final manuscript.
ACKNOWLEDGEMENTS
We acknowledge the staff members of the histopathology lab at the Moi Teaching and Referral
Hospital for the support with specimen preparation.
We also acknowledge the affiliate institution Moi Teaching and Referral hospital in Eldoret,
Kenya for allowing us access to patient information.
FINANCIAL SUPPORT
There was no financial support
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TABLES AND FIGURES
Figure 1: Primary cutaneous tuberculosis of the little finger (after debridement)
Figure 2: Inflammation; plasma cells and lymphocytes
Figure 3: Epithelioid cells
Figure 4: Giant cell of Langerhans
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REFERENCES
1.
Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM: Cutaneous tuberculosis:
diagnosis and treatment. Am J Clin Dermatol 2002, 3(5):319-328.
2.
Rodrigues LC, Smith PG: Tuberculosis in developing countries and methods for its
control. Trans R Soc Trop Med Hyg 1990, 84(5):739-744.
3.
Sehgal VN, Verma P, Bhattacharya SN, Sharma S, Singh N, Verma N: Cutaneous
tuberculosis: a diagnostic dilemma. Skinmed 2012, 10(1):28-33; quiz 34.
4.
Kim JK, Kim TY, Kim DH, Yoon MS: Three cases of primary inoculation
tuberculosis as a result of illegal acupuncture. Ann Dermatol 2010, 22(3):341-345.
5.
Ho CK, Ho MH, Chong LY: Cutaneous tuberculosis in Hong Kong: an update. Hong
Kong Med J 2006, 12(4):272-277.
6.
Gawkrodger DJ: Mycobacterial infections. In: Text Book of Dermatology 6th ed.
Volume Vol 2, edn. Edited by Champion RH, Burton JL, Ebling FJG. London: Blackwell
Scientific Publications; 1998: 1181–1214.
7.
Ramesh V, Misra RS, Jain RK: Secondary tuberculosis of the skin. Clinical features
and problems in laboratory diagnosis. Int J Dermatol 1987, 26(9):578-581.
8.
Hooker RP, Eberts TS, Strickland JA: Primary inoculation tuberculosis. J Hand Surg
1979, 4A:270 –273.
9.
Sehgal VN, Wagh SA: Cutaneous tuberculosis. Current concepts. Int J Dermatol
1990, 29:237–247.
10.
Opara TN, Gupte CM, Liyanage SH, Poole S, Beverly MC: Tuberculous arthritis of the
knee with Staphylococcus superinfection. J Bone Joint Surg Br 2007, 89(5):664-666.
11.
Bravo FG, Gotuzzo E: Cutaneous tuberculosis. Clin Dermatol 2007, 25(2):173-180.
12.
Handog EB, Gabriel TG, Pineda RTV: Management of cutaneous tuberculosis.
Dermatologic Therapy 2008, 21(3):154-161.
13.
Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M: Tuberculosis of the hand.
J Hand Surg Am 2011, 36(8):1413-1421; quiz 1422.
14.
Meltzer M, Nacy C: Cutaneous tuberculosis. In: Emedicine. 2006.
9
15.
Almaguer-Chávez J, Ocampo-Candiani J, Rendón A: Current Panorama in the
Diagnosis of Cutaneous Tuberculosis. Actas Dermo-Sifiliográficas (English Edition)
2009, 100(7).
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FIGURES
Figure 3: primary cutaneous tuberculosis of the little finger (after debridement)
Figure 2: Inflammation (x40) plasma cells and lymphocytes
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Figure 3: Epithelioid cells
Figure 4: Giant cell of langerhans
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