18 Jun 2021

3/25/21: Cutaneous Tuberculosis

PGY3 Denaly Chen presented a case of 41 y/o F with history of CKD Stage 4, HTN, Psoriasis and previous COVID-19 infection who presented for evaluation of worsening skin lesions.  Patient reports a history of plaques and erythematous for the past few years and she was told she had psoriasis.  Patient was previously seen by ENT for cough, hoarse voice and dysphagia with difficulty breathing and globus sensation.  She was noted to have laryngeal lesions and supraglottic stenosis in which she was started on Humir 40mg q2weeks 3 months ago by Rheum for treatment of presumed sarcoidosis.  Afterwards, the previous plaques she had subsequently became larger, ulcerated and tender to palpation with a burning sensation.  Patient was diagnosed with COVID-19 2 months prior to this admission with symptoms including cough productive of clear sputum, nausea and vomiting.  +30 pound weight loss in the last 2 months.  Denies any fevers/chills. 

ROS: per HPI

Home medications: Amlodipine 10mg qday, Captopril 25mg BID, Ferrous Sulfate 325mg BID, Vitamin D2 50K IU qweek, Humira q2weeks

Social History: Denies tobacco/alcohol/drug use.  Born in Tijuana, lived in CA x12 years, works in restaurant, no chemical exposure, worked as housekeeping in hotel in the past.  Has 2 dogs at home.

Vitals: T 36.8, HR 114, RR 18, BP 107/71, O2 sat 100% on RA

Physical Exam significant for hoarse/soft voice, mild supraclavicular LAD (L>R), normal cardiac and pulm exams, skin with erythematous plaques with well demarcated borders on inner R upper arm close to axilla, chest, mid-epigastric abdomen, R side of back.  Extremities with mild swelling in R ankle up to the lower calf with TTP posterior R ankle.

CBC: WBC 4.9> Hb 11/Hct 33.1 <Plt 227 (MCV 81.3, RDW 18.8%)

CMP:

Na 135/K 4.3/Cl 101/HCO3 22/BUN 44/Cr 2.88<Glucose 101 (Cr baseline 2-2.4)

ALP 234>T.protein 7.2/Albumin 3.6/AST 15/ALT 13/Tbili 0.3/Dbili <0.2

Ca 13.5, Mg 2.1, Phos 2.7

Coags: PT 14.2, INR 1.11, PTT 31.1

Infectious workup negative for BCx, UA, UCx ,HIV, cocci, histo and Hepatitis panel.

Hypercalcemia workup:

  • PTH 14 (L)
  • PTHrP 21 (normal 14-27)
  • Vit D 25 OH: 25 (L)
  • Vit D 1,25 OH 103 (H)
  • ACE <5

Rheum labs negative for ANA, ANCA, SSA, SSB, anti-centromere, Scl-70 Ab, Sm/RNP Ab, Anti-Jo-1 Ab.

Supraglottic Lesion Biopsy from several months prior showed squamous epithelium with non-caseating granuloma.

Skin biopsy: necrotizing granulomatous dermatitis

AFB culture and smear from back, sputum and face were initially negative but became positive for MTB after 2-3 weeks.

MTB PCR positive x1 after 1 day.

Treatment: Dermatology was immediately consulted for the rash and Endocrinology consulted for the hypercalcemia.  Patient was started on calcitonin x48 hours and IVF.  Sputum MTB PCR became positive the second day and patient was started on RIPE therapy along with prednisone 40mg qday per Endocrine.  Patient was discharged with RIPE therapy with continued follow up with TB control outpatient.

Teaching points:

  • Cutaneous TB should be considered on the differential in patients with unusual, atypical, long-lasting skin disorders, especially in TB endemic areas.
  • The appearance of cutaneous TB can vary drastically.
  • Diagnosis is based on biopsy, AFB stain and culture, as well as PCR amplification.
  • Main treatment is RIPE therapy with an initiation phase and maintenance phase.

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