158
NOTES
Cutaneous Tuberculosis: A Rare Presentation of Malignancy Deborah S. Asnis and Alfred R. Bresciani
From the Department of Infectious Diseases, Flushing Hospital Medical Center, Affiliate ofthe Albert Einstein College of Medicine, Flushing, New York
An 88-year-old woman presented with fever, a neck ulcer, and multiple subcutaneous nodules on her upper extremities and thorax. Her condition was initially diagnosed as malignancy associated with metastatic disease to the skin. A subcutaneous nodule was aspirated. A gram stain of the aspirate revealed weakly gram-positive bacilli, and a stain for acid-fast bacilli was positive. Mycobacterium tuberculosis was isolated from a culture of a specimen of the skin lesion.
Received 13 November 1991; revised 12 February 1992. Reprints or correspondence: Dr. Deborah S. Asnis, Department of Internal Medicine, Flushing Hospital Medical Center, 4500 Parsons Boulevard, Flushing, New York 11355.
Clinical Infectious Diseases 1992;15:158-60 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1501-0015$02.00
gle. The patient had bibasilar rales and a systolic murmur. Findings of the rest of the physical examination were unremarkable except for multiple nonmotile, nontender subcutaneous nodules (1.0-1.5 em in diameter) that were distributed over the breast, chest, abdomen, and arms (figure I). Laboratory examinations on admission revealed the following values: white blood cells, 16,600/mm 3 , with 88%segmented neutrophils, 4% lymphocytes, and 8% monocytes; hemoglobin, 11.6 g/dl.; hematocrit, 35%; and platelets, 339,000/mm 3 . Serum chemistry analysis revealed the following levels: sodium, 127 mliq/L; potassium, 4.3 mEq/L; chloride, 94 mliq/L; bicarbonate, 21 mEq/L; urea nitrogen, 25 mg/dL; glucose, 120 mg/dL; and creatinine, 1.5 mg/dL. Results of liver function tests were normal except for the level of aspartate aminotransferase (60 IU/L). The results of a urinalysis were normal. An electrocardiogram and a chest roentgenogram were within normal limits. Therapy with iv cefazolin was initiated, but the patient's condition did not improve. She had daily temperatures of 38.4°C. Specimens from the neck wound were cultured on three occasions. Two specimens yielded yeast on culture; the third specimen did not yield any growth. A single specimen from the neck ulcer did not reveal acid-fast bacilli on staining. The result of a tuberculin test was negative, and the patient was anergic. On hospital day 3, a computed tomographic scan of the abdomen and pelvis revealed multiple subcutaneous nodules (3 mm to 1.5 em in diameter) at every level (figure 2). The liver, spleen, and pancreas were normal. The gallbladder was markedly larger than normal. A subcutaneous nodule on the chest was aspirated with a needle at the patient's bedside. Gram stain of the aspirate yielded weakly gram-positive beaded rods but no white blood cells or yeasts. A stain for acid-fast bacilli was positive. Therapy with isoniazid, rifampin, and pyrazinamide was started. On hospital day 10, the patient had melena. A colonoscopy revealed multiple diverticulosis as well as an inflamed cecum and ileocecal valve. Biopsy of the colon revealed no
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 16, 2015
In 1953, the first year national data on tuberculosis (TB) were collected, there were 84,304 cases ofTB recorded in the United States. From 1953 until the mid-1980s, TB declined at an annual rate of 5%-7%. In 1989, the total number of cases ofTB reported was 23,495, ofwhich 4,350 were identified as extrapulmonary [1]. Infection with Mycobacterium tuberculosis is increasing in the United States, and this increase is most likely secondary to infection with human immunodeficiency virus, homelessness, and immigration. Cutaneous TB is extremely rare and underreported. In a review of the literature in 1980, we found 121 cases of all forms of skin TB [2]. Skin TB was common during the early 20th century in Europe but now represents
NOTES
Cutaneous Tuberculosis: A Rare Presentation of Malignancy Deborah S. Asnis and Alfred R. Bresciani
From the Department of Infectious Diseases, Flushing Hospital Medical Center, Affiliate ofthe Albert Einstein College of Medicine, Flushing, New York
An 88-year-old woman presented with fever, a neck ulcer, and multiple subcutaneous nodules on her upper extremities and thorax. Her condition was initially diagnosed as malignancy associated with metastatic disease to the skin. A subcutaneous nodule was aspirated. A gram stain of the aspirate revealed weakly gram-positive bacilli, and a stain for acid-fast bacilli was positive. Mycobacterium tuberculosis was isolated from a culture of a specimen of the skin lesion.
Received 13 November 1991; revised 12 February 1992. Reprints or correspondence: Dr. Deborah S. Asnis, Department of Internal Medicine, Flushing Hospital Medical Center, 4500 Parsons Boulevard, Flushing, New York 11355.
Clinical Infectious Diseases 1992;15:158-60 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1501-0015$02.00
gle. The patient had bibasilar rales and a systolic murmur. Findings of the rest of the physical examination were unremarkable except for multiple nonmotile, nontender subcutaneous nodules (1.0-1.5 em in diameter) that were distributed over the breast, chest, abdomen, and arms (figure I). Laboratory examinations on admission revealed the following values: white blood cells, 16,600/mm 3 , with 88%segmented neutrophils, 4% lymphocytes, and 8% monocytes; hemoglobin, 11.6 g/dl.; hematocrit, 35%; and platelets, 339,000/mm 3 . Serum chemistry analysis revealed the following levels: sodium, 127 mliq/L; potassium, 4.3 mEq/L; chloride, 94 mliq/L; bicarbonate, 21 mEq/L; urea nitrogen, 25 mg/dL; glucose, 120 mg/dL; and creatinine, 1.5 mg/dL. Results of liver function tests were normal except for the level of aspartate aminotransferase (60 IU/L). The results of a urinalysis were normal. An electrocardiogram and a chest roentgenogram were within normal limits. Therapy with iv cefazolin was initiated, but the patient's condition did not improve. She had daily temperatures of 38.4°C. Specimens from the neck wound were cultured on three occasions. Two specimens yielded yeast on culture; the third specimen did not yield any growth. A single specimen from the neck ulcer did not reveal acid-fast bacilli on staining. The result of a tuberculin test was negative, and the patient was anergic. On hospital day 3, a computed tomographic scan of the abdomen and pelvis revealed multiple subcutaneous nodules (3 mm to 1.5 em in diameter) at every level (figure 2). The liver, spleen, and pancreas were normal. The gallbladder was markedly larger than normal. A subcutaneous nodule on the chest was aspirated with a needle at the patient's bedside. Gram stain of the aspirate yielded weakly gram-positive beaded rods but no white blood cells or yeasts. A stain for acid-fast bacilli was positive. Therapy with isoniazid, rifampin, and pyrazinamide was started. On hospital day 10, the patient had melena. A colonoscopy revealed multiple diverticulosis as well as an inflamed cecum and ileocecal valve. Biopsy of the colon revealed no
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 16, 2015
In 1953, the first year national data on tuberculosis (TB) were collected, there were 84,304 cases ofTB recorded in the United States. From 1953 until the mid-1980s, TB declined at an annual rate of 5%-7%. In 1989, the total number of cases ofTB reported was 23,495, ofwhich 4,350 were identified as extrapulmonary [1]. Infection with Mycobacterium tuberculosis is increasing in the United States, and this increase is most likely secondary to infection with human immunodeficiency virus, homelessness, and immigration. Cutaneous TB is extremely rare and underreported. In a review of the literature in 1980, we found 121 cases of all forms of skin TB [2]. Skin TB was common during the early 20th century in Europe but now represents
