Managing Cutaneous Tuberculosis: A Case Report
Tuberculosis (TB) continues to be a prevalent disease worldwide; an estimated one third of the world’s population is infected and 2015 data from the World Health Organization show 10 million people had an active infection. Although TB often is cited as a disease that most commonly occurs in underdeveloped countries, the evolution of drug-resistant forms of TB and infection sensitivity of immunocompromised individuals have made this disease a focal point for industrialized countries as well.
When TB is spread, it commonly affects the lungs, but it can infect any organ of the body. An uncommon version — cutaneous TB — affects <2% of all individuals with an active form of TB. This study describes a 34-year-old man with multiple comorbidities, including peripheral vascular disease and a remote history of travel to Latin America who presented to a wound care clinic with a 2-year history of painful shallow necrotic ulcers on his right lower limb and previous treatments that included a positive response to antibiotics. Once TB was confirmed via 2 positive Quantiferon Gold tests, the patient received therapy (directly observed by the state health department) that included pyrazinamide, rifampin, ethambutol, isoniazid, and undocumented vitamin B6. Treatment for the TB-related lesions, concomitant cellulitis, and a Stage 2 pressure injury under his first right metatarsal head was initiated as well. The patient received local wound care for 40 days that included sharp debridement, offloading for the pressure injury, and pain relief before treatment at the wound care clinic and daily as prescribed by his primary care provider. All wounds were securely covered with collagen dressings followed by silicone-bordered bandages. Local wound care was provided for 40 days, with biweekly follow-up for an additional 30 days. The wounds resolved and the patient was discharged from the wound care clinic but remained on the caseload for 30 days in the event his pain increased or the wounds recurred. Cutaneous TB, uncommon and challenging, should be a consideration in patients with an increased likelihood of occurrence.
Tuberculosis (TB) is a serious, communicable disease caused by a rod-shaped bacillus (Mycobacterium tuberculosis [Mtb]) with a high lipid cell envelope, increasing its resistance to many medications.1-5 TB has been referenced in ancient texts and has been identified in tissues extracted in mummified material through DNA analysis.6 An active human pathogen, TB had a 20% to 25% mortality rate during the 17th and 19th centuries.1,2,7 Historical research by Daniel3 and Comas et al8 suggests Mtb has been an active human pathogen for >70 000 years and has adapted and modified itself, maintaining its capacity to spread.9
When a person is infected with pulmonary or laryngeal TB (testing positive, regardless of being in the latent or active phase) coughs, laughs, sneezes, or sings, the nuclei are spread into the air; these nuclei are known to remain suspended for several hours.7 According to the Centers for Disease Control and Prevention,10 the number of nuclei expressed is directly related to the amount of infectious material an individual is able to expel into the environment. The next individual that inhales these particles can develop either active pulmonary or extrapulmonary TB or a latent form that can remain dormant for years.1
TB is unique in that it is one of few airborne bacteria and therefore highly contagious. It is also known to be a slow-replicating organism, which can allow it to evade an immune response from the host.11 The prevalence of individuals with either latent or active TB infection increased during the early to mid-20th century due to the proliferation of concurrent human immunodeficiency virus (HIV) infection and multidrug resistant TB.1,12 Reviews of the literature1,9,13 have shown improved living conditions and decreased crowding with increased environmental sanitation, nutrition, and income have reduced the occurrence of TB in industrialized countries. However, even with the current knowledge of transmission, diagnostic methods, and treatment options, TB continues to infect nearly one third of the world’s population and is the cause of >1 million deaths annually.
Although the most familiar form involves pulmonary presentation, TB can affect any system of the human body, including muscles, bone, and skin.6,9 Cutaneous TB (CTB) accounts for <2% of cases of TB, although worldwide this represents a significant number of people and affects quality of life.14 Because CTB is rare and has different physical characteristics based on its clinical form, it is not widely described in the literature. Several case reports15 and retrospective studies11 have been published and provide the basis of information for providing treatment for individuals with CTB.
Although TB often is cited as most prevalent in underdeveloped countries, the advent of drug resistance and infection sensitivity of immunocompromised individuals (especially persons with HIV) have pushed this disease to the forefront in industrialized countries as well, further leading to the need to increase the knowledge base for the providers who treat it.2,4,16 With the increase of both the latent and active forms of TB comes a natural increase in persons with atypical presentations, including CTB. Increased awareness and continuing release of information would be of benefit for all practitioners that may encounter patients with less common forms of TB.
Initial diagnosis can be difficult due to the different physical presentations, from scaly psoaric plaque formations to papules.4,14,16 It is even possible to have various presentations of CTB in 1 individual.1 Owing to the multiple physical characteristics of CTB and medical doctors, nurses, dermatologists, wound care specialists, and other medical professionals who may encounter this disease, it is important to share information, treatment plans, and subsequent outcomes. The purpose of this case study is to describe the history and care of a patient who presented to the wound clinic with CTB.
Mr. K, a 34-year-old Caucasian, presented to his primary care physician (PCP) in May 2015 with multiple, painful, partially dried black nodular plaques surrounding the lower portion of his right leg (see Figure 1). Per his medical chart, these lesions would originate as erythematous purple lesions and develop into ulcers with serous exudate and then form escharotic plaques. His past medical history included uncharacterized vasculitis process, arterial thrombosis since 2008 that required bypass grafts, and peripheral arterial disease. The CT scan of his abdomen showed a partially occluded right external iliac and common femoral, superficial femoral, and popliteal arteries, with polytetrafluoroethylene grafts and vascular stents in both extremities. Mr. K had developed pseudoaneurysms of the anterior tibial artery and multiple bouts of cellulitis of his right leg. Ehlers-Danlos syndrome (an inherited disorder of the connective tissues) was deemed a possible diagnosis, but all current tests of possible connective tissue diagnoses yielded no results; as of publication, Mr. K not been provided a diagnoses for the cause of arterial failure in his legs.
After 2 years of recurrent nodular plaques to his lower legs, differential diagnoses of vascular ulcers, infection, phlebitis, or possible rheumatologic condition/inflammation were explored. As part of the differential diagnosis, Mr. K was referred to a rheumatologist who requested testing for possible TB: Mr. K had a remote history of traveling to Latin America during his childhood to countries with a known elevated prevalence of the disease. In addition, several extended antibiotic treatments including amoxicillin/clavulanate, sulfamethoxazole trimethoprim, clindamycin, and doxycycline had been previously prescribed for these same nodular appearances with intermittent positive results.
The diagnosis of CTB was confirmed after 2 positive Quantiferon Gold tests,17 an in vitro testing method approved by the United States Food and Drug Administration. Chest x-rays were found to be negative, as were HIV, rheumatoid factor, and antinuclear antibody screening tests. Following the diagnosis, the state health department directly observed daily therapy that included a multidrug TB medication regimen of pyrazinamide (500 mg oral tablet, 1500 mg per day), rifampin (600 mg intravenous injection daily), ethambutol (400 mg oral tablet, 1200 mg per day), and isoniazid (300 mg oral tablet daily). Vitamin B6 also was prescribed, but the dosage was not available in the medical record.
Mr. K was provided a wound care consult to the author’s Outpatient Physical Therapy Clinic by his PCP because of continued ulcer formation on his lower right leg and increasing pain on the dorsal surface of his right foot that was limiting ambulation. Mr. K required long-term anticoagulation with warfarin (5 mg oral tablet) with a therapeutic goal to reduce the risk of future deep vein thromboses because his INR range was 2.0 to 3.0. He continued weekly visits to his PCP for pain management and for active treatment of concomitant cellulitis to the same area as the wounds. Sulfamethoxazole trimethoprim (800 mg/160 mg oral tablet) was provided daily. The introduction of Mtb medication increased INR levels to 6.2, and warfarin intake had to be adjusted weekly.
Biweekly wound care visits were completed in a negative pressure room; the lesions produced minimal to moderate drainage, increasing the possibility of aerosolization during wound cleansing and debridement.10 N95 masks were worn by physical therapists throughout wound care sessions; the treatment table and chairs that came in contact with Mr. K were cleaned with bleach (0.55% sodium hypochlorite) for the mandatory 3-minute period (per hospital and product guidelines) for documented kill rate of any possible aerosolized TB bacilli.
Initially, Mr. K reported increased pain when the ulcers were drained; tactile examination had to be terminated because manipulation of the ulcer borders using cotton-tipped applicators also increased his pain level. On subsequent PT wound care visits, Mr. K was premedicated with oxycodone as prescribed by his PCP, with eventual dosage of 80 mg per day for pain tolerance; wound care providers requested the addition of 4% lidocaine solution to apply to right leg 10 to 15 minutes before treatment to desensitize his skin and permit gentle sharp debridement of his wounds (see Figure 2). In addition to lesions on the entire leg distal to his knee, a Stage 2 pressure injury was identified under the first metatarsal head of his right foot.
During the second week of wound care treatment, Mr. K presented with a full body rash. The Chief Medical Officer of the Health Department opted to stop all TB medication for 2 weeks as a precaution for a possible allergic reaction to one of the medications. In addition, Mr. K’s PCP prescribed amoxicillin/clavulanate (875 mg/125 mg oral tablet every 12 hours). The TB regimen was restarted after 14 days as the rash subsided, and no further reactions were present for the duration of the wound care treatments.
Throughout the wound care visits, Mr. K’s ulcers were cleansed thoroughly with Skintegrity Wound Cleanser (Medline Industries, Mundelein, IL). Mechanical debridement of nonstable necrotic tissue and slough, determined through visual and tactile examination, was performed using cotton-tipped applicators and tweezers as able. Cavilon No Sting Barrier Film swab (3M, St Paul, MN) was applied to the perimeter of all ulcers, followed by collagen (Puracol, Medline Industries) and silicone-bordered bandages (Aquacel Foam; ConvaTec, Greensboro, NC) for ease of dressing removal and periwound protection. The same technique was used for the Stage 2 pressure injury under his right first metatarsal head.
To address potential spread of the bacteria, the wounds were completely covered between dressing changes to reduce environmental contamination and provide additional support to primary dressings. Because aerosolization of wounds likely could occur due to use of wound cleanser, Mr. K initially was treated in negative pressure room as previously noted. However, care subsequently moved to a regular wound care clinic; the Infection Control Officer of the facility deemed Mr. K of minimal risk to others as long as no patients were scheduled and treated in the wound care room for 2 to 3 hours after his visit. As a precaution, no further treatments were conducted for a minimum of 12 hours.
Mr. K used crutches for nearly the entire duration of open ulcers and remained as nonweight-bearing as possible. Over a period of 40 days, Mr. K was seen by physical therapists 10 times and then twice weekly until the wounds resolved (see Figure 3). He self-limited pain medication as the wounds progressed and he was weight-bearing ~2 weeks into treatment, initiating full weight-bearing for short distances. At the time of discharge, Mr. K had stopped the pyrazinamide and ethambutol; he continued the isoniazid and rifampin for the full 9-month term prescribed by the state health department. The combination of adhering to the medication regimen, being provided appropriate pain control by his PCP, and maintenance of wound care follow-up facilitated resolution of the lesions in <60 days.
TB is a disease that has persisted for thousands of years. The ability of TB to transfer from patient to patient and remain in a latent phase for many years makes it difficult to eliminate.5 Vaccines have helped reduce the number of infected people worldwide, particularly in developing countries16; however, a surge in the prevalence of TB in industrialized countries, especially in persons who are already immunocompromised, has kept TB on the list of notifiable diseases that require follow-up by the department of public health.
Pulmonary TB remains the most common form, although TB can affect other organs in the body, including the skin. CTB is likely not the first diagnoses considered when examining a nonhealing wound with an atypical presentation. It can be confused with psoriasis or a canker sore.1,11 In this case, taking a thorough medical and travel history increased the ability of providers to include TB during the differential diagnosis process. After accepting Mr. K into their wound care clinic, the authors conducted a literature review and noted a lack of information was available. Literature involving CTB is mostly provided through other patient case studies.15 Although the origin of the ulcers was not a typical diagnosis for wound care providers, should a chronic wound not respond to treatment standards, the travel history of the individual should be investigated and appropriate diagnostic tests performed. The multidrug therapy that is prescribed for pulmonary TB is also effective for eradicating other forms of active TB.1,15,18
This case study was presented to provide additional information to clinicians regarding CTB, its presentation, and the course of 1 patient’s experience and care management. CTB is uncommon, and differential diagnosis requires a multidisciplinary approach. Additional research regarding various treatment methods to reduce the time to wound healing and improve patient quality of life would be of benefit and is encouraged.
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18. Centers for Disease Control and Prevention. Guidelines for Using the QuantiFERON®-TB Gold Test for Detecting Mycobacterium tuberculosis Infection, United States. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm. Accessed June 17, 2017.
Potential Conflicts of Interest: none disclosed
Ms. Brown-Gallardo is a staff physical therapist, Sandoval Regional Medical Center, Rio Rancho, NM. Please address correspondence to: Bettina M. Brown-Gallardo, MPT, CWS, 3001 Broadmoor Boulevard NW, Rio Rancho, NM 87144; email: firstname.lastname@example.org.