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Table of Contents
Year : 2011  |  Volume : 5  |  Issue : 2  |  Page : 59-61

Tuberculosis in the left inguinal region associated with cutaneous tuberculosis of left second toe: An unusual presentation of extrapulmonary tuberculosis

1 Department of Medicine, Midnapur Medical College, West Bengal, India
2 Department of Surgery, Medical College, Kolkata, India
3 Department of Gynaecology and Obstetrics, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication17-Feb-2012

Correspondence Address:
Jugal K Kar
B-13 Keranitola, Singha Compound, Paschim Medinipur, West Bengal - 721 101
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0331-3131.92952

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We report an uncommon case of tuberculosis involving left second toe associated with left inguinal lymphadenopathy and an ulcer in a 30-year-old male with no other pulmonary or extra pulmonary tubercular infection. Diagnosis was made by biopsy. He responded very well to anti tubercular treatment.

Keywords: Extra pulmonary tuberculosis, inguinal lymphadenopathy, left second toe, ulcer

How to cite this article:
Kar JK, Kar M, Maiti S. Tuberculosis in the left inguinal region associated with cutaneous tuberculosis of left second toe: An unusual presentation of extrapulmonary tuberculosis . Ann Nigerian Med 2011;5:59-61

How to cite this URL:
Kar JK, Kar M, Maiti S. Tuberculosis in the left inguinal region associated with cutaneous tuberculosis of left second toe: An unusual presentation of extrapulmonary tuberculosis . Ann Nigerian Med [serial online] 2011 [cited 2021 May 11];5:59-61. Available from: https://www.anmjournal.com/text.asp?2011/5/2/59/92952

   Introduction Top

Tuberculous lymphadenopathy most commonly involves cervical nodes usually in children. Isolated involvement of toes and inguinal lymph nodes due to tubercular infection in the absence of pulmonary and/or other extra pulmonary tuberculosis is relatively rare in adults. [1] Moreover, tubercular cutaneous ulcer is not much seen nowadays. This rarity makes our case interesting.

   Case Report Top

A 30-year-old Hindu male from rural West Bengal, India, presented with an ulcerated lesion left inguinal region for last one year. History of evening rise of temperature (range 98.8 to 99° F) was present. There was no history of any pulmonary or extra pulmonary complaints which could give us any clue for tuberculous affection elsewhere. No history of contact with tuberculosis was noted. He was treated with various antibiotics empirically in the previous months but not yielding expected results. On examination, the ulcer was mildly tender, not much oozing present, but with undermined edges [black arrow, [Figure 1]. There were matted, tender enlarged lymph nodes in the left inguinal region [white arrow, [Figure 1]. On meticulous search, we found some non tender papulo-nodular lesions with hyperkeratosis and fissure formation and an ulcer with undermined edges on the dorsolateral aspect of left second toe [[Figure 2], white arrow]. There were also chronic paronychia and brittle toenails due to chronic fungal infection [[Figure 2], black arrow]. No other lesion/site of infection could be detected in lower extremity and external genital region. He had no signs related to pulmonary or other extra pulmonary tubercular infection elsewhere. Routine blood examination showed hemoglobin 10.4 gm %, total leukocyte count 7800/cmm, neutrophil 61%, lymphocyte 36%, eosinophil 3%, monocyte 0%, basophil 0%. ESR was 23 mm/1 st hour. Blood sugar (fasting and postprandial), blood urea nitrogen, and creatinine were normal. Blood test for human Immunodeficiency virus I and II were negative. Urine routine and microscopic examination was normal. Chest X-ray and ultrasonography of whole abdomen were noncontributory. X-ray of left foot did not reveal any bony involvement. The Ziehl-Neelsen stain of the pus from the thigh ulcer was AFB positive. Monteux test was positive (indurations 15 ×14 mm), but tuberculosis-polymerase chain reaction (both typical and atypical mycobacteria) was negative. Fine needle aspiration cytology (FNAC) from lymph nodes revealed granulomatous reaction suggestive of tuberculosis. Biopsy from the ulcer margins (both from toe and thigh ulcer) showed epitheloid cell granuloma with Langhans giant cells and confirmed the diagnosis of tubercular infection.
Figure 1: Tubercular ulcer (black arrow) and lymphadenopathy (white arrow) of the left inguinal region

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Figure 2: Papulonodular lesions, ulcer with undermined edges (white arrow) on dorsolateral aspect of left 2nd toe, chronic paronychia and brittle toe nails (black arrow)

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We considered differential diagnosis with diseases characterized by granuloma like leprosy, schistosomiasis, cat-scratch disease, sarcoidosis. There was no hypoesthetic patch, no local nerve thickening and no other lesion elsewhere to suggest leprosy. Schistosomiasis is not seen in this part of India. Cat-scratch disease was ruled out as there was no history of cat scratch or cat flea bite and the lesions were not responded to azithromycin, ciprofloxacin, given earlier by the primary physician. We ruled out sarcoidosis by normal chest X-ray (absence of bilateral hilar or pulmonary infiltrates), positive Monteux test and absence of raised serum calcium and angiotensin-converting enzyme level.

He was put on anti tubercular treatment (directly observed treatment short course-category III as per World Health Organization guidelines × six months) and responded very well.

   Discussion Top

Cutaneous tuberculosis is usually caused by Mycobacterium tuberculosis, Mycobacterium bovis, and Bacillus calmette Guerin (BCG). The portals of entry for Mycobacterium tuberculosis are lungs, tonsils and intestine, rarely through skin. The disease spread via lymphatic's to the regional lymph nodes and then to the blood stream. [2] Primary coetaneous tuberculosis due to inoculation from exogenous source usually takes three forms namely tuberculous chancre, warty tuberculosis (nodular tuberculosis/ tuberculosis varicose cutis) and lupus vulgaris. Nodular variety is the most common form of skin tuberculosis in the Asian continent, which tends to occur in persons with moderate immunity from previous infections or immunization. [2] It usually affects lower extremities and buttock in Asians, at the sites of minor abrasions or wounds. [2] Initial lesion is a asymptomatic small papule or papulopustule, later become hyperkaratotic plaque formation with clefts and fissures. Spontaneous involution occurs or changes to tumor-like, wart-like, psoriasis-like or keloid-like forms. Regional lymphadenitis is usually pyococcal, [3] but in our case, the ulcer and lymphadenopathy of the left inguinal region was of tubercular origin. A high index of suspicion, in patients with peripheral lymphadenopathy, is therefore required in regions where tuberculosis is more prevalent. [4] Biopsy is essential either histologically or microbiologically to confirm diagnosis. [5] However, FNAC gives positive diagnosis in many cases of peripheral lymphadenopathy. [4] A positive tuberculin skin test is also useful. [1],[4] In the absence of complications such as sinus or abscess, chemotherapy alone gives excellent results. Surgery is required in the presence of complications. [6]

   Conclusion Top

This report emphasizes the need to consider tuberculosis in the differential diagnosis in any case of isolated chronic unilateral inguinal lymphadenitis, especially in developing countries.

   References Top

1.Dayal A, Pai S, Shenoy KV, Kansakar P, Kannan A, Sharma Y, et al. Isolated primary tuberculosis of inguinal lymph nodes: An acute presentation. Internet J Surg 2008;1:4.  Back to cited text no. 1
2.Goh SH, Ravintharan T, Sim CS, Chang HC. Nodular skin tuberculosis with lymphatic spread: A case report. Singapore Med J 1995;36:99-101.  Back to cited text no. 2
3.Khan AS, Bakhshi GD, Ellur S, Nilkant B, Jyothi J, Poraura TK. Primary Koch's inguinal lymphadenopathy presenting as a mass. Bombay Hosp J 2004;46:224-5.  Back to cited text no. 3
4.Rahi R, Biswas M, Khanna R, Khanna AK. Isolated inguinal tubercular lymphadenopathy. Ann Trop Med Public Health 2009;2:24-5.  Back to cited text no. 4
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5.Ekrem G, Selma G, Hasan U, Canan E. An Unusual Presentation of extra pulmonary Tuberculosis in an adolescent: Isolated unilateral inguinal lymphadenitis. Turk J Med Sci 2007;37:387-9.  Back to cited text no. 5
6.Koo HK, Kim YS, Kim MJ, Roh TS, Rah DK. A case report of isolated inguinal tuberculous lymphadenitis. J Korean Soc Plast Reconstr Surg 2010;37:705-7.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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