Erdei, Irén

Horkay, Irén

Hunyadi, János

Kiss, Mária

Nagy, Béla

Remenyik, Éva

Sápy, Mónika

Veres, Imre

Acta Diabetologica

University of Debrecen Electronic Archive

Sporotrichoid Cutaneous Mycobacterium Tuberculosis Infection in a Child
E´va Remenyik1, Be´la Nagy2, Ma´ria Kiss3, Imre Veres1, Mo´nika Sa´py1, Ire´n Horkay1, Ire´n Erdei1 and Ja´nos Hunyadi1
Departments of 1Dermatology and, 2Pediatrics, University of Debrecen, Medical and Health Science Center, University of Debrecen,
Nagyerdei ko¨ru´t 98, HU-4012 Debrecen, Hungary and 3Department of Dermatology and Allergology, University of Szeged, Szeged,
Hungary. E-mail: remenyik@jaguar.dote.hu
Accepted December 22, 2004.
Sir,
Although every third person in the world is infected with
Mycobacterium tuberculosis (MT), cutaneous tuber-
culosis is a rare disease (1). In highly developed countries
with good socio-economic environments, children are
less likely to get infected. Therefore, childhood tuber-
culosis can be considered an infrequent disorder (2),
especially cutaneous involvement (3, 4). In 2001, in
Hungary, the incidence of symptomatic MT was 33/
100 000 and of these 11 were children (0–14 years old)
and 4 patients suffered from extrapulmonary manifesta-
tions only. We describe here a case of MT skin infection
with an unusual sporotrichoid clinical appearance in
an otherwise healthy child, emphasizing the diagnostic
difficulties.
CASE REPORT
A 12-year-old girl with good social background and
negative personal and family history of tuberculosis is
presented. She had received Bacillus Calmette-Gue´rin
(BCG) vaccination after birth. The otherwise healthy
girl experienced a small red inflamed wound on the
dorsal surface of her right ring finger, in May 2001. It
was thought to be a consequence of a minor trauma,
because she had helped her grandfather in a pet shop.
Despite antibacterial treatment and surgical incision the
lesion spread. About 6 weeks after the first symptoms,
she was referred to our clinic. She had a lilac-brown
oedemic-based papule covered with yellowish transpar-
ent tubers 1–2 mm in diameter on the dorsal surface of
the proximal interphalangeal joint of her right fourth
finger (Fig. 1). A pink nodule, 1 cm in diameter with red
incision wound on its surface and two painless
subcutaneous nodules 0.5 cm in diameter located
proximally and distally to it could be palpated on the
dorsal part of the hand. No cubital and axillary
DOI:10.1080/00015550510030096
Fig. 1. A lilac-brown oedemic papule on the dorsal surface of the
proximal interphalangeal joint of a 12-year-old girl’s right fourth
finger. A pink nodule, 1 cm in diameter with red incision wound was
noted on its surface on the dorsal part of the wrist.
Letters to the Editor 375
Acta Derm Venereol 85
lymphadenopathy or other positive physical findings
were seen.
The following laboratory tests were normal or
negative: erythrocyte sedimentation rate, blood count,
serum and urinary chemistry, immunoglobulins, lympho-
cyte subsets, chest X-ray. After laboratory samples,
doxycyline therapy was initiated. Cultures and smears
from the base of the wound were negative for bacteria
and fungi. Serology tests for tularaemia, bartonellosis,
syphilis and HIV infection were negative. Purified
protein derivative 5 IU intradermal injection disclosed
a 13-mm skin induration. A slow progression was
observed; therefore a subcutaneous intact nodule of the
dorsal hand was excised in toto.
Histopathological section of the nodule showed
tuberculoid granuloma without caseation. Ziehl-
Neelsen, PAS and Gram staining did not reveal any
pathogens. A fresh sample in sterile physiological saline
was sent to the Department of Pulmonology,
Semmelweis University, Budapest for culture for atypi-
cal mycobacteria, MT and fungi.
Because of the possibility of infection by atypical
mycobacteria, clarithromycin (250 mg twice a day
orally) was started. Atypical mycobacterium colonies
could not be cultured, but MT was identified. No
resistance to antituberculotic drugs was found. It took
almost 3 months to complete the laboratory results. At
that time, DNA was isolated from the formalin-fixed
paraffin-embedded block and PCR was done using the
M. genus (5) and MT species-specific primers (6). Myco-
bacterium DNA was detected with both sets of primers.
After the results of the culture were obtained,
isoniazid 350 mg, rifampin 600 mg and ethambutol
1000 mg daily were administered for 2 months. As a
result of these medications, the skin lesions started to
heal. After finishing the three-drug combination ther-
apy, daily isoniazid and rifampin treatment with the
same dosage were used for 4 further months, whereafter
complete healing was achieved. No side effects of
the therapy were experienced. The source of the
infection could not be determined.
DISCUSSION
With the presented sporotrichoid cutaneous symptoms,
we confirmed MT infection by two separate methods
(culture and PCR) performed in two separate labora-
tories. Tuberculin skin test was also positive. Three-drug
combination antituberculotic therapy (2) achieved com-
plete healing. The symptoms of MT infection depend on
the route of the infection, the pathogenicity and drug
resistance of the bacteria, the immune status of the host
and various local factors. Percutaneous inoculation is
possible (7, 8). Animals in the pet shop could have been
the source of the infection (9). The anthropo-zoonotic
spreading may be an explanation for the unusual clinical
appearance but unfortunately the source of the infection
could not be detected.
We want to emphasize that cutaneous tuberculosis
can occur in an unusual form in an immunocompetent
child. The disease deserves special attention because
its prevalence can be expected to increase due to
immunosuppression (10–12) and intensive international
migrations (refugees), as well as socio-economic
changes.
REFERENCES
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Incidence of cutaneous tuberculosis in patients with organ
tuberculosis. Int J Dermatol 2003; 42: 197–200.
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tuberculosis in children. Lancet Infect Dis 2003; 3:
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3. Liang MG, Rooney JA, Rhodes KH, Calobrisi SD.
Cutaneous inoculation tuberculosis in a child. J Am
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Acta Derm Venereol 85
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Sporotrichoid Cutaneous Mycobacterium Tuberculosis Infection in a Child

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Sporotrichoid Cutaneous Mycobacterium Tuberculosis Infection in a Child

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