Citric acid treatment of non-healing sinus of neck in a patient treated with anti-Koch therapy.

Abstract

Tuberculous ulcers/sinuses are rare clinical entities. The frequency of formation of neck ulcers/sinuses is very low. Surgical excision of ulcers/sinuses along with affected underlying lymph nodes, followed by short course of anti-tubercular chemotherapy, is the effective method of their treatment, and majority of the cases are successfully treated using this combined treatment strategy 1, 2. However, in some cases, ulcers/sinuses do not heal even after the tuberculosis is successfully cured 3, 4. Such cases, which do not heal even after successful treatment regimen for tuberculosis, can be treated by local application of 3% citric acid ointment 3, 4. We recently came across a case of tuberculous neck ulcer that developed into sinus later on, which did not respond to antituberculous treatment regimen mentioned above but responded very well to local application of 3% citric acid ointment. A 35-year-old-female presented with a slightly painful, progressively increasing swelling over the right side of the neck over 6 months in supraclavicular region. Earlier, on the basis of Fine Needle Aspiration Cytology (FNAC), she was diagnosed at another centre with chronic non-specific inflammation and treated accordingly, but in vain. At our centre, she was thoroughly examined and investigated for routine blood and urine examinations, chest radiograph, computed tomography (CT) thorax, CT spine, ultrasonography (USG) of abdomen and cervical mass. Swelling was surgically excised and subjected to histopathological examination and Ziehl–Neelsen stain. She was given anti-Koch treatment (AKT-ethambutol hydrochloride, isoniazid, pyrazinamide and rifampicin) for 9 months. With this treatment, the swelling was resolved, but there was persistence of residual non-healing ulcer, which later developed into a sinus (Figure 1). Based on biopsy results of this ulcer, she was given different groups of antibiotics for more than 6 months, but in vain. With the consent of patient, a decision was taken to topically apply 3% citric acid ointment, prepared using petroleum jelly as a base, applied once daily for 25 days. Physical examination revealed a diffuse, slightly tender lump (3 × 2 cm) on the right supraclavicular region. The physical examination of other systems was unremarkable. Routine blood and urine examinations were normal except for ESR, which was slightly raised (24 mm at the end of 1 hour). Chest radiograph, CT Thorax, CT spine, ultrasonography (USG) of abdomen and blood chemistry did not reveal any abnormality. USG cervical mass revealed infective pathology. On excision, gross examination showed a mass measuring 3 × 2 × 2 cm. The cut surface showed large areas of caseous necrosis. Histopathological examination and Ziehl–Neelsen stain of excised mass confirmed the diagnosis of tuberculosis. Although swelling was resolved with anti-Koch treatment for 9 months, there was persistence of residual non-healing ulcer, which later developed into a sinus and did not respond to different groups of antibiotics for more than 6 months. However, topical application of 3% citric acid ointment prepared using petroleum jelly as a base once daily resulted in complete healing in 25 applications (Figure 2). The effective use of citric acid as part of post-anti-Koch treatment for non-healing ulcers/sinuses has been reported with excellent outcome in our earlier studies 3-5. Based on our earlier experiences of treating such cases using local application of 3% citric acid ointment 3-5, we could successfully treat this case, which was refractory to antituberculous treatment regimen and later treatment with different groups of antibiotics for more than 6 months. The results of the present study and earlier experiences of treating a similar type of cases suggest that when healing is a matter of great concern in spite of conventional treatment strategy, 3% citric acid treatment can be thought of as one of the alternative approaches. There were no conflicts to declare.