Perianal involvement and inguinal adenitis as unusual presentation of tuberculosis

Abstract

An 8-month old boy, a Rumanian gypsy immigrant to Spain, presented with a 2-month history of bilateral inguinal tumour and, at the beginning of this period, fever and vomiting. The mother was admitted for pulmonary tuberculosis with positive sputum smears in the infectious ward a week before the child. Examination revealed a well-nourished and afebrile child but in a bad hygienic condition. Both inguinal tumours were about 2x3 cm in size, painless and covered in normal cold skin. The left tumour fluctuated while the right one was hard and firmly adherent and, after 7 days, also became fluctuating (Fig. 1). The rest of the examination was unremarkable except for an erythematous perianal patch with a lineal ulcer (Fig. 2). The TST given was reactive (15 mm). The chest radiograph revealed a right hilar enlargement and computerized tomography (CT) demonstrated mediastinal adenopathy (10 mm) in the right hilum, an inflammatory infiltrate in the right anterior segment. The pleura was not affected. Acid-fast stains of the gastric juices were negative. The blood coagulation analysis was altered (prothrombin time 11.1 s, fibrinogen 575 mg/dl and APTT 57.2 s), and showed an unspecific decrease of intrinsic system factors. Serological tests for HIV, toxoplasma, and CMV were negative. In addition to tuberculous lesions, the differential diagnosis in this patient included lymphoma, and sexual abuse lesions. A skin biopsy from the perianal lesion revealed a chronic granulomatous inflammation. Acid fast stains of skin biopsy and FNA of the inguinal nodes were negative. Due to the unclear preliminary results, a lymphadenectomy was undertaken [5] and sample yielded also negative for stain. With the MGIT system (BD), a mycobacterial culture of the cutaneous and surgical specimens became positive. DNA probes (GenProbe) demonstrated the organism to be within the Mycobacterium tuberculosis complex. The isolate was shown to be susceptible to antituberculous agents. A regimen of rifampicin and isonizazid for 6 months, plus pyrazinamide for the first 2 months was initiated. Streptomycin was also included until susceptibility tests were available because of the risk of resistance owing to the country of origin [2]. This antibiotic was then discontinued. Eur J Pediatr (2007) 166:967–968 DOI 10.1007/s00431-006-0324-8