TUBERCULOUS GUMMA AN UNUSUAL EXTRAPULMONARY TB IN A 17-YEAR-OLD MALE: A CASE REPORT

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Extrapulmonary TB (EPTB) is estimated at 15% of the global burden and 1.5% of these cases are cutaneous TB. Tuberculous gummas, are unusual forms of cutaneous TB, with an incidence of 1%–2% of all cutaneous TB cases. Local data shows a total 139 tuberculosis of skin and subcutaneous among pediatric population as reported by the accredited hospitals of the Philippine Pediatric Society. CASE PRESENTATION: This is a case of a 17-year-old male, Filipino, from Metro Manila with a history of chest pain, aggravated by exertion, relieved by rest and a lumbar mass a year prior to consult. He was seen at outpatient clinic with a lumbar mass measuring 16cm x 17cm, on the right and 9cm x 7cm on the left, both were soft and non-tender. (Figure 1) His chest CT scan showed opacities in the mediastinum, reticulonodular opacities in the left upper lobe and pericardial thickening with a large, well-circumscribed, non-enhancing hypodense mass in the right posterior chest wall underneath the right trapezius muscle. Ultrasound of his lumbar mass revealed subcutaneous anechoic masses and greenish purulent fluid was evacuated. The collected specimen was positive for reverse transcriptase PCR for M. tuberculosis DNA. DISCUSSION: Tuberculosis (TB) is primarily transmitted via airborne. Cutaneous TB a rare form is acquired via 4 routes: (1) direct inoculation from an exogenous source such as in tuberculous chancre and verrucosa cutis; (2) direct extension from a primary focus such as in scrofuloderma; (3) hematogenous spread such as in miliary tuberculosis and tuberculous gumma and (4) lymphatic spread such as in lupus vulgaris. Metastatic tuberculous abscess known as tuberculous gumma presents as non-tender and fluctuant subcutaneous abscess, solitary or multiple on the trunk, extremities and often invade the skin. Similarly, our patient had a lumbar mass which was soft and non-tender. The National Tuberculosis Control Program recommends treatment of newly diagnosed tuberculosis involving the skin with 2 months intensive therapy with Isoniazid (10 mkd), Rifampicin (15 mkd), Pyrazinamide (30 mkd) and Ethambutol (20 mkd), followed by 4 months maintenance therapy of isoniazid and rifampicin whether bacteriologically confirmed or clinically diagnosed. In this patient, there was a significant decrease in the mass after 1-month intensive therapy with resolution of chest pain. CONCLUSIONS: Tuberculosis mimics various disease condition. This report presents a case of a patient with a rare form of extrapulmonary TB. Extrapulmonary TB should be a part of the differential diagnosis among individuals with baffling presentation, in our case a mass skin lesion. Adherence to government mandated preventive measures must be strictly implemented to further decrease the transmission of TB. It is likewise important to upskill health care personnel to identify possible cases of extrapulmonary TB and prevent its' dreaded outcomes. REFERENCE #1: Global Tuberculosis Report, Executive Summary 2020, Available, https://www.who.int/tb/publications/global_report/TB20_Exec_Sum_20201014.pdf REFERENCE #2: Machan A, Hanafi T, Hjira N, Boui M. Tuberculous gummas: Epidemiological, clinical, bacteriological, immunological, and therapeutic features. Int J Mycobacteriol 2018;7:203-11 REFERENCE #3: Philippine Pediatric Society ICD10 Registry. Philippine Pediatric Society. [cited 2021 April 24]. Available from https://pps.org.ph/icd-10-registry DISCLOSURES: No relevant relationships by Edmund Anthony Sumayod, source=Web Response