Case and research letter
Periorificial Cutaneous Tuberculosis of the Vulva
Tuberculosis cutánea periorificial vulvar
D. Jiménez-Galloa,
, N. Navas-Garcíab, C. Albarrán-Planellesa, F. Guerrero-Sánchezc
Autor para correspondencia
a Unidad de Gestión Clínica de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Puerta del Mar, Cádiz, Spain
b Unidad de Gestión Clínica de Anatomía Patológica, Hospital Universitario Puerta del Mar, Cádiz, Spain
c Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Puerta del Mar, Cádiz, Spain
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Hematoxylin-eosin, original magnification ×20.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Periorificial cutaneous tuberculosis, or tuberculosis cutis orificialis, accounts for approximately 2% of cases of tuberculosis of the skin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It results from the auto-inoculation of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> into the periorificial oropharyngeal, anal, or genital skin or mucosa from a pulmonary, intestinal, or genitourinary focus, respectively.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The definitive diagnosis is made by the isolation of <span class="elsevierStyleItalic">M tuberculosis</span> from the ulcer and detection of the focus of mycobacterial infection responsible for the disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 78-year-old woman who was referred to our outpatient clinic for mild vulvar bleeding and a long-standing painful ulcer of the labia minora of the vulva. The patient had no other symptoms. Of note in her past medical history was a cadaveric orthotopic kidney transplant in 2005 for chronic kidney failure of unknown etiology. Since that time she had been on immunosuppressive treatment with oral corticosteroids, tacrolimus, and mycophenolate mofetil.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a very painful, irregular ulcer of 4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>cm on the left labium minus. The base of the ulcer was soft and erythematous and was covered with areas of adherent whitish pseudomembrane (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no palpable regional lymph nodes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Skin biopsy showed a superficial material formed of fibrin and white blood cells and deeper in the tissue there were numerous granulomas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), some with a necrotic center of caseous appearance, epithelioid cells, and Langhans-type multinucleated giant cells (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). No acid-alcohol-fast bacilli were observed with Ziehl-Neelsen stain. These findings were compatible with a diagnosis of ulceration with tuberculoid granulomas.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Given the presence of tuberculoid granulomas and ulceration, a request was made for screening for mycobacteria in the exudate from the ulcer and in the urine obtained by catheterization. Study of the exudate from the ulcer by polymerase chain reaction (PCR) was weakly positive. Ziehl-Neelsen stain of the sample taken from the skin was negative, but it was positive on the urine. Cultures of samples from both sites in Middlebrook 7H9 liquid medium were positive after an adequate incubation time. The microorganism isolated was identified as <span class="elsevierStyleItalic">M tuberculosis</span> using DNA hybridization probes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was completed by hysteroscopy, chest x-ray, abdominal ultrasound, and abdominal computed tomography; there were no signs of active or residual tuberculosis. The tuberculin skin test was negative. Based on these results, a diagnosis was made of vulvar tuberculosis cutis orificialis secondary to auto-inoculation from a urinary focus.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was immediately started on treatment with isoniazid at a dosage of 250<span class="elsevierStyleHsp" style=""></span>mg/d, rifampicin, 600<span class="elsevierStyleHsp" style=""></span>mg/d, pyrazinamide, 1500<span class="elsevierStyleHsp" style=""></span>mg/d, and ethambutol, 800<span class="elsevierStyleHsp" style=""></span>mg/d, which were continued for 2 months; she was subsequently treated for a further 4 months with only isoniazid and rifampicin. The clinical course was favorable with the treatment administered.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There is a high prevalence of tuberculosis in Spain (16.96 cases/100 000 population in 2009 according to the Spanish Network for Epidemiological Monitoring, and 30/100 000 population in 2007 according to the World Health Organization).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most common variant of cutaneous tuberculosis is lupus vulgaris.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Tuberculosis cutis orificialis is a rare variant and accounts for only 2% of cases of cutaneous tuberculosis. It occurs mainly in immunosuppressed individuals,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the majority of patients are middle-aged men.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This clinical form affects the oral, perianal, or genital mucosas and the periorificial skin after auto-inoculation of the bacillus, which is derived from a pulmonary, intestinal, or genitourinary focus by direct spread. The lesions mainly occur in traumatized areas. Lymphocytic or hematogenous dissemination and the involvement of adjacent organs is rare.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The disease is defined clinically by yellowish papules or nodules that rapidly ulcerate, giving rise to very painful, punched-out ulcers with a granular base covered by a whitish pseudomembranous material. Histology of the lesions will show tuberculoid granulomas. Culture and the tuberculin skin test are usually positive.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Untreated, the disease can be fatal within a few months, due to miliary dissemination of the bacillus.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of tuberculosis cutis orificialis requires the correlation of clinical, histopathological, and microbiological findings. Conventional mycobacterial culture continues to be the most reliable method for confirming the presence of mycobacteria and their antibiotic sensitivity, as well as for monitoring treatment; however, it has the disadvantage of a long delay until the results are available.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> PCR testing is a powerful tool for the diagnosis of cutaneous tuberculosis, as it is rapid, reliable, and very sensitive.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The differential diagnosis of ulcerated genitourinary lesions similar to those presented includes Lipschütz ulcer, herpes simplex, tumors, pyoderma gangrenosum, sarcoidosis, chancroid, syphilis, lymphogranuloma venereum, tuberculosis, leishmaniasis, and the deep mycoses.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Cutaneous tuberculosis, including the periorificial form, is treated using the standard treatment regimens for pulmonary tuberculosis.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara"><span class="elsevierStyleBold">Please cite this article as:</span> Jiménez-Gallo D, et al. Tuberculosis cutánea periorificial vulvar. Actas Dermosifiliogr. 2012;103;929–30.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1218 "Ancho" => 1585 "Tamanyo" => 184354 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulceration of the left labium minus covered by whitish pseudomembranes. The ulcer showed slight extension towards the right labium minus.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1193 "Ancho" => 1585 "Tamanyo" => 529290 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Vulvar mucosal stroma presenting a granulomatous reaction formed of palisaded epithelioid histiocytes and areas of central necrosis. Hematoxylin-eosin, original magnification ×10.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1190 "Ancho" => 1585 "Tamanyo" => 435313 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Epithelioid histiocytes and Langhans-type cells in the tuberculoid granulomas. 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Sánchez-Saldaña" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Peru" "fecha" => "2003" "volumen" => "13" "paginaInicial" => "195" "paginaFinal" => "214" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack35264" "titulo" => "Acknowledgments" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">We would like to thank Dr José Luis Parra Martínez for his accurate initial diagnosis made at his private pathology laboratory, and for supplying us with the fixed histological specimen to complete the study.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010300000010/v1_201304241352/S1578219012003150/v1_201304241352/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010300000010/v1_201304241352/S1578219012003150/v1_201304241352/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219012003150?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 16 | 13 | 29 |
| 2024 Octubre | 83 | 47 | 130 |
| 2024 Septiembre | 81 | 37 | 118 |
| 2024 Agosto | 114 | 83 | 197 |
| 2024 Julio | 111 | 45 | 156 |
| 2024 Junio | 104 | 46 | 150 |
| 2024 Mayo | 77 | 49 | 126 |
| 2024 Abril | 75 | 49 | 124 |
| 2024 Marzo | 92 | 51 | 143 |
| 2024 Febrero | 68 | 37 | 105 |
| 2024 Enero | 64 | 33 | 97 |
| 2023 Diciembre | 64 | 28 | 92 |
| 2023 Noviembre | 89 | 32 | 121 |
| 2023 Octubre | 70 | 26 | 96 |
| 2023 Septiembre | 73 | 37 | 110 |
| 2023 Agosto | 55 | 19 | 74 |
| 2023 Julio | 78 | 39 | 117 |
| 2023 Junio | 75 | 31 | 106 |
| 2023 Mayo | 70 | 29 | 99 |
| 2023 Abril | 57 | 44 | 101 |
| 2023 Marzo | 55 | 37 | 92 |
| 2023 Febrero | 61 | 32 | 93 |
| 2023 Enero | 54 | 38 | 92 |
| 2022 Diciembre | 66 | 40 | 106 |
| 2022 Noviembre | 23 | 30 | 53 |
| 2022 Octubre | 20 | 30 | 50 |
| 2022 Septiembre | 21 | 65 | 86 |
| 2022 Agosto | 25 | 54 | 79 |
| 2022 Julio | 18 | 39 | 57 |
| 2022 Junio | 25 | 22 | 47 |
| 2022 Mayo | 47 | 38 | 85 |
| 2022 Abril | 54 | 50 | 104 |
| 2022 Marzo | 56 | 62 | 118 |
| 2022 Febrero | 43 | 29 | 72 |
| 2022 Enero | 53 | 57 | 110 |
| 2021 Diciembre | 44 | 41 | 85 |
| 2021 Noviembre | 57 | 55 | 112 |
| 2021 Octubre | 52 | 64 | 116 |
| 2021 Septiembre | 45 | 51 | 96 |
| 2021 Agosto | 40 | 37 | 77 |
| 2021 Julio | 42 | 31 | 73 |
| 2021 Junio | 33 | 35 | 68 |
| 2021 Mayo | 47 | 40 | 87 |
| 2021 Abril | 141 | 71 | 212 |
| 2021 Marzo | 85 | 38 | 123 |
| 2021 Febrero | 97 | 36 | 133 |
| 2021 Enero | 53 | 24 | 77 |
| 2020 Diciembre | 58 | 17 | 75 |
| 2020 Noviembre | 43 | 31 | 74 |
| 2020 Octubre | 74 | 20 | 94 |
| 2020 Septiembre | 46 | 19 | 65 |
| 2020 Agosto | 39 | 27 | 66 |
| 2020 Julio | 42 | 17 | 59 |
| 2020 Junio | 51 | 27 | 78 |
| 2020 Mayo | 42 | 11 | 53 |
| 2020 Abril | 26 | 15 | 41 |
| 2020 Marzo | 48 | 20 | 68 |
| 2020 Febrero | 3 | 3 | 6 |
| 2020 Enero | 0 | 1 | 1 |
| 2019 Diciembre | 4 | 1 | 5 |
| 2019 Noviembre | 0 | 1 | 1 |
| 2019 Octubre | 0 | 3 | 3 |
| 2019 Septiembre | 3 | 3 | 6 |
| 2019 Julio | 0 | 5 | 5 |
| 2019 Junio | 3 | 39 | 42 |
| 2019 Mayo | 1 | 34 | 35 |
| 2019 Abril | 0 | 20 | 20 |
| 2019 Marzo | 2 | 10 | 12 |
| 2019 Febrero | 0 | 2 | 2 |
| 2019 Enero | 1 | 3 | 4 |
| 2018 Diciembre | 3 | 6 | 9 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 4 | 2 | 6 |
| 2018 Agosto | 0 | 4 | 4 |
| 2018 Julio | 0 | 2 | 2 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 0 | 2 | 2 |
| 2018 Marzo | 27 | 2 | 29 |
| 2018 Febrero | 189 | 8 | 197 |
| 2018 Enero | 183 | 6 | 189 |
| 2017 Diciembre | 251 | 10 | 261 |
| 2017 Noviembre | 158 | 4 | 162 |
| 2017 Octubre | 178 | 9 | 187 |
| 2017 Septiembre | 157 | 7 | 164 |
| 2017 Agosto | 167 | 5 | 172 |
| 2017 Julio | 163 | 12 | 175 |
| 2017 Junio | 152 | 17 | 169 |
| 2017 Mayo | 99 | 6 | 105 |
| 2017 Abril | 53 | 6 | 59 |
| 2017 Marzo | 49 | 38 | 87 |
| 2017 Febrero | 136 | 10 | 146 |
| 2017 Enero | 91 | 21 | 112 |
| 2016 Diciembre | 99 | 7 | 106 |
| 2016 Noviembre | 139 | 10 | 149 |
| 2016 Octubre | 188 | 17 | 205 |
| 2016 Septiembre | 208 | 13 | 221 |
| 2016 Agosto | 166 | 19 | 185 |
| 2016 Julio | 72 | 19 | 91 |
| 2016 Junio | 15 | 17 | 32 |
| 2016 Mayo | 8 | 19 | 27 |
| 2016 Abril | 7 | 7 | 14 |
| 2016 Marzo | 17 | 1 | 18 |
| 2016 Febrero | 12 | 14 | 26 |
| 2016 Enero | 12 | 1 | 13 |
| 2015 Diciembre | 9 | 6 | 15 |
| 2015 Noviembre | 13 | 1 | 14 |
| 2015 Octubre | 13 | 10 | 23 |
| 2015 Septiembre | 10 | 7 | 17 |
| 2015 Agosto | 14 | 8 | 22 |
| 2015 Julio | 130 | 14 | 144 |
| 2015 Junio | 70 | 14 | 84 |
| 2015 Mayo | 75 | 14 | 89 |
| 2015 Abril | 90 | 15 | 105 |
| 2015 Marzo | 45 | 8 | 53 |
| 2015 Febrero | 47 | 13 | 60 |
| 2015 Enero | 63 | 12 | 75 |
| 2014 Diciembre | 50 | 18 | 68 |
| 2014 Noviembre | 34 | 10 | 44 |
| 2014 Octubre | 45 | 11 | 56 |
| 2014 Septiembre | 59 | 8 | 67 |
| 2014 Agosto | 71 | 11 | 82 |
| 2014 Julio | 61 | 6 | 67 |
| 2014 Junio | 74 | 10 | 84 |
| 2014 Mayo | 54 | 16 | 70 |
| 2014 Abril | 24 | 6 | 30 |
| 2014 Marzo | 13 | 10 | 23 |
| 2014 Febrero | 10 | 6 | 16 |
| 2014 Enero | 17 | 8 | 25 |
| 2013 Diciembre | 16 | 15 | 31 |
| 2013 Noviembre | 20 | 7 | 27 |
| 2013 Octubre | 10 | 14 | 24 |
| 2013 Septiembre | 10 | 2 | 12 |
| 2013 Agosto | 13 | 8 | 21 |
| 2013 Julio | 7 | 8 | 15 |
| 2013 Junio | 6 | 16 | 22 |
| 2013 Mayo | 11 | 6 | 17 |
| 2013 Abril | 22 | 12 | 34 |
| 2013 Marzo | 19 | 13 | 32 |
| 2013 Febrero | 65 | 9 | 74 |
| 2013 Enero | 198 | 20 | 218 |
| 2012 Diciembre | 45 | 11 | 56 |
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