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   Table of Contents      
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 41-43

Chronic Ulcerative Eyelid Lesion: A Rare Manifestation of Tuberculosis


1 Department of Emergency Medicine, Max Superspeciality Hospital, New Delhi, India
2 Department of Ophthalmology, Lady Hardinge Medical College, New Delhi, India

Date of Web Publication27-Mar-2018

Correspondence Address:
Anuj Taneja
Taneja Clinic, F1/18, Budh Vihar Phase 1, New Delhi 110086
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_60_17

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  Abstract 


Any organ system in the body can be affected by tuberculosis (TB). While pulmonary TB is the most common presentation, extrapulmonary TB including ocular TB is also an important clinical problem. Most commonly, ocular TB presents as anterior uveitis or choroiditis, which is caused either by hematogenous infection or hypersensitivity after another organ infection. Eyelid involvement by TB is mostly secondary to orbital TB and often presents as a draining sinus. Isolated eyelid TB is, however, uncommon. We present the case of a 6-year-old girl with eyelid TB presenting as chronic nonhealing skin ulcer.

Keywords: Extrapulmonary tuberculosis, eyelid tuberculosis, ocular tuberculosis, orbital tuberculosis, tuberculosis


How to cite this article:
Taneja A, Taneja GK, Jain S, Garg R. Chronic Ulcerative Eyelid Lesion: A Rare Manifestation of Tuberculosis. MAMC J Med Sci 2018;4:41-3

How to cite this URL:
Taneja A, Taneja GK, Jain S, Garg R. Chronic Ulcerative Eyelid Lesion: A Rare Manifestation of Tuberculosis. MAMC J Med Sci [serial online] 2018 [cited 2019 Dec 8];4:41-3. Available from: http://www.mamcjms.in/text.asp?2018/4/1/41/228655




  Introduction Top


Tuberculosis (TB) is a multisystem infectious disease caused by Mycobacterium tuberculosis. TB has a large spectrum of extrapulmonary manifestations including ocular TB. Only 1–2% of the patients with systemic manifestations of TB present with simultaneous ophthalmic manifestations.[1] The most common presentation of ocular TB is the anterior uveitis or choroiditis[2] caused either by hematogenous infection or hypersensitivity after another organ infection. Eyelid TB is a relatively uncommon presentation of ocular TB.[3],[4] It may be primary or secondary, with primary being less common. Eyelid involvement is mostly secondary to orbital TB and usually presents as a draining sinus.

We present the case of a 6-year-old girl patient with isolated eyelid TB presenting as chronic nonhealing skin ulcer.


  Case Report Top


A 6-year-old girl presented to the hospital with the chief complaints of swelling over the left eyelid for 4 months. There was no associated history of pain, redness, or increase in the temperature of overlying skin. There was history of incision and drainage of the swelling performed elsewhere 25 days before presentation following which it developed into a pus-discharging sinus. The patient was on Tab Cefixime since then with no improvement. There was no history of TB or TB contact. On examination, a bone deep excavated skin ulcer of dimensions 13 mm × 9 mm was present below left eyebrow with surrounding excoriated skin [[Figure 1] and [Figure 2]]. There was no tenderness on palpation and no oozing of blood or pus from the lesion. There was a single, mobile, enlarged, nonmatted, palpable, nontender deep cervical lymph node on the left side of 1 cm × 1 cm in size. Extraocular movements were full and free in all gazes. The patient was orthophoric although there was a pseudo-esodeviation of the left eye because of the lateral displacement of medial canthus due to the scarring of the upper lid. There was no lagophthalmos. There was a well-defined swelling over the left scapular region, 7 cm × 9 cm in size, soft in consistency, nontender with no overlying skin changes [Figure 3]. Routine blood investigations revealed hemoglobin to be 9.6 g% and erythrocyte sedimentation rate (ESR) to be 60. Montoux test was read to be 33 mm × 39 mm at 48 h. Chest X-ray revealed the left hilar prominence of the vascular origin. Fine needle aspiration cytology (FNAC) from the left scapular swelling was negative for acid-fast bacilli. Contrast enhanced computed tomography (CECT) of head and orbit revealed a well-defined lesion of soft tissue attenuation measuring 13 mm × 8 mm × 10 mm showing heterogenous postcontrast enhancement involving the left upper eyelid and extending superiorly, eroding the left frontal bone and the lateral wall of orbit. No intraocular or intracranial extension was seen. The above findings were suggestive of chronic inflammatory etiology, likely tubercular osteomyelitis of the frontal bone. Skin biopsy from the skin ulcer was taken. The superficial dermis showed epitheloid cell granulomas with chronic lymphoplasmacytic infiltrate in the dermis. Ziehl Neelson stain for acid-fast bacilli was positive in the skin biopsy sample. The patient was started on Category 1 anti-tubercular treatment (ATT) according to pediatric dose. On 2 weeks follow-up, the excoriation surrounding the ulcer had decreased and the skin ulcer started showing signs of healing [[Figure 4] and [Figure 5]].
Figure 1: Clinical photograph of the patient

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Figure 2: Clinical photograph of the patient showing the skin ulcer on the left upper eyelid

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Figure 3: Clinical photograph of the patient showing the swelling over the left scapular region

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Figure 4: Clinical photograph of the patient at 2 weeks follow-up after starting ATT

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Figure 5: Skin ulcer showing improvement after starting ATT

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  Discussion Top


Cutaneous TB is frequently misleading and challenging, as it mimics a wide differential diagnosis. Eyelid involvement by TB is most of the times secondary to orbital involvement and often seen in the form of a draining sinus. Scarring of the eyelids may lead to cicatricial ectropion, lagophthalmos, or adhesion of the eyelid structures to the underlying orbital bones. Isolated involvement of the eyelid without orbital or systemic involvement is extremely uncommon.[4],[5] We present a case of childhood TB in an immunocompetent girl child manifesting as a chronic skin ulcer. In our case, pyogenic infection was ruled out because of the absence of response to broad-spectrum antibiotics. Treatment was started in both cases depending on the tuberculin skin test, histopathology, and chronicity of lesions showing no response to broad-spectrum antibiotics. Multiplicity of lesions and multifocal disseminated involvement in scrofuloderma and lupus vulgaris is common. However, our patient had an isolated skin ulcer. Response to anti-TB treatment was further supportive of the diagnosis. In conclusion, although the incidence of cutaneous TB is rare, it should be considered in patients presenting with suggestive skin lesions. Early diagnosis and the initiation of treatment are important to achieve complete recovery and avoid deformities. Increased awareness of TB is highly recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Demirci H, Shields CL, Shields JA, Eagle RC. Ocular tuberculosis masquerading as ocular tumours. Surv Ophthalmol 2004;49:78-89.  Back to cited text no. 1
    
2.
Rosen PH, Spalton DJ, Graham EM. Intraocular tuberculosis. Eye 1990;4:486-92.  Back to cited text no. 2
[PUBMED]    
3.
Sheu SJ, Shyu JS, Chen LM, Chen YY, Chirn SC, Wang JS. Ocular manifestations of tuberculosis. Ophthalmology 2001;108:1580-5.  Back to cited text no. 3
[PUBMED]    
4.
Helm CJ, Holland GN. Ocular tuberculosis. Surv Ophthalmol 1993;38:229-56.  Back to cited text no. 4
[PUBMED]    
5.
D’Souza P, Garg R, Dhaliwal RS, Jain R, Jain M. Orbital tuberculosis. Int Ophthalmol 1994;18:149-52.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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