Multifocal tuberculosis of the nose and lymph nodes without pulmonary involvement: a case report.

Abstract

Tuberculosis of the nose is very rare. When it does occur, it almost always arises secondary to primary pulmonary tuberculosis. Nasal tuberculosis is most common in women older than 20 years. We report the case of a 16-year-old girl who presented with epistaxis, fever, submental swelling, and enlargement of multiple cervical and axillary lymph nodes. The patient was diagnosed with tuberculous granuloma of the nose and tuberculous lymphadenopathy. She was successfully treated with a 6-month regimen of standard antituberculous therapy.

Introduction

Tubercular involvement of the nose is extremely rare; when it does occur, it almost always arises secondary to primary pulmonary tuberculosis. (1) It is even more rare to see a case of nasal tuberculosis with simultaneous involvement of the lymph nodes but no primary involvement of the lungs.

Patients with nasal tuberculosis usually present with nasal obstruction and discharge. Other symptoms include nasal discomfort, epistaxis, crusting, postnasal drip, ulceration, and recurrent polyps. Nasal tuberculosis generally occurs in patients older than 20 years (2); women are affected more than men by a margin of 3:1. (3) In this article, we report a case of multifocal tuberculosis that involved the nose, cervical lymph nodes, and axillary lymph nodes in a younger female.

Case report

A 16-year-old girl was referred to our ENT outpatient department with complaints of epistaxis, fever, and multiple neck swellings. She said she had experienced at least 6 episodes of epistaxis during the preceding 2 months along with an intermittent low-grade fever. The neck swellings were of 1 month's duration and were progressive. She did not report productive cough, dyspnea, or weight loss.

Physical examination of the neck revealed a visibly enlarged submental lymph node abscess (figure 1, A). The 2 x 3-cm mass was soft in consistency, tender, mobile, and discrete. The right upper deep cervical lymph nodes were firm in consistency, nontender, mobile, and matted. In addition, the patient had palpable supraclavicular and axillary lymph nodes on both sides; each of the nodes measured approximately 1 x 2 cm, and each was firm in consistency, nontender, and mobile. Findings on the remainder of the ENT examination were within normal limits.

[FIGURE 1 OMITTED]

General examination revealed the presence of multiple skin lesions over both forearms (figure 1, B) and the dorsa of the hands. The lesions were firm, nontender papules, and some exhibited crusting surrounded by erythema. They were diagnosed clinically as erythema multiforme.

Anterior rhinoscopy detected an ulcerative lesion measuring approximately 1.5 x 1 cm over the left side of the anterior part of the cartilaginous septum. The lesion was shallow, it had a red floor, and it was surrounded by discolored, unhealthy mucosa (figure 2, A). Granulations were present at the anterior end of the inferior turbinate on the right, which bled to the touch (figure 2, B). The postnasal examination was negative.

[FIGURE 2 OMITTED]

The patient underwent a series of laboratory tests. Her hemoglobin level was low (8.3 g/dl), and her erythrocyte sedimentation rate was high (65 mm/hr). An enzyme-linked immunosorbent assay for human immunodeficiency virus was negative. X-ray (occipitomental view) of the paranasal sinuses showed haziness of all the sinuses and mucosal thickening of the maxillary sinuses, more so on the left. Achest x-ray detected no abnormality. Fine-needle aspiration cytology of the lymph nodes was suggestive of tuberculosis, and the Mantoux test was strongly positive. Computed tomography (CT) revealed mucosal thickening of the left maxillary sinus and destruction of the cartilaginous septum.

The patient was put on intravenous antibiotics, and a biopsy of the lesion was planned. However, because the patient was not cooperative, we decided to perform the procedure with general anesthesia. Nasal examination with a 0[degrees] sinoscope revealed that more lesions were present than what we had seen clinically. Pale granulations were seen over both middle turbinates and the septal lesions. Sinoscopy confirmed that the septal lesions were shallow and that the floor of each lesion was red with undermined edges. A deficiency of the cartilage was felt on probing.

Multiple biopsy specimens were obtained from all the lesions and sent for histopathologic examination. Findings on analysis of the primary ulcer--which contained caseating necrosis with florid granulomas, Langerhans' giant cells, and abundant epithelioid cells--were strongly suggestive of tuberculosis (figure 3). Tissue smears revealed acid-fast bacilli. The biopsies from other sites showed granular changes. Excision biopsy of the submental lymph node was also suggestive of tuberculosis.

[FIGURE 3 OMITTED]

The patient was put on antituberculous therapy for 6 months (rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months) and concurrently treated for her skin conditions with topical sodium fusidate cream and 2% ketoconazole shampoo. During monthly follow-up examinations, her lymphadenopathy had resolved and her skin lesions had improved. Scarring of the septum was minimal. Follow-up CT at 6 months showed the deficiency of the septal cartilage and minimal mucosal changes (figure 4). Overall, her general condition had improved markedly.

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Discussion

Nasal tuberculosis is contracted by inhalation of infected drops or dust or by inoculation via a finger? It is rare because of the protection provided by the ciliary action of the nasal mucosa and the nasal vibrissae and by the bactericidal properties of nasal secretions? In our patient, the usual symptoms of nasal obstruction and discharge were not present; her only complaints were recurrent epistaxis, fever, and multiple neck swellings.

The most common sites of involvement in nasal tuberculosis are the cartilaginous septum, the turbinates, and the nasal floor. (5) Exophytic and granular lesions are more common than the ulcerative and infiltrative types. (6) Skin lesions, which were diagnosed as erythema multiforme in our patient, are said to represent an acute mucocutaneous hypersensitivity reaction. These reactions are of variable severity, and they are triggered by a variety of stimuli, particularly bacteria (including Mycobacterium tuberculosis), viruses, and chemical products. (7)

The differential diagnosis of nasal tuberculosis includes other granulomatous diseases such as Wegener's granulomatosis, syphilis, rhinoscleroma, rhinosporidiosis, blastomycosis, histoplasmosis, and coccidioidomycosis. Leishmaniasis and sarcoidosis also have similar characteristics. (5)

The diagnosis is not based solely on a histopathologic finding of a typical granuloma; it is also based on the results of acid-fast bacilli staining by the Ziehl-Neelsen technique and the patient's response to therapy. (3) Compared with other types of granulomas, the tuberculous variety tends to involve a greater number of epithelioid and giant cells. (3) A positive Mantoux test is also used to confirm the diagnosis.

Nasal tuberculosis responds well to the same regimen of antituberculous drugs recommended for any other type of extrapulmonary tuberculosis. Our treatment regimen included rifampicin, i soniazid, pyrazinamide, and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months. Other than the deficiency of the septal cartilage (without perforation), our patient experienced no untoward complications such as septal perforation, local spread, central nervous system involvement, atrophic rhinitis, or nasal stenosis. (5)

Nasal tuberculosis should be considered in the differential diagnosis for any patient with granulomatous lesions of the nose. Early diagnosis and aggressive management can result in a complete cure of this rare entity.

References

(1.) Howard D. Nonhealing granulomas. In: Mackay IS, Bull TR, eds. Scott-Brown's Otolaryngology: Rhinology. 6th ed. Oxford: Butterworth-Heinemann; 1997:4/20:1-11.

(2.) Butt AA. Nasal tuberculosis in the 20th century. Am J Med Sci 1997:313(6):332-5.

(3.) Batra K, Chaudhary N, Motwani G. Rai AK. An unusual case of primary nasal tuberculosis with epistaxis and epilepsy. Ear Nose Throat J 2002;81(12):842-4.

(4.) Messervy M. Primary tuberculoma of the nose with presenting symptoms and lesions resembling a malignant granuloma. J Laryngol Otol 1971;85(2):177-84.

(5.) Waldman SR, Levine HL, Sebek BA, et al. Nasal tuberculosis: A forgotten entity. Laryngoscope 1981;91(1): 11-16.

(6.) Goguen LA, Karmody CS. Nasal tuberculosis. Otolaryngol Head Neck Surg 1995;113(1):131-5.

(7.) Chapel TA, Chapel J. Erythema multiforme. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York: McGraw-Hill: 1995:1114-16.

M. Panduranga Kamath, MS; Kiran M. Bhojwani, MS; Shivananda Prabhu, MS; Ramdas Naik, MD; Geo P. Ninan, MBBS; Yeshwanth Chakravarthy, MBBS

From the Department of Otolaryngology-Head and Neck Surgery, Kasturba Medical College, Mangalore, Karnataka State, India.

Reprint requests: Dr. M. Panduranga Kamath, Upstairs, Panduranga Ganapaya and Sons, Opposite the Taj Mahal Cafe, Car St., Mangalore 575001, Karnataka State, India. Phone: [phone]; fax: [phone]; e-mail: [e-mail]