Dermacademy Challenge – Clinical Case #3 – Pr. Zaslavsky

Clinical case shared by Pr. Zaslavsky

Clinical Presentation

Patient K., 5 years old, accompanied by her mother N., 36 years old, was referred for consultation. According to the patient's mother at admission, the patient complained of skin eruptions on the body, upper and lower limbs, neck, and scalp.The child has had this condition for about a year when an inflammation site first appeared on the back of the neck. The patient's mother does not associate the disease onset with anything.

Family History

The patient's mother has had cutaneous tuberculosis since early childhood. Negative allergic anamnesis. No bad habits. Past diseases: acute respiratory disease. Denies sexually transmitted diseases, hepatitis, HIV. No history of hemotransfusions or surgeries. Mother's pregnancy and childbirth without abnormalities.

Physical Examination

A coarse keloid scar formed on the surgery site, and a spot, growing in size, appeared on the head. Later, the skin process began to spread: skin eruptions appeared on the body and limbs, as well as on the scalp. The mother began self-administration of rifampicin lotion on the head.

Satisfactory general condition. Regular build. Clear regular heart sounds. Vesicular breath sounds heard throughout all lung fields, without rales. Abdomen is soft and nontender, nondistended, non-asymmetric. The liver edge does not protrude below the costal margin; dense, elastic consistency; nontender, even. The spleen is not palpable. The kidneys are nontender on palpation. Murphy's punch sign is negative on both sides. Lymph nodes are not enlarged. Stool and urination without abnormalities.

Multiple eruptions, predominantly located on the scalp, back of the neck, side surfaces of the body, upper and lower limbs. An inflammatory lesion on the scalp, 6x4 cm, with signs of atrophy, pustular rash elements, round-shaped, of scarlet-brown color (Figure 1). Multiple dense conical-shaped tubercles of golden-brown color covered with easily removable crusts (Figure 2) are noted on the skin of upper and lower limbs. Single, slightly tender dense mulberry nodules, of 1.5–2 cm, surgical scars (Figure 3) are noted on the back surface of the neck. The nodules are slightly tender on palpation; diascopy reveals a strong positive ""apple-jelly"" sign. Peripheral lymph node groups are not enlarged, not adherent to the skin, movable, nontender. Nail plates on fingers and toes are unchanged. No subjective perception.

Laboratory Result

In recent years, Mantoux tuberculin skin tests (2TU) have shown a normergic reaction with augmentation (р = 15 mm). Inactivity of TB infection, absence of clinical and radiological evidence suggestive of TB, negative reactions to the test with Diaskintest and ELISPOT required consultation by an oncologist who sampled material for histological verification of diagnosis. Pathologists suggested granulomatous inflammation.

Biopsy Result

According to the description of the morphological material, there are tissue fragments covered with non-keratinized stratified squamous epithelium with diffuse round-cell infiltrate in the subepithelial stroma. Pronounced caseous necrosis with epithelioid cell granulomas and single Langhans multinucleated giant cells, mainly without a clear demarcation area (Figure 4), is identified in the infiltrate. Single granulomas are surrounded by a thin rim of collagen fibers. Non-keratinized stratified squamous epithelium with diffuse infiltration by segmented neutrophils and mononuclear leukocytes. The molecular genetic test of the biopsy material has isolated the DNA of the M.tuberculosis complex which allows for verification of cutaneous tuberculosis diagnosis.