she is a 26 yrs old married female, from Jhansi (UP). she these lesions on her mandibular area, neck, lt groin n rt axilla, for 2 yrs. as per her, initially these were large pus filled lesions, which ruptured by itself n become lik dis in photo. lesions started one-by-one. for these lesions she consulted a local doctor where she was told that these r Tubercular lesions n adviced ATT bt she refused that. since then she took no treatment, but lesions became stable. now she came to me with minimal pain n itching in dese lesions. she also told that she has low grade fever since den. she has no medical illness. no family h/o TB. her HP report is attached. her present ESR is 70. Hb is 9. dx n treatment???



Dear @Dr. Lakshya Kumar , gone through your case....... Rule in/out EXTRAPULMONARY TUBERCULOSIS and SUBCUTANEOUS MYCOSIS by taking samples for GeneXpert ( GeneXpert system, a platform for rapid and simple-to-use nucleic acid amplification tests or NAAT, provided by free of cost at different Tertiary Care Center throughout India.......), GRAM'S STAIN, KOH PREPARATION and FUNGAL CULTURE....... AND SENSITIVITY SOS....... Will pinpoint the DIAGNOSIS and GUIDE for the line of TREATMENT, whether the patient will put on ATT or ANTIFUNGALS....... ** Skin TUBERCULOSIS in Tropical country like India is mainly caused by MYCOBACTERIUM ULCERANS, an ATYPICAL MYCOBACTERIUM (NTM).......called BURULI ULCER is an infectious disease caused by Mycobacterium ulcerans. The early stage of the infection is characterised by a painless nodule or area of swelling. This nodule can turn into an ulcer. The ulcer may be larger inside (UNDERMINED EDGE) than at the surface of the skin, and can be surrounded by swelling....... It's the only MYCOBACTERIUM which produces TOXIN.......Skin ulcer by MYCOBACTERIUM MARINUN is mostly COMMON IN temperate and subtemperate ZONE/COUNTRIES....... but PREVALENCE is worldwide....... BURULI ULCER is an infectious disease caused by Mycobacterium ulcerans. ... The treatment often includes the medications RIFAMPICIN and STREPTOMYCIN. CLARITHROMYCIN or MOXIFLOXACIN range of antibiotics that can be used in the treatment of Buruli ulcer, awaiting confirmation of the efficacy of full oral antibiotics in ongoing studies....... A pregnant patient in Benin with BURULI ULCER was successfully treated with a combination of RIFAMPICIN and CLARITHROMYCIN....... ** Mycobacterium marinum is a free-living bacterium, which causes opportunistic infections in humans. M. marinum sometimes causes a rare disease known as aquarium granuloma, which typically affects individuals who work with fish or keep home aquariums....... Mycobacterium marinum is a non-tuberculous mycobacterium found in non-chlorinated water, with worldwide prevalence. It is the most common atypical Mycobacterium that causes opportunistic infection in humans. It presents as a solitary, red-to-violaceous plaque or nodule with an overlying crust or verrucous surface, or as inflammatory nodules or abscesses, usually in a sporotrichotic type of distribution. Deep infections may also occur. Although diagnosis is confirmed by isolation and identification of the organism in practice diagnosis remains largely presumptive based on clinicohistological features and the response to treatment. Polymerase chain reaction allows the routine early detection of the organism from a biopsy specimen. In the near future, it seems possible that histopathological examination might be greatly assisted by the rapidly improving possibilities with in vivo imaging. There have been many therapeutic modalities used effectively in the treatment of M. marinum infections. Spontaneous remission has also been reported in untreated infections and in immunocompetent hosts. However, there is no proven treatment of choice because M. marinum is naturally multi-drug resistant species and treatment is based primarily on the personal experience and preference of individual investigators, without the benefit of large studies. In superficial cutaneous infections minocycline, clarithromycin, doxycycline and trimethoprim-sulfamethoxazole as monotherapy are effective treatment options, but drug resistance varies and thereby combination therapy usually of two drugs may be required. Ciprofloxacin has shown considerable effectiveness. In cases of severe infections, including those with a sporotrichoid distribution pattern, a combination of rifampicin and ethambutol seems to be the recommended regimen. The use of isoniazid, streptomycin and pyrazinamide as empirical treatment options should be avoided. Surgical treatment is not usually recommended and must be cautiously applied. Cryotherapy, X-ray therapy, electrodesiccation, photodynamic therapy and local hyperthermic therapy have been reported as effective therapeutic alternatives. M. marinum infection should always be included in the DIFFERENTIAL DIAGNOSIS of all cases with POOR-HEALING WOUNDS IN upper extremities and A HISTORY OF EXPOSURE TO AQUARIUMS....... IF DIAGNOSIS GOES IN FAVOUR OF SUBCUTANEOUS MYCOSIS.......(eg, SPOROTRICOSIS caused by a dimorphic fungus called Sporothrix schenckii........THEN SYSTEMIC ANTIFUNGALS as per protocols....... THE DRUG OF CHOICE IS ITRACONAZOLE. ** The RARE cases of LIFE-THREATENING, visceral, or disseminated infection require therapy with INTRAVENOUS AMPHOTERICIN B, which is ALSO used IN PATIENTS who do NOT RESPOND TO ITRACONAZOLE.......

Dr. Lakshya kumar, I got through your case. No doubt it is SKIN TUBERCULOSIS called CUTANEOUS TUBERCULOSIS . Same bacteria can cause TB of lungs and extra pulmonary organs. 2 years duration , Pus filled lesions, Low grade fever,ESR 70 are positive findings. So confirm the SKIN TB by Tuberculosis sensitivity test(Mantoux tests) Chest X ray to detect pulmonary TB CT scans Sputum blood and culture sensitivity tests. PCR...Polymerase chain reaction test is high specific and sensitivity test for confirm the diagnosis. If patient is reluctant to do these., Only do ESR , sputum, And Mantoux test And follow Antituberculosis treatment . for 2 months can give good result. Follow Basic regime like.....RIPE regime.

thnx sir. well her cxr in normal. sputum sent fr afb.

SKIN TUBERCULOSIS / CUTANEOUS TUBERCULOSIS can't be confirmed by Mantoux test, dear Sir @Dr. P.kishore Kumar , rather Z. N. Stain is of value in CXR is normal, chance of pulmonary tuberculosis is a remote possibility and hopefully sputum for AFB will be negative as she has no SYMPTOMS OF PULMONARY TUBERCULOSIS.... and possibly she is not IMMUNOCOMPROMISED....dear... @Dr. Lakshya Kumar ....... correction of haemoglobin is needed.......

thnx sir

TB. Lesions. Do screpin complete and do H/P examination For confirmation. Start ATT. And give antibiotics for 10 to 15 days for eradication secondary Becterial infection. More important things are when ATT will Stat then some Pt .increase the secretion Frome the lesions so at that time don't worry It is best signs of recovery. And this secretion Will disappear automatic after some time but You continue ATT.

Look for nodes at other places Go for chest scan Possibly these are tubercular and att should be given Cbnaat of fluid from lesion can be done Fluid from nodes should be seen for bio also

cxr is normal. no lymphadenopathy.

I agree with Dr I Khan

Thanks respected

She must continue anti koacs treatment raise the immunity at drugs must be take,..amrita bhallataka lehyam . Swarna malini vasanta one bid with Talisadi chu plus vaikranta bhasma,.this is the best course for her,.

Scrofuloderma. DD suppurative lymphadenitis, mycoses.

@Dr. Avitus John Raakesh Prasad @Dr. Asv Prasad @Dr. P.kishore Kumar @Dr. M V Subramanyam @Dr. Aniruddha Lele @Dr. Supriya Patil @Dr. Sreenivasa Rao


sir she is poor pt..cant afford such investigations. wat else can we do to reach dx.??

No Metter rich or poor systemetic treatment Necessary

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