INTRODUCTION: Skin abnormalities can be the initial manifestation of an underlying systemic disease. Many diseases can present with concomitant skin and pulmonary manifestations. Nasal tuberculosis, while rare, should be a consideration.
CASE PRESENTATION: A 66 yo Polish female with a history of ischemic cardiomyopathy, hypertension, atrial fibrillation, diabetes, and CVA presented with a chronic right nares ulceration (FIGURE 1) and an abnormal CT of the chest. Six months prior to this hospitalization she was hospitalized for a CVA during which time she had an NG tube in place for an extended period of time. Over the proceeding six months, she was noted to have progressive ulceration of her right nares. A biopsy revealed a staphylococcus infection for which she received treatment. She was admitted most recently for decompensated heart failure. As part of her evaluation, a CT of the chest was performed (FIGURE 2) and revealed mediastinal and hilar adenopathy, but no parenchymal disease. On further questioning, she did have a chest CT performed about 6 months prior which also showed mediastinal and hilar adenopathy, but to a lesser degree. She did admit to exertional dyspnea, but denied fever, chills, cough, weight loss, or night sweats. A PPD was positive and the patient was placed on respiratory precautions. Laboratory tests were remarkable for a normal ESR, normal ACE level, negative C-ANCA, negative RPR/FTA-Ab, and negative HIV. A bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration was negative for AFB but did show caseating necrosis. A mediastinoscopy revealed epithelioid granulomas with central necrosis but negative AFB smears. AFB culture of the lymph node was positve for M. Tuberculosis.
DISCUSSIONS: Extrapulmonary tuberculosis is relatively uncommon accounting for about 5.4% of TB cases in the US. TB lymphadenitis and cutaneous TB are a few examples, with the former accounting for over 30% of cases. The clinical presentation of nasal ulceration and mediastinal adenopathy is not specific to one disease entity. Besides tuberculosis, other infectious diseases to consider include leprosy, syphilis, mucormycosis, aspergillus, blastomycosis, histoplasmosis, coccidioidomycosis, rhinosporidiosis, and herpes. Noninfectious causes included Wegener's granulomatosis, sarcoidosis, inhalation granuloma (silicosis and berylliosis), and NK-T cell lymphoma. Nasal tuberculosis is classified as either primary nasal tuberculosis or spontaneous nasal tuberculosis which occurs following pulmonary tuberculosis. Women are three times more likely to be affected then men, and symptoms include nasal obstruction, rhinorrhea, epistaxis, and crust formation. The cartilaginous portion of the nasal septum is most commonly affected followed by the turbinate and nasal floor. A definitive diagnosis requires isolating M. tuberculosis from biopsied tissue since nasal secretion swabs have a very low yield. 6–12 months of a multi-drug anti-TB regimen is necessary.
CONCLUSION: Nasal TB is very uncommon and can present a diagnostic dilemma. Pulmonary TB should be ruled out in someone suspected of having nasal TB.
DISCLOSURE: Christopher Wyckoff, None.