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National report - Patients who present with groin or perineallesions may have a form of tuberculosis, says Allison Readinger,M.D., a resident in dermatology at the University of Texas MedicalBranch, Galveston, Texas.
National report - Patients who present with groin or perineal lesions may have a form of tuberculosis, says Allison Readinger, M.D., a resident in dermatology at the University of Texas Medical Branch, Galveston, Texas.
Dr. Readinger discusses the specific case of one of her patients, a 28-year-old Hispanic man with a past history of condyloma who presented with a three-year history of perineal, scrotal and penile edema with Dermatology Times.
Exam & Diagnosis
Dr. Readinger says a CAT scan revealed mild rectal wall thickening, soft-tissue edema of the scrotum and possible abscess in the perineal area. Chest x-rays showed bilateral nodular opacities with the worst in the upper lung consistent with granulomatous infection. Two 4 mm punch biopsy specimens - one for biopsy, one for tissue culture - were taken from the left inguinal area. A rectal swab and a skin biopsy both showed AFB (acid-fast bacilli), the type of bacteria that causes tuberculosis.
"Treatment included this patient being started on a four-drug anti-tuberculosis regimen and antibiotics for MRSA (methicillin-resistant Staphylococcus aureus) pending the culture results," Dr. Readinger says. "Also, we did an end-sigmoid colostomy for fecal incontinence, Dobhoff tube feeds and blood transfusion. We noted improvement in healthy granulation of tissue prior to transferring the patient to an outside facility."
According to Dr. Readinger, it may be difficult to recognize tuberculosis as a potential cause for groin or perineal lesions such as she observed in what she calls this rare variant of periorificial tuberculosis. She says this variant usually occurs with systemic signs and symptoms of pulmonary tuberculosis, and that it must be considered as a potential diagnosis if the patient also has groin lesions. She adds that periorificial tuberculosis may occur around the mouth as well as the genitoanal area.
"In caring for this patient, I was surprised to learn that, in addition to anti-tuberculosis medication, the patient would require surgery to heal," Dr. Readinger says. "His groin area was continually affected by fecal incontinence and would not have healed without the end-sigmoid colostomy, which helped keep his perineal and groin wounds clean."
Dr. Readinger says she was also fascinated by the pathogenesis of this variant of tuberculosis.
"Although lymphatic or hematogenous spread cannot be excluded as the pathogenesis," she explains, "the current theory is that one expectorates sputum containing tuberculosis and it passes through or infects the gastro-intestinal tract and then spreads to mucous membranes."