title: Parotid tuberculosis associated with cutaneous tuberculosis on a medial epicanthus.
abstract: An 83-year-old woman presented with a 2-month history of a gradually enlarging, reddish, crusted papule on her left medial epicanthus. Her medical history did not reveal any systemic disease. She gave no personal history of tuberculosis or any systemic symptoms, such as night sweat, weight loss, and pulmonary abnormalities. Her husband had been treated for pulmonary tuberculosis 30 years ago. A dermatologic examination revealed a 2.5 x 1.2-cm nontender, erythematous plaque with fine, white adherent scales on the left medial epicanthus (figure 1A). All laboratory values were within the normal range. Results from a tuberculin skin test were initially negative. A skin biopsy was performed, and a pathological examination demonstrated multiple noncaseating granulomas with various diameters in the reticular dermis and an infiltrate of neutrophils and lymphocytes in the surrounding dermis (figure 2). Periodic acid-Schiff, Ziehl-Nilsen, gram, and giemsa stains were negative for any microorganism. Leishman-Donovan-like bodies were observed within the epitheloid histiocytes that formed the granulomas. The pathological diagnosis was granulomatous dermatitis. The patient was diagnosed with cutaneous leishmaniasis (CL) based on her clinical appearance and histopathological findings, although the parasite was not detected in the tissue specimens. Treatment with intralesional glucantime for 5 consecutive weeks did not improve her condition. By the end of the fifth week, the patient developed asymptomatic facial swelling and a 1.5 x 1.2-cm erythematous plaque in the left parotid area (figure 1B). An ultrasonographic examination demonstrated a 13 x 11 x 17-mm hypoechoic mass, which suggested pleomorphic adenoma. In addition, lymph nodes, the largest of which were 9 x 10 mm, were noted in the left cervical area. A skin biopsy from the erythematous plaque of the left parotid area demonstrated diffuse neutrophilic infiltration with formation of focal granulomas. Tuberculosis was suspected, and mycobacterium tuberculosis (MT) was isolated from the culture. A tuberculin skin test was performed again, which was positive (12 mm). The erythrocyte sedimentation rate was 35 mm/h, and all other laboratory tests were within normal limits. Pulmonary radiography and thoracic computerized tomography findings were normal. Fine needle aspiration biopsy and ultrasonographic examination of the parotid mass were performed, which revealed necrotic material with neutrophils and lymphocytes (figure 3). We treated the patient with a standard antituberculous regimen, comprising isoniazid 300 mg/d, rifampin 600 mg/d, ethambutol 1200 mg/d, and pyrazinamide 1500 mg/d. By the end of the second month of treatment, the patient improved considerably. There was a marked reduction in facial swelling, and the lesion on the left medial epicanthus regressed dramatically (Figure 4A and Figure 4B). No adverse effects of the medication occurred. An additional 7 months of therapy with isoniazid and rifampin was planned.
authors.affiliation: Department of Dermatology and Pathology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey. gulsentukenmez@yahoo.com
authors.forename: Gulsen Tukenmez
authors.initials: GT
authors.lastname: Demirci
authors.forename: Ilknur Kivanç
authors.initials: IK
authors.lastname: Altunay
authors.forename: Eda
authors.initials: E
authors.lastname: Mertoğlu
authors.forename: Damlanur
authors.initials: D
authors.lastname: Sakiz
mesh_terms: D000369:Aged, 80 and over; D000995:Antitubercular Agents / Q000627:therapeutic use; D005143:Eyelids; D005260:Female; D006801:Humans; D010305:Parotid Diseases / Q000150:complications* / Q000382:microbiology*; D014382:Tuberculosis, Cutaneous / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D014393:Tuberculosis, Oral / Q000150:complications* / Q000188:drug therapy
chemical_list: D000995:Antitubercular Agents