A REPORT ON 3 CASES OF TUBERCULOUS INJECTION
ABSCESS
JG SALUJA*, MS AJINKYA**, PS MAMTORA***,NARENDRA REGE***, RAJIV JAIN****
*Head and Associate Professor; **Associate Professor, Department of Pathology;
***Hon. Orthopaedic Surgeon at CMPH Medical College and Shri Mumbadevi Homeopathic
Hospital, Irla, Vileparle (West), Mumbai 400 056. ****Hon. General Surgeon
at Jain and Maru Hospital.
Presenting three cases of Tuberculoses
Injection Abscess.
INTRODUCTION
Mycobacteria are acid fast, weakly gram positive rods. The modified Runyon classification
of mycobacteria is divided into Slow Growing Mycobacteria obligate human
pathogen and facultative human pathogens. Rapidly Growing Mycobacteria facultative
human pathogens.
Infections due to mycobacterium tuberculosis are classified according to the
inoculation route. The inoculation can occur from an exogenous source, from
an endogenous source or from haematogenous spread.
Both the general immunologic state of the host and the specific host immunity
are factors to decide the lesion type that will develop from each type of inoculation.
Non-Tuberculous mycobacteria unlike Mycobacteria tuberculosis are not usually
transmitted from person to person. These opportunistic organisms are found in
many types of water and soil, with entry most often from direct inoculation.
Less commonly, infection occurs by inhalation or ingestion. What causes these
organisms to become pathogenic is not known, although immunosuppression of the
host plays a role in the ability of many of these organisms to produce infection.
Primary infection due to Mycobacteria tuberculosis and Non-tuberculous mycobacteria
may occur in immunocompetent individuals, usually with resolution of infection
but immuno-suppression facilitates spread or dissemination of disease and may
be what allows many Non-tuberculous organisms to become pathogenic.
CASE PRESENTATION
Case 1
Male Age 20 yrs
Came to Ortho OPD with:
*Swelling and pain in left gluteal region since 6 to 8 months.
*Pain while walking
*H/O injection at the site of swelling.
*O/E (Locally) : Oedematous swelling in left gluteal region; Diffuse; No sign
of inflammation; Tenderness on pressure.
*G/E : Afebrile; Lean thin built; BP 130/80; Pulse 80/min; RR 18/min.
*Systemic Examination
| *Impression |
? Antibioma |
| |
? Bursitis |
*Investigation H/O Aspiration done NO significant pathology reported.
CBC HB - 11.4, WBC - 9,800, N - 60, E - 2, L - 38
ESR - 48 mm/1hr
FBS - 80.8 m%
HIV - Non-reactive
HbsAg - Negative
TBIgG - 245 units (NR = upto 225 units)
X-Ray - Chest NAD
*Incision and Drainage under GA
*Frank Pus caseous material mixed with blood collected under asepsis.
*Chronic villous hyperplasia and inflammatory cells with huge capsule 6" x 4"
extending around left hip joint capsule excised in toto.
*Histopathology : - Gross capsule cut open showing fibrinous exudative tags
covered with necrotic yellowish material.
*Microscopically H and E stained section reveals proliferative fibroblastic
connective tissue with infiltrating inflammatory cells viz. Lymphocytes, plasma
cells, epitheloid cells, occasional multinucleated giant cells seen.
*Smear prepared from caseous material stained by modified ZNCF staining revealed
AFB.
Case 2
Female Age - 14 yrs
Came to Ortho OPD with:
*Left gluteal abscess since 3 months. With sinus formation and oozing of cheesy
material.
*H/O injection at the site of swelling 6 months back for fever (twice drained
elsewhere).
*O/E (Locally) : Cystic swelling measuring 2x3x3 cms. With sinus discharge.
Length of sinus measuring 6 cms. depth. No sign of inflammation; Tenderness
on pressure.
*G/E : Afebrile; Average built; Pallor + Brittle nails; BP 100/70; Pulse 78/min.;
R 10/min.
*Systemic Examination
| RS |
|
| CVS |
NAD |
| GIT |
|
| CNS |
|
| No Lymphoadenopathy |
*Impression? Tuberculous sinus with abscess. Advice excision drainage.
*Investigation
CBC - Hb 10, WBC - 14,800, N - 40, E - 0, L - 60 (reactive)
ESR - 80 mm/1 hr
HIV - Non-reactive
HbsAg - Negative
TBIgG - 195 units (NR = upto 225 units)
X-ray - Chest Healed lesion at right mid zone.
X-ray hip/spine - Normal
*Incision and Drainage under GA
Histopathology : Reveals non-specific inflammatory changes.
Smear prepared from tissue shows AFB positive.
(Modified Method)
Case 3
Female Age 70 yrs
Came to Shri Mumbadevi Homocompathic Hospital ORTHO OPD with:
*Left gluteal abscess since 8 months.
*Drained by surgeon.
*Started broad spectrum antibiotics.
*Non-healing
*Close irrigation of wound washing
*No impovement in healing.
*H/O injection at the site of swelling one year back.
*O/E (Locally) : Non-healing wound; Unhealthy vascular oedematous margin with
minimal induration measuring 3x2x2 cms.
*G/E : Afebrile; Stocky built; BP 140/100 mm Hg; Pulse 100/min.; RR 22/min.
*Systemic Examination
*Advice X-Ray Chest; X-ray sacroiliac joints;
biopsy; smear from the tissue.
*Investigation
CBC Hb - 12.5, WBC - 12,800, N - 50, E - 0, L - 50
ESR - 100 mm/1hr
HIV - Non-reactive
HbsAg - Negative
TBIgG - 265 units (NR = upto 225 units)
X-ray - Chest NAD
X-ray Sacroiliac Joints - Reveals lytic area at sacroiliac joints showing changes
of osteomyelitis at sacrum.
*Biopsy - Reveals characterised epitheloid granuloma with multinucleated giant
cells.
Smear from the tissue revealed AFB on staining with modified ZNCF staining.
DISCUSSION
Tuberculosis has also been described following subcutaneous or intra-muscular
injection. Either the syringe, needle or fluid to be injected has been contaminated
or the medical attendant has exhaled tubercle bacilli into the patient's skin
which are then introduced by the injection. A primary syringe transmitted infection
of a muscle should be distinguished from secondary infection of a muscular haematoma
with tuberculosis elsewhere in the body. As later cases often occur due to regular
obligate pathogenic mycobacteria, while the former may be due to other mycobacteria
which are facultative human pathogens.
There is a report of 102 children developing primary tuberculosis at the site
of typhoid and para typhoid A+B (TAB) vaccination transmitted by a school vaccinator
who was found to have active tuberculosis.[1] Primary cutaneous
tuberculosis has followed venepuncture[2], it may be difficult
to differentiate primary tuberculosis of the skin from secondary.[3]
Perhaps in years to come the form of cutaneous primary complex may be commoner
than pulmonary primary complex.[4] Organisms probably disseminated
during the course of primary pulmonary infection with scattered inactive tubercle
bacilli.
|
Comparative
findings of three cases
|
| |
Case 1 |
Case 2 |
Case 3 |
| Age |
20 years |
14 years |
70 years |
| Sex |
Male |
Female |
Female |
| Clinical H/O |
Swelling (L) Gluteal Region |
Sinus (L) Gluteal Region |
Non-healing ulcer(L) Gluteal Region |
| Finding |
Abscess |
Abscess |
Abscess |
| WBC Count |
9,800/cu. mm |
14,800/cu. mm |
12,800/cu. mm |
| Differential count (Lymphocyte) |
38% |
60% |
50% |
| ESR at 1 hr |
48 mm |
80 mm |
100 mm |
| TBIGG |
254 units |
195 units |
265 units |
| X-ray chest |
NAD |
Healed lesion Rt. Midzone |
NAD |
| Histopath Microscopy |
Tuberculo-Infiltration |
Non-Specific Inflammation |
Tubercular Granuloma |
| ZNCF (Modified Staining) |
AFB Detected |
AFB Detected |
AFB Detected |
Index : WBC Count Normal
- 4,000 to 11,000/cu. mm; TBIgG (ELISA) Normal - 225 units; ESR Normal
- Male 0 to 15 mm at the end of one hr.; Female 0 to 20 mm at the end
of one hr. (Westergren Method)
HIV (Immunocomb) HbsAg (Monozyme Hepstick Chromatographic technique, specificity
100%, sensitivity 0.5 ng/ml) |
Mycobacterium scrofulaceum and fortuitum are common pathogens distributed in
nature are found in water and soil. Most cutaneous regions due to these have
occurred post operatively after mammoplasty, catheter placement, and trauma
in immunocompromised individual.[5] The incubation period for
infection on an average is about 4 weeks to 6 weeks.[6]
Histologically the hallmark of tuberculosis is well defined focus of epitheloid
cells formed by an infiltration of other mononuclear cells frequently, however
one does not find the typical tubercle but only epitheloid cells intertwined
within an inflammatory infiltrate with or without necrosis. This variation is
called "Tuberculoid infiltration".[7] There is significance
of cellular immunity contributing to whether the predominant histologic pattern
shows well defined tubercle with or without tuberculous infiltration.
Non-tuberculous mycobacterium show a histologic picture variable as the clinical
finding. Early lesion often show a non-specific inflammatory infiltrate of neutrophil,
monocytes and macrophages. Later after several months a few epitheloid cell
granuloma and multinucleated giant cells appear.[8,9]
After 6 months or more a typical tuberculoid infiltrate usually occur with or
without caseous necrosis. The presence or absence of Acid fast bacilli on histopathology
is dependent on the tissue reaction.
However, whatever may be the histological type of picture or the aetiology they
have to be considered as mycobacterial tubercle infection and treated accordingly.
The importance of such abscess developing in the frequency lately should be
indexed to avoid delay in diagnosis and treatment.
ACKNOWLEDGEMENT
We sincerely thank the Dean Dr. SK Goel for giving permission to publish the
data. We are grateful to Dr. Prachi Bedekar for helping in preparing the manuscript.
REFERENCES
1.Tomura M, Ogawa G, et al. Observation on an epidemic of cutaneous
and lymphatic tuberculosis which followed the use of Anti typhoid vaccine. Am
Rev Tuberc 1955; 71 : 465-72.
2.Irani A, Colaco P, Desai MP. Cutaneous primary complex following
Venepuncture Indian Pediatric. 1978; 15 : 181-3.
3.Strikas R, Venezio FR, O'Keefe JP. A case of Cutaneous Tuberculosis
Primary or Secondary? Am Rev Respiratory Disease 1983; 128 : 316-8.
4.Caplan SE, Kauflman CL. Primary inoculation tuberculosis after
immunotherapy for malignant melanoma with BCG vaccine. J Am Acad Dermatol 1996;
35 : 783-5.
5.Sehgal V, Wagh SA. Cutaneous tuberculosis current concepts.
International Journal of Dermatology 1996; 35 : 783-5.
6.Weissler JC. Southwestern
Internal medicine conference tuberculosis - immunopathogenesis and therapy.
Tuberculosis 1993; 52 : 305.
7.Beyt BE Jr, et al. Cutaneous
mycobacteriosis analysis of 34 cases with a new classification of the disease.
Medicine (Baltimore) 1981; 95 : 60.
8.Hanke CW, Temefeew RK,
Slama SI. Mycobacterium Kansassii infection with multiple cutaneous lesion.
J Am Acad Dermatol 1987; 1122 : 6.
9.Savin JA. Mycobacterial
infections. Textbook of Dermatology 5th Edition Black Well Scientific Publications,
London. 1992; 2 : 1033.
