297 Tüberküloz ve Toraks Dergisi 2010; 58(3): 297-300
Primary nasal tuberculosis:
a case report
Fadlullah AKSOY, Yavuz Selim YILDIRIM, Ümit TAŞKIN, Gülüm BAYRAKTAR, Osman KARAASLAN
SB Haseki Eğitim ve Araştırma Hastanesi, Kulak Burun Boğaz Kliniği, İstanbul.
ÖZET
Primer nazal tüberküloz: Olgu sunumu
Tüberküloz son zamanlarda geniş bir yayılım alanı içermekte, hemen hemen tüm vücutta ciddi formlarda ortaya çıkabil- mektedir. Primer nazal tüberküloz nadir bir hastalıktır. Klinisyenler primer nazal tüberkülozun semptomlarını tanımada zor- lanırlar ve buna bağlı olarak da tanı ve tedavi geç olmaktadır. Altmış yaşında kadın hasta, epistaksis ve burun içinde ka- buklanma şikayetiyle başvurdu. Lezyon kenarından biyopsi alındı. Tanı histopatoloji temelinde antitüberküloz tedaviye başarılı yanıtla konuldu. Ekstrapulmoner tüberkülozun ve pulmoner tüberkülozun tedavisindeki temel prensipler, nazal tü- berkülozun klinik özellikleriyle beraber tanıdaki zorluklar tartışıldı.
Anahtar Kelimeler: Nazal tüberküloz, granülomatöz reaksiyon, ekstrapulmoner tüberküloz.
SUMMARY
Primary nasal tuberculosis: a case report
Fadlullah AKSOY, Yavuz Selim YILDIRIM, Ümit TAŞKIN, Gülüm BAYRAKTAR, Osman KARAASLAN
Department of Otolaryngology-Head and Neck Surgery, Haseki Training and Research Hospital, Istanbul, Turkey.
Tuberculosis can involve virtually any organ and it manifests itself in various forms. When tuberculosis is as widespread as it is currently in this paper. Primary nasal tuberculosis is a rare disease. The clinicans fail to diagnose its symptoms as primary nasal tuberculosis and therefore its diagnosis and treatment is often delayed. We aim to present in the light of rel- evant literature the case of a 60-year-old woman with epistaxis and crusting who was admitted to a clinic. A biopsy of the
Yazışma Adresi (Address for Correspondence):
Dr. Yavuz Selim YILDIRIM, SB Haseki Eğitim ve Araştırma Hastanesi, Kulak Burun Boğaz Kliniği, 34089 Aksaray, İSTANBUL - TURKEY
e-mail: dryavuzselim@yahoo.com
Primary nasal tuberculosis is an exceedingly rare manifestation of infection by Mycobacteri- um tuberculosis (1). Thus far, about 40 cases of primary nasal tuberculosis have been repor- ted. The clinicans fail to diagnose its symptoms as primary nasal tuberculosis and therefore, its diagnosis and treatment is often delayed. Ext- rapulmonary tuberculosis occurs in perhaps 15% of all patients with tuberculosis. Tubercu- losis is known to affect almost every organ in the body, and it should be a concern of each and every medical practitioner. However, many otolaryngologists have a limited experience of tuberculosis of the head and neck (2). In this paper, we aim to present, in the light of relevant literature, a primary nasal tuberculosis case that was diagnosed one year after the patient was admitted to a clinic.
CASE REPORT
A 60-year-old woman complained of intermit- tent epistaxis and nasal crusting without nasal obstruction. Our case first went to an internist and otolaryngologist. When she did not benefit from the medication she received from them, she attended our outpatient clinic one year later.
During the physical examination of the front wall of nasal septum, a fragile, pinkish, ulcerative le- sion that was 2 x 2 cm in diameters was detec- ted (Figure 1).
In nasal cavity, there was no obstruction, nor an abnormal sign. The physical examination espe- cially otorhinolaryngology examination did not reveal any other pathological findings. The labo- ratory tests indicated a hemoglobin level of 12.9 g/dL, leukocyte 10 x 106 dL, with 80% poly- morphonuclear cells, and erythrocyte sedimen- tation rate 18 mm/hour. The patient had been given a BCG vaccination when she was a child.
Other biochemical tests, as well as chest X-ray, thorax high resolution computed tomography
and paranasal sinus tomography were also nor- mal. Patient did not have any documented his- tory of pulmonary tuberculosis and diabetes mellitus or any known immunologic problems to include human immunodeficiency virus (HIV) infection, hematologic malignancies, or rhe- umatologic diseases. Several biopsies of lesion margins were taken, and there was relatively litt- le amount of bleeding during biopsy. The speci- mens were sent for histopathological and micro- biological (bacterial, fungal, and mycobacterial) examination. Subsequent Ziehl-Neelsen staining revealed acid-fast bacilli (AFB) negative and an assay for purified protein derivative was strong- ly positive (16 x 16 mm) and Löwenstein-Jen- sen cultures yielded negative. Three times of analysis of sputum for AFB was negative, VDRL, TPHA, C-ANCA, and anti-HIV tests were also negative too. The pathologic examination reve- aled caseating granulomatous lesion, inflamma- tion with epithelioid cells, lymphocytes and few giant cells (Figure 2,3). Patient consult with chest clinics and these findings suggested nasal tuberculosis. So, the patient was administered
Primary nasal tuberculosis: a case report
Tüberküloz ve Toraks Dergisi 2010; 58(3): 297-300 298
marginal tissue was performed. The diagnosis was based on histopathology and successful response to antituberculous drug treatment. The basic principles that the treatment of pulmonary tuberculosis and extra-pulmonary forms of the dis- ease to elucidate the clinical characteristics of nasal tuberculosis and to discuss its diagnostic difficulties.
Key Words: Nasal tuberculosis, granulomatous reaction, extra-pulmonary tuberculosis.
Figure 1. Front wall of nasal septum, a fragile, pink- ish, ulcerative lesion that was 2 x 2 cm.
Renkli
isoniasid, rifampicine, pyrazinamid, and etham- butol for two months, which was followed by iso- niasid and rifampicine for four months. At the end of the treatment, the lesion completely di- sappeared (Figure 4).
DISCUSSION
Nasal tuberculosis was first reported in 1761 by Giovanni Morgani, who described autopsy fin- dings of a young man with ulcerative lesions in the soft palate, nasopharynx, and nasal cavity (3). Before HIV epidemics two decades ago, it was observed that whereas cases of pulmonary tuberculosis decreased each year, the number of extra-pulmonary cases remained stable. Later, the percentage of cases resulting from extra-
pulmonary tuberculosis subsequently increased, largely due to coinfection with HIV (4).
Nasal tuberculosis can be classified as sponta- neous nasal tuberculosis, which occurs secon- darily after pulmonary tuberculosis, and as pri- mary nasal tuberculosis, which occurs without a prior pulmonary tuberculosis infection. It has previously been reported that spontaneous na- sal tuberculosis was more common than pri- mary nasal tuberculosis (5). Despite the incre- ase in extra-pulmonary tuberculosis, the tuber- culosis of the head and neck occurs infrequently and the involvement of the nose is extremely ra- re (6). The reason for the scarcity of nasal tuber- culosis was not clearly established. It has been postulated that nasal mucosa is inherently resis- tant to mycobacterial growth, due to the effecti- ve bactericidal activity of the nasal secretions, the filtering function provided by the nasal vib- rissae, and mechanical protection achieved by ciliary movements (2). Studies of the nasal tu- berculosis show that the patients are commonly women (7). Our case was also a woman, but she was 60-year-old, and on that account, she was above the average median age. With our case, the lesion was unilateral consistent with nasal tuberculosis incidents generally observed in lite- rature. However, it should be noted that one third of the cases may be bilateral (8).
The most common complaints associated with primary nasal tuberculosis are nasal obstructi- on, rhinorrhea, decreasing sense of taste and
Aksoy F, Yıldırım YS, Taşkın Ü, Bayraktar G, Karaaslan O.
299 Tüberküloz ve Toraks Dergisi 2010; 58(3): 297-300 Figure 2. Showing caseating granulomatous lesion,
inflammation with epithelioid cells, and lymphocytes and few giant cells. Hematoxylin and eosin; original magnification (HE x200).
Renkli
Figure 4. End of the treatment, the lesion completely disappeared.
Renkli
Figure 3. Showing typical caseating granulomatous lesion an area of central necrosis, inflammation with epithelioid cells, Langerhans and lymphocytes and few giant cells. Hematoxylin and eosin; original mag- nification (HE x400).
Renkli
Primary nasal tuberculosis: a case report
Tüberküloz ve Toraks Dergisi 2010; 58(3): 297-300 300 smell, and recurrent polyps. With nasal tuber- culosis, signs, such as epistaxis and crusting, are reported seldomly (9). Yet, in countries like Turkey, where tuberculosis incidences are high, the signs of epistaxis and crusting should be considered as differential diagnosis in nasal tu- berculosis. ln addition to inflammatory and ne- oplastic disorders, such as Wegener’s granulo- matosis, sarcoidosis, inhalation granuloma (si- licosis and berylliosis), and NK-T cell lympho- ma, should also be considered in the differenti- al diagnosis (10).
The definite diagnosis of tuberculosis is made by isolating M. tuberculosis. However, we were ina- dequate in growing and displaying bacilli. Ne- vertheless, the histopathological findings, such as caseation and granuloma, which are charac- teristics of tuberculosis, and the patient’s res- ponse to treatment, indicated tuberculosis. It should be recalled that sometimes tuberculosis could occur with non-caseating granuloma. In this case, the differential diagnosis of tuberculo- sis should consist of Wegener’s granuloma, sar- coidoz, leprosy, mycoses, malignancy and syphilis (11).
The basic principles that underlie the treatment of pulmonary tuberculosis also apply to extra- pulmonary forms of the disease. However, extra- pulmonary foci usually respond to treatment more rapidly than does cavitary pulmonary tu- berculosis (12). In some studies, treatment con- sisting of three drugs was found to be effective against extra-pulmonary tuberculosis. When the community rate of isoniacid resistance is greater than 4%, empiric therapy for disease should consist of four-drug therapy especially in new di- agnosed cases (13). In our country, drug resis- tant tuberculosis is a problem and since we co- uldn’t isolate the bacilli and we could not have the susceptibility results, we added ethambutol to the first two-months therapy (14).
Tuberculosis can involve virtually any organ and it manifests itself in various forms. When tuber- culosis is as widespread as it is today, with cases that display epistaxis and crusting, these symp- toms should be considered as differential diag-
nosis in nasal tuberculosis. In order to reach a definite diagnosis microbiological and histopat- hological sample should be taken.
Acknowledgement
Special thanks for comments Pathologist Doctor Faruk ATAY.
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