Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 13205  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Articlesmenu-bullet Search Instructions Online Submission Subscribe Etcetera Contact
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  Article in PDF (1,182 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Abstract
 :: Introduction
 :: Case Report
 :: Discussion
 :: Conclusion
 ::  References
 ::  Article Figures

 Article Access Statistics
    PDF Downloaded17    
    Comments [Add]    
    Cited by others 2    

Recommend this journal


  Table of Contents     
Year : 2018  |  Volume : 64  |  Issue : 3  |  Page : 174-176

Cutaneous tuberculosis mimicking a mycetoma

Department of Skin and VD, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India

Date of Submission12-Dec-2016
Date of Decision18-Feb-2017
Date of Acceptance30-Jun-2017
Date of Web Publication11-Jul-2018

Correspondence Address:
Dr. R V Vora
Department of Skin and VD, Shree Krishna Hospital, Karamsad, Anand, Gujarat
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpgm.JPGM_710_16

Rights and Permissions

 :: Abstract 

Atypical presentations of cutaneous tuberculosis (TB) are not uncommon and are frequently overlooked in clinical practice, leading to late diagnosis and increased morbidity. Strong clinical suspicion, histopathology, and response to antituberculous treatment are required for its diagnosis. In today's era, when TB threatens to burst into pandemics again, early diagnosis and treatment are very important for the control of disease. We are reporting a case of cutaneous TB which was initially thought to be a mycetoma.

Keywords: Cutaneous tuberculosis, histopathology, mycetoma

How to cite this article:
Vora R V, Diwan N G, Singhal R R. Cutaneous tuberculosis mimicking a mycetoma. J Postgrad Med 2018;64:174-6

How to cite this URL:
Vora R V, Diwan N G, Singhal R R. Cutaneous tuberculosis mimicking a mycetoma. J Postgrad Med [serial online] 2018 [cited 2023 Sep 26];64:174-6. Available from:

 :: Introduction Top

Cutaneous tuberculosis (TB) is relatively uncommon form of extrapulmonary TB. Although the incidence of cutaneous TB has fallen from 2% to 0.1% among skin outpatient departments, atypical forms with varied manifestations are still being reported worldwide.[1] These atypical forms can mimic various other dermatological conditions leading to delay in diagnosis and therefore increased morbidity. Delaying in initiating therapy in undiagnosed, long-standing cases results in complications such as squamous cell carcinoma, nasal perforation, and disfiguring scars.[2],[3],[4],[5] Here, we are reporting a rare presentation of cutaneous TB which was mimicking a mycetoma. Strong clinical suspicion, histopathology, and response to antitubercular treatment led to the diagnosis.

 :: Case Report Top

A 90-year-old male, farmer by occupation, had skin lesion over the left leg for the last 10 years. The lesion was asymptomatic, but in the last 30 days, nodules developed over that site were painful and itchy. Those nodules gradually increased in size and then foul smelling discharge started from multiple sinuses. There was no history of trauma over that site in recent past. The patient did not give a history of fever, cough, cold, and TB in past. Patient had no other systemic complaints. Patient had taken ayurvedic treatment, but there was no improvement. Cutaneous examination showed multiple serosanguinous discharging sinuses with deep nodules and ulcerative lesions over the left leg with surrounding erythema and mild edema [Figure 1]. Right leg was normal. There were no lesions elsewhere. No significant findings were present on systemic examination.
Figure 1: Multiple serosanguinous discharging sinuses with deep nodules and ulcerative lesion over the left leg

Click here to view

All routine blood reports were done. His hemogram, liver function tests, renal function test, and blood sugar levels were within normal limits, and his erythrocyte sedimentation rate was slightly raised (30 mm in first hour). Gram stain of pus collected from the site of the lesion showed moderate number of capsulated Gram-negative bacilli with scanty pus cells. Potassium hydroxide wet mount of that pus showed no fungal morphology. Ziehl–Neelsen stain was negative. Pus culture detected Aeromonas hydrophila. Mantoux test was negative and chest X-ray was normal. Radiograph of left leg anteroposterior/lateral showed no abnormality.

Biopsy showed many epithelioid cell granulomas with central caseous necrosis and periphery arranged epithelioid cells and Langhans giant cells. Moderate lymphocytic infiltration seen. Epidermis was normal [Figure 2]. No fungal organism detected and periodic acid–Schiff stain was negative.
Figure 2: Epithelioid cell granulomas with central caseous necrosis and periphery arranged epithelioid cells and Langhans giant cells. Moderate lymphocytic infiltration seen. Epidermis was normal (H and E, ×4, ×10 and ×40)

Click here to view

Anti-Koch's treatment category 2 was given to the patient for 8 months and the patient improved within 2 months of treatment [Figure 3].
Figure 3: Depigmentation after 2 months of Anti-Koch's treatment

Click here to view

 :: Discussion Top

Cutaneous TB is invasion of skin by Mycobacterium tuberculosis, Mycobacterium bovis, or following BCG vaccination. Cutaneous TB can be acquired exogenously (inoculation from injury) or endogenously (hematogenous spread). Lupus vulgaris (LV) is the most common morphological variant of cutaneous TB (74%) followed by scrofuloderma, TB verrucosa cutis, miliary TB, and tuberculid.[6]

LV presents with small sharply defined reddish-brown lesions with a gelatinous consistency (called apple jelly nodules). In scrofuloderma, skin lesions result from direct extension of underlying TB infection of lymph nodes, bone, or joints. It presents as firm, painless lesions that eventually ulcerate with a granular base. TB verrucosa cutis occurs after direct inoculation of TB into the skin and presents as a purplish or brownish-red warty growth most often over knees, elbows, hands, feet, and buttocks. Miliary TB occurs in immunocompromised patients and spreads from the primary infection (usually in the lungs) to other organs and tissues through the bloodstream. Skin lesions are small (millet-sized) red spots that develop into ulcers and abscesses. Tuberculid occurs as generalized exanthem in patients with moderate or high degree of immunity to TB because of the previous infection. Patient usually has good health with no identifiable focus of active TB in skin or elsewhere.

Diagnosis of cutaneous TB becomes a challenge at times. Nowadays, latest technique like polymerase chain reaction (PCR) is available which can effectively diagnose the condition. However, sometimes, even histopathology and PCR also make the condition difficult to diagnose like in paucibacillary nature of disease.[7],[8] Furthermore, there are many histopathological differential diagnoses present such as sarcoidosis, tuberculoid leprosy (which has granulomas predominantly around dermal nerves), deep fungal infections (special stains can reveal fungus), and granulomatous foreign body reactions (polariscopic examination can reveal the agent).[9] Sometimes, therapeutic trial of antitubercular treatment (ATT) may become the only solution.[10] Various unusual forms of LV are reported in literature. Heo et al. described a case of LV which was misdiagnosed as tinea and treated for 10 years without relief.[11] Saritha et al. described three cases of LV mimicking actinomycosis and mycetoma which were diagnosed by histopathology and lesions resolved completely with ATT.[12] Our patient presented with lesions resembling mycetoma affecting the left leg, however, histopathology and excellent response to ATT led to the confirmation of diagnosis.

 :: Conclusion Top

Noduloulcerative lesions with discharging sinuses is an unusual presentation of cutaneous TB. High clinical suspicion, histopathology, and response to antitubercular therapy can only establish the diagnosis of cutaneous TB in such mimicking dermatoses.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 :: References Top

Yates VM, Rook GA. Mycobacterial infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. London: Blackwell Science Limited; 2004. p. 28.1-28.39.  Back to cited text no. 1
Yerushalmi J, Grunwald MH, Halevy DH, Avinoach I, Halevy S. Lupus vulgaris complicated by metastatic squamous cell carcinoma. Int J Dermatol 1998;37:934-5.  Back to cited text no. 2
Kanitakis J, Audeffray D, Claudy A. Squamous cell carcinoma of the skin complicating lupus vulgaris. J Eur Acad Dermatol Venereol 2006;20:114-6.  Back to cited text no. 3
Hagiwara K, Uezato H, Miyazato H, Nonaka S. Squamous cell carcinoma arising from lupus vulgaris on an old burn scar: Diagnosis by polymerase chain reaction. J Dermatol 1996;23:883-9.  Back to cited text no. 4
Matsumoto FY, Clivati Brandt HR, Costa Martins JE, Rivitti EA, Romiti R. Nasoseptal perforation secondary to lupus vulgaris. J Dermatol 2007;34:493-4.  Back to cited text no. 5
Bhandare CA, Barad PS. Lupus vulgaris with endophthalmitis – A rare manifestation of extrapulmonary tuberculosis in India. Indian J Tuberc 2010;57:98-101.  Back to cited text no. 6
Tan SH, Tan BH, Goh CL, Tan KC, Tan MF, Ng WC, et al. Detection of Mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids. Int J Dermatol 1999;38:122-7.  Back to cited text no. 7
Hsiao PF, Tzen CY, Chen HC, Su HY. Polymerase chain reaction based detection of Mycobacterium tuberculosis in tissues showing granulomatous inflammation without demonstrable acid-fast bacilli. Int J Dermatol 2003;42:281-6.  Back to cited text no. 8
Glusac EJ, Shapiro PE. Non-infectious granulomas. In: Elder DE, Elenitsas R, Johnson BL Jr., editors. Lever's Histopathology of the Skin. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 373-99.  Back to cited text no. 9
Gawkrodger DJ. Sarcoidosis. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. London: Blackwell Science Limited; 2004. p. 58.158.24.  Back to cited text no. 10
Heo YS, Shin WW, Kim YJ, Song HJ, Oh CH. Annular lupus vulgaris mimicking tinea cruris. Ann Dermatol 2010;22:226-8.  Back to cited text no. 11
Saritha M, Parveen BA, Anandan V, Priyavathani MR, Tharini KG. Atypical forms of lupus vulgaris – A case series. Int J Dermatol 2009;48:150-3.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Cutaneous tuberculosis of the foot clinically mimicking mycetoma: A case report
Ayman Ahmed, Amel Ahmed Hagelnur, Hala Fathi Eltigani, Emmanuel Edwar Siddig
Clinical Case Reports. 2023; 11(5)
[Pubmed] | [DOI]
2 Chronic foot ulcers Rule out cutaneous tuberculosis!
Sunita Arora, Tejinder Kaur, Guneet Gandhi
Indian Journal of Paediatric Dermatology. 2021; 22(4): 363
[Pubmed] | [DOI]


Print this article  Email this article
Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow