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CASE SNIPPET
Year : 2022  |  Volume : 68  |  Issue : 2  |  Page : 115-116

Long standing untreated multifocal cutaneous tuberculosis with development of breast carcinoma


Department of Dermatology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, MG Road, Mysore, Karanataka, India

Date of Submission27-May-2021
Date of Decision31-Jul-2021
Date of Acceptance30-Sep-2021
Date of Web Publication11-Apr-2022

Correspondence Address:
P S S Ranugha
Department of Dermatology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, MG Road, Mysore, Karanataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_144_21

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How to cite this article:
Srihari S, Ranugha P S, Shastry V, Betkerur J B. Long standing untreated multifocal cutaneous tuberculosis with development of breast carcinoma. J Postgrad Med 2022;68:115-6

How to cite this URL:
Srihari S, Ranugha P S, Shastry V, Betkerur J B. Long standing untreated multifocal cutaneous tuberculosis with development of breast carcinoma. J Postgrad Med [serial online] 2022 [cited 2022 Aug 17];68:115-6. Available from: https://www.jpgmonline.com/text.asp?2022/68/2/115/342813




Cutaneous tuberculosis (TB) constitutes 0.1% of the total TB cases and 1.5% cases of extrapulmonary TB in India.[1] A 35-year-old female patient presented with skin lesions of 20 years duration and swelling in the left mammary area for 3 weeks. On examination, three ulceroproliferative lesions with atrophic depigmented areas ranging from 3 to 8 cm were seen over the outer aspect of the left arm, left elbow, and left knee [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Hyperpigmented papules were present over the left ear with partial resorption of the ear lobule [Figure 1]e. Matted lymphadenopathy was present in the left axilla with a solitary node in the left infraclavicular area. She had a kyphoscoliotic deformity since childhood [Figure 1]f. A firm to hard painful mass of size 3 cm × 5 cm was palpable in the outer quadrant of the left breast [Figure 2]a and [Figure 2]b. Routine blood investigations were normal, ESR was 100 mm/1h, and the human immunodeficiency virus (HIV) serology was negative. The smear for acid-fast bacilli (AFB) from the ulceroproliferative lesion was negative, the Mantoux test was strongly positive (27 mm), and the tissue culture grew M. tuberculosis (MTB).
Figure 1: (a) ulceroproliferative growths over the left arm and below the left cubital fossa; (b) lesion over the left arm with areas of slough and crusting; (c and d) depigmented atrophic scars over the left elbow and right knee with superficial ulceration in some areas; (e) hyperpigmented papules in the left retroauricular area with partial resorption of the left ear (black arrow); (f) kyphoscoliosis of the spine

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Figure 2: (a and b) mass in the outer quadrant of the left breast with a visible lower margin; (c) biopsy from the lesion over the left arm showing edematous dermis with diffuse infiltration by lymphocytes, plasma cells, epithelioid cells, and Langhan's giant cells (arrow), negative for AFB suggestive of lupus vulgaris (H&E, 20X); (d and e) contrast-enhanced CT chest and abdomen showing a large rim enhancing solid lesion in the retro-mammary area and along the left axillary tail (black arrows); (f) x-ray spine lateral view showing kyphoscoliosis and multiple vertebral body height reduction (black arrows)

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The biopsy from the lesion over the left arm and ear revealed findings of cutaneous TB [Figure 2]c. Fine needle aspiration cytology (FNAC) and core needle biopsy of the breast lump showed findings suggestive of poorly differentiated breast carcinoma (Ca) [Figure 3]. Computerized tomographic (CT) scan of the chest and abdomen [Figure 2]d and [Figure 2]e confirmed the findings. The X-ray of the spine showed kyphoscoliosis with loss of curvature of the thoraco-lumbar spine and L2–L4 block vertebra, multiple vertebral body height reductions, and calcified nodes in the pelvic region [Figure 2]f. A diagnosis of chronic multifocal cutaneous tuberculosis—papular and ulcerative form of lupus vulgaris (LV) with metastatic breast malignancy and kyphoscoliosis (probably secondary to Pott's spine) was established and treatment was initiated with category 1 antituberculous therapy (ATT). Before further evaluation for breast malignancy could be done, the patient died of acute gastroenteritis-induced sepsis.
Figure 3: FNAC from the breast lump revealed large highly pleomorphic cells with anisonucleosis, hyperchromatic nuclei, prominent nucleoli and abundant cytoplasm. Numerous foci revealed cytoplasmic streaking of tumor cells and background showed necrotic material

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Cutaneous tuberculosis continues to be a significant medical problem, even with the advent of highly effective antituberculous drugs. LV and tuberculosis verrucosa cutis (TBVC) are the most common forms of cutaneous TB seen in adults, whereas in children, it is scrofuloderma followed by LV and tuberculids.[1] With the advent of the HIV pandemic and indiscriminate use of antibiotics, the presentations of cutaneous TB are diverse and atypical.

Multifocal cutaneous TB is rare in immunocompetent individuals. Multifocal LV patients presenting as erythematous plaques[2] have been described in the immunocompetent. A case of multifocal ulcerative lupus in malnourished[3] and another with a granulomatous folliculitis-like presentation[4] have been reported in the past. The concurrent presentation of papular, ulcerative, and destructive lesions of lupus in an immunocompetent individual with probably Pott's spine as in the present patient has not been reported so far.

Three different types of associations between malignancy and TB have been described: (i) the development of cancer on the background of a previous tuberculous infection; (ii) the concurrent existence of TB and malignancy in the same patient(s) or clinical specimen(s); and (iii) the diagnostic challenges arising from the multi-faceted presentations of these two disorders. Mycobacterial infections escape the host's cellular response and killing, to establish chronic and persistent inflammation.[5] Chronic inflammatory conditions have been thought to create the appropriate microenvironment for malignancy development through a number of mechanisms; i.e., the higher rate of cell turnover is thought to increase the risk for genetic errors.[6] Even though the development of squamous cell Ca has been observed in the longstanding lesions of cutaneous tuberculosis,[5] untreated longstanding cutaneous TB with internal solid organ as in our case after malignancy has rarely been reported in the literature. There have been reports in the past of co-existence of TB and malignancy at the same site, namely, in the lung, breast, cervical / supra-clavicular/ axillary / mediastinal / peri-pancreatic / para-aortic lymph node(s), liver, thymus, fallopian tubes, uterus, ovary and colon.[5] The association of systemic tuberculosis with breast cancer is rare, ranging between 0.1 and 4.9% cases of TB with malignancy. All the previous reports of breast Ca with TB had TB mastitis/tuberculous axillary lymphadenitis in association with breast Ca.[5] To the best of our knowledge, the present case is probably the first-ever description of long-standing untreated multifocal cutaneous TB with associated development of breast Ca. Studies have shown that chronic inflammation due to longstanding TB can predispose to malignancy development at the same site.[5] Our patient had untreated multifocal TB of skin and bone of more than 20 years duration. We postulate that the prolonged inflammation might have acted as a trigger for development of breast malignancy.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Singal A, Sonthalia S. Cutaneous tuberculosis in children: The Indian perspective. Indian J Dermatol Venereol Leprol 2010;76:494-503.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Mehta M, Anjaneyan G, Rathod K, Vora RV. Multifocal cutaneous tuberculosis in immunocompetent individual. J Clin Diagn Res 2015;9:WD01-2.  Back to cited text no. 2
    
3.
Verma S, Thakur BK, Gupta A. Multifocal childhood cutaneous tuberculosis: Report of two interesting cases from Sikkim, India. Pediatr Dermatol 2013;30:e1-4.  Back to cited text no. 3
    
4.
Hruza GJ, Posnick RB, Weltman RE. Disseminated lupus vulgaris presenting as granulomatous folliculitis. Int J Dermatol 1989;28:388-92.  Back to cited text no. 4
    
5.
Falagas ME, Kouranos VD, Athanassa Z, Kopterides P. Tuberculosis and malignancy. QJM 2010;103:461-87.  Back to cited text no. 5
    
6.
Schottenfeld D, Beebe-Dimmer J. Chronic inflammation: A common and important factor in the pathogenesis of neoplasia. CA Cancer J Clin 2006;56:69-83.  Back to cited text no. 6
    


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