Oral manifestation of tuberculosis: a case-report

brazjinfectdis2016;20(2):210–213

w w w . e l s e v ie r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

Oral

manifestation

of

tuberculosis:

a

case-report

Bárbara

Capitanio

de

Souza

_,

_Vania

_Maria

_Aita

_de

_Lemos

_,

Maria

Cristina

Munerato

a_{DentistrySchool,UniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,Brazil}

b_{HospitaldeClínicasdePortoAlegre(HCPA),UniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,Brazil}

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Articlehistory:

Received17August2015 Accepted1December2015 Availableonline31December2015

Keywords: Mycobacteriuminfection Orallesion Oraltuberculosis Mycobacteriumtuberculosis

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Thepresentcase-reportdescribestuberculosisontheoralmucosa,inararemanifestationof thedisease.Theimportanceofappropriatediagnosisandawarenessoftheclinical manifes-tationsishighlighted.Orallesionsseemtooccuraschroniculcers,nodularorgranularareas, andrare,firmleukoplakiaregions.Mostextra-pulmonarylesionsrepresentsecondary infec-tionsofaprimarylunginfectiousfocus;therefore,earlyandaccuratediagnosisisrequired forplanningofthebesttreatmentandstrategiestocontrolthedisease.

©2016PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Tuberculosis (TB) isa chronicinfectious disease caused by

Mycobacterium tuberculosis. Most often it affects the lungs, althoughsomepatientspresentthediseaseinotherorgans and systems. Extra-pulmonary TBaccounts for25% ofthe caseswith10–35%detectedintheheadandneckregion.1,2

OralmanifestationofTBmayaffectpeopleofallages, espe-ciallytheelderly,andisusuallypresentedasanulcer.Ithas beenhypothesizedthat autoinoculationmay happenwhen theinfectedpulmonarymucusinteractswithwounded, sus-ceptible areas of the mucosa, eliciting the emergence of lesions.3_{Thepresentcase-reportdescribesoralmanifestation}

ofTBinanadultpatient.

∗ _{Correspondingauthorat:FaculdadedeOdontologia–UFRGS,RuaRamiroBarcelos,2492,DepartamentodeOdontologiaConservadora}

(DOC),PortoAlegre,RS,CEP90035-003,Brazil.

E-mailaddress:mcmunerato@gmail.com(M.C.Munerato).

Case-report

A61-year-oldmale patientwithahistory ofsmoking habit and alcoholabuse was being followed up for uncontrolled type 2 diabetesmellitus, peripheral neuropathyassociated withvasculopathy,systemichypertension,andchronic pan-creatitisinHospitaldeClínicasdePortoAlegre(HCPA),state of Rio Grande do Sul, Brazil. The patient was referred to theStomatologyUnitofthesamehospitalduetothe emer-genceoflesionsontheoralmucosa.Preliminaryexamination revealedtwolesions,eachmeasuringapproximately10mm acrossand presentingagranulomatouscentralportionand whitishhalo.Thelesionswerelocatedontheupperlipmucosa nearthemedianlineandontheleftjugalmucosaadjacentto

http://dx.doi.org/10.1016/j.bjid.2015.12.001

1413-8670/© 2016 Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.

brazj infect dis.2016;20(2):210–213

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Fig.1–ClinicalaspectsoforalTBlesionsandlung radiographicfindings.Ulcerativelesionswith

granulomatouscenterandwhitishhaloontheupperlabial mucosanearthemedianline(A)andontheleftjugal mucosa,nearthelabialposteriorcommissure(B).Full radiographofthelowerleftpulmonarylobe.Presenceof activediseasemanifestedasbuddingtree-likecentrilobular nodulesinbothlungs,especiallyontheright(C).

thelabialanteriorcommissure(Fig.1Aand B,respectively). The patient complained of pain, productivecough for the past 15 days, night sweats, episodic fever inthe morning, andslightweightlossintheprevioustwomonths.However, these complaintswere intermittently made bythe patient alongthescheduledappointments,whichmayhaveaddedto thedifficultyforanearlydiagnosis ofthedisease.Samples of lesions were collected by incision and stained accord-ingtothehematoxylin–eosin(HE)andZiehl–Neelsen(BAAR) protocols.Thepathologicalreportwasnegativeforthe pres-enceofalcohol–acidresistantmicroorganisms(Fig.2).Dueto the comparatively lowcountofmicroorganisms inthe tis-suesanalyzed,thespecialstaininguseddidnotsuccessfully detectthepresenceofthebacterium.However,sincea neg-ativeresultinthis kindofanalysisdoesnotruleout TB,a

Fig.2–Histopathologicalanalysisofasamplecollected fromoralTBlesions.Granulomassurroundedbyintense mixedinflammatoryinfiltrate,withinflammatorycells insidetheepithelium.Hematoxylin–eosinstaining,100× magnification(A).Well-shapedgranulomassurroundedby epithelioidhistiocytesandinflammatorycells.Arrows indicateincipientnecrosis.Hematoxylin–eosinstaining, 200×magnification(B).ArrowindicatesgiantLanghans cell,withnucleidistributedacrosstheperipheral

cytoplasm,inanecklacepattern.Langhanscellsaretypical ofTB.Ziehl–Neelsenstaining,600×magnification(C).

sampleofbronchoalveolarlavagewasanalyzedaccordingto theZiehl–Neelsen(BAAR)protocol,withapositiveresultfor

M.tuberculosis.Aradiographofthethoraxwassuggestiveof presenceofactiveinfectiousdisease,manifestedasbudding tree-like centrilobular nodulesinboth lungs, especially on theright.Inthiscasereport,thepathologicalanalysisofthe samplescollectedfromthepatientwasnotconclusive, requir-ingaMantouxassayandtheinvestigationofbronchoalveolar

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lavageinordertoconfirmtheTBsuspicion.TheMantoux pro-tocolindicated a13-mminflammatory reactionconfirming TB.Anti-HIVtestwasnegative.Thepatientwasreferredto apulmonologistforexaminationandtreatmentbasedonthe pulmonaryextensionofthedisease(Fig.1C).Nonetheless,30 daysintothetreatmentthepatientdiedduetothe worsen-ingofclinicalconditions,sepsis,respiratoryfailure,andacute kidneyfailure.

Discussion

Clinically, a patient infected with M. tuberculosis and pre-sentinganactivemanifestationofTBmayalsoexhibitsigns andsymptomssuchaspersistentandproductivecough,night sweats,weightloss,andlowmorningfever.TBisanessentially airbornediseasewhosetransmissiondependsonprolonged contact with aninfected patient.4 _{Theefficiency of}

trans-mission is a functionof the patient’s contagious potential (whichisassociatedwithM.tuberculosisload),theintensity andfrequencyofcough,andpresenceoflungcavitation(based onradiographicexamination).Inaddition,theintensityand durationofcontactswithaTBpatientalsoareimportantto bringaboutthe possibility ofTBdiagnosis.4 _{Inthe present}

case-report, the patient described the symptoms intermit-tently along different appointments,which made anearly diagnosisofTBmoredifficult.

Thetuberculinesensitivityassay,alsocalledMantouxtest, isthestandardproceduretodiagnoseTB.Theassayincludes theintradermal inoculationofapurifiedproteinderivative ofM.tuberculosistoassessthecellularimmuneresponseto the antigens. An inflammatory reaction takes place in M. tuberculosissensitizedpatients.Inspectionisconductedafter 48–72h, andisvalidfor7days.Theevaluationisbasedon thediameteroftheinflammationareameasuredtransversally againstthelongitudinaldirectionofthechallengedforearm. Aninflammationareaover10mminimmunocompetent sub-jectsisconsideredapositiveresult.Inimmunocompromised patients,anarealargerthan5mmindicateTB.Inturn,the minimumsizeofinflammatoryarea inlow-riskindividuals andchildrenunder15yearsofageis15mm.Althoughthe Mantoux reactionisthe methodofchoiceinTBdiagnosis, thetesthasafewlimitations,suchasthelowsensitivityin immunocompromisedpatients (whichpoints tothe riskof falsenegativeresults),thedifficultytouseinchildren,the sub-jectivecharacterofinterpretations,andtheneedforasecond appointmentforconfirmationpurposesinsomecases.4

Clinically,TBhasseveralclinicalforms.However,dueto thelowprevalence,thelesionscharacteristicoforalTBare oftenoverlooked inthe differential diagnosis of other oral lesions.ItisassumedthatoralTBlesions accountfor0.1% to5%oftheinfectionscausedbyM.tuberculosis.5_Orallesions

causedbyTBmaybeprimary,whicharerareandoccurasa resultofthedirectinoculationoforaltissues,orsecondary, duetohematogenousorlymphaticdisseminationand exten-sionsofnearbystructures.1,6_{Autoinoculationmaytakeplace}

upondirectinteractionofinfectedmucuswithawoundon theoralmucosa.SecondaryoralTBisconsideredmost preva-lentinelderlypatients,whiletheprimarymanifestationofthe diseaseismorecommoninyoungindividuals.7

Althoughthe oralpresentationofTBcanbeprimary,in thiscasehematogenousspreadisevidentthehematogenous spread.However,sincethepathologicalanalysisrevealedno acid fastbacilliaMantouxassaywasrequestedinaddition tobronchoalveolarlavageinordertoconfirmtheTB suspi-cion. If oralTBisdiagnosed, it is importantto attemptto locate a primary siteofthe disease before the former can beconsideredprimary.Thisisimportantinordertoassess theextentofdiseaseactivityaswellastomonitor complica-tionsininvolvedorgans.Thequantityofthebacilliobserved indicates the demonstration of the severity of disease onsite.

Systemicandlocalfactorsalsoplayanimportantrolein the developmentoforallesions.Examplesofsystemic fac-torsareimmunosuppressionandtheincreaseinvirulenceof pathogens.8_{Inturn,thelistoflocalfactorsincludespoororal}

hygiene,localtrauma,chronicinflammations,tootheruption, surgical lesions,periodontaldisease,caries,pulpexposure, cysts,andtoothabscesses.6,8_{Itispossiblethatthevirulence}

oftheM.tuberculosisstrainalsoinfluencestheinvolvementof oralstructures.9_{Thepatienthereindescribedfailedto}

com-plywithfollow-upandtreatmentinstructionsforhischronic underlyingdiseases,thusworseninghisTBandleadingtothe unfavorableoutcomereported.

TheoralmanifestationofTBmaypresentasanulcerative, painless lesion onthepalate, lips, ortongue,accompanied by persistent cervical lymphadenopathy.8 _{The differential}

diagnosis ofTBulcers includesa varietyofulcerative dis-eases and conditions, such as squamous cell carcinoma, traumaulcers,aphthousstomatitis,syphilisulcers, actinomy-cosis,Wegener’sgranulomatosis,sarcoidosis,leishmaniosis, zygomycosis,andHansen’sdisease.9_{Itisimportantto}

high-lightthatoralulcersmaypresentasimilarpicture,10_requiring

adiagnosisbasedonmicroscopicfindingsinadditiontothe Mantoux testandbaciloscopy.11 _{Theappropriate}

identifica-tionoforalTBisimportantnotonlyforthepatient,butalsofor thedentistryprofessionalsandthecommunityatlarge,since thepatientisapotentialsourceoftransmission.Lesionsinthe headandneckregionshouldalwaysbeconsideredinthe dif-ferentialdiagnosisofTB,especiallyinhigh-riskpopulations. Incasemorethanoneclinicalconditionissuspected,a com-prehensivelaboratoryinvestigationandthoraxradiographic examinationshouldbeimplementedtoidentifyandcontrol TB.9,12,13_{Althoughoralmanifestationofthediseaseisrare,a}

carefuldifferentialdiagnosisoforallesionsisofparamount importanceforacorrectdiagnosis,especiallywhenthereis suspicionofTB.14

Inconclusion,despitebeingararemanifestationofTBoral lesionsshouldbeincludedinthedifferentialdiagnosisoforal lesionsingeneral,irrespectiveoftheexistenceofpulmonary signsandsymptoms,andwhetherthepatientlivesinaTB endemicregionornot.Earlyandaccuratediagnosisis essen-tialintheestablishmentofappropriatetreatmentaimingat curingthepatientwithTB.

Conflicts

of

interest

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