A destruent case of recurrent primary naso-pharyngeal tuberculosis in a migrant

Abstract

A 24-year-old Ukrainian man with post-natal developmental disability was treated for presumptive facial cutaneous TB in 2018 in his home country. After moving to Italy, his nostril lesion recurred in 2021, expanding to the upper lip, but he was lost to follow-up before a diagnosis was made. In 2023, when symptoms worsened, a biopsy was performed showing chronic inflammation and negative microbiological molecular tests and culture. By 2024, the lesion spread to the eyelids with worsening ulcerations. After surgical resection, histology revealed a vegetative, haemorrhagic mucosa with necrotic granulomatous inflammation and rifampin-susceptible Mycobacterium tuberculosis (Mtb) was detected at molecular testing. Diagnosis of recurrent primary cutaneous TB without pulmonary involvement was made and treatment for drug susceptible TB was initiated, leading to complete remission of the facial lesions. Primary cutaneous TB without pulmonary involvement is rare, presenting as nodules, plaques, papules, or ulcers. Diagnosis requires systemic evaluation, imaging, infection screening and expert consultation. Cutaneous TB (CTB) is uncommon in Ukraine and accounts for less than 2% of extrapulmonary TB cases with frequent association with immunosuppression and delayed presentation. Although infrequent, CTB mirrors the wider TB scenario, that is also characterized by MDR-TB in 27% of new and 45% of retreatment cases, and XDR-TB in 13% of MDR-TB cases. In individuals coming from TB endemic areas with strong clinical suspicion, empirical TB diagnosis should always be considered despite negative microbiology to enable timely treatment and prevent progression. A multidisciplinary approach is essential for accurate diagnosis and optimal management.

Keywords: : primary cutaneous tuberculosis; TB; endemic countries; recurrent skin lesions.

Figure 1

Panel A: nasal tip was deformed from atrophic and retracting scars, as result of recurrent ulcerative-exudative phenomena. Moreover, the upper lip was disrupted, being enlarged, and thinner, with intact skin, except for the labiogenial margins, showing ulcerative-exudative lesions with serous-crusted material. Similar structural alteration was observed in the homolateral upper and lower eyelids, appearing replaced by inflammatory tissue, with a mamillated and exudative appearance. Panel B: clinical presentation after 9 months of antitubercolar treatment ( 2 months HRZE, 7 months HR).