a case of nasal tuberculosis mimicking

8/10/2019 A Case of Nasal Tuberculosis Mimicking

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A Case of Nasal Tuberculosis

Mimicking

Malignancy

Dr. Santhosh Kumar P.

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Introduction

Tuberculosis of the nose was first described by Professor Giovanni

Morgagni in Italy, when conducting an autopsy of a young man

with pulmonary tuberculosis

Primary nasal tuberculosis is said to be much rarer than

spontaneous nasal tuberculosis

There has been a steady rise in the number of tuberculosis

cases in the last two decades-AIDS epidemic,

-increase in drug resistance &

-more international travel

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Primary nasal tuberculosis

Rare- head & neck TB

Routes- direct inoculation- nose picking or fingernail trauma,

-open pulmonaryTB- haematogenous

F:M - 3:1

3 Types (ONODI) - ulcerative, proliferative &infiltrative

Upper respiratory tract TB- 1.8% Pts OF TB

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Case report

A 45 yr old female patient presented to the

outpatient department with complaints of Nasal obstruction- 2months( initially left side)

Recurrent epistaxis- spontaneous, bilateral

On examination of the nasal cavity, a smooth exophytic

growth nearly filling both nasal cavities was seen

A nasal endoscopy was done and the clinical findings

of a nasal mass in both nasal cavities were confirmed

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Endoscopic image of mass in right and

left nasal cavity

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CT scan

Showed an ill

defined soft

tissue

attenuationarising from

the nasal

septum

extending into

both nasal

cavities, more

on the left side

Perforation of6


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Histopathology

Showed caseating

granulomatous

lesions andepitheloid cells

suggestive of

tuberculosis

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Treatment

She was immediately started on category I

antitubercular therapy (for extra pulmonary

tuberculosis)

Declared cured after completion of 6

months of treatment

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Discussion

Tuberculosis causes about 2 billion deaths per yearworldwide

The increase of tuberculosis in the recent years hasbeen associated with features such as

o emergence of multidrug resistance,

o atypical manifestations with aggressive progressionof disease in patients infected with the HIV virus

Increased incidence in the 25-44 yr old age group ofextra pulmonary tuberculosis which constitutes twothirds of reported cases

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Despite the resurgence of tuberculosis, primary nasaltuberculosis continues to remain a rare clinical entity

The nose is least liable to invasion by acute tuberculosis

because of the structure of mucosa,

respiratory movements of the cilia and

bactericidal secretion

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i O l b l i f h


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Antoni B, Anna R, Ewa O et. al. Tuberculosis of the

head and

neckepidemiological and clinical presentation. Jan

2013 35.6% patients with lymph node

tuberculosis,

27.4% with laryngeal tuberculosis

13.7% with oropharyngeal tuberculosis

12.3% with salivary gland tuberculosis

4.1% with tuberculosis of paranasal sinuses

4.1% with aural tuberculosis

2.7% with skin tuberculosis

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The involvement of the cartilaginous part of theseptum or inferior turbinate and floor aremost common

The lesions may lead to septal perforationbut bony septum is not involved

The patient usually presents with nasalobstruction, crusting, discharge and epistaxis

Bilateral presentation has also beendocumented but all involved septal lesions

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Differential diagnosis

Wegeners granulomatosis, sarcoidosis

leprosy, mycoses

malignancy

rhinoscleroma, rhinosporidiosis

foreign body

The diagnosis is difficult as CT and MRIfindings are non specific. They may show softtissue mass with or without bone destruction

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Definitive diagnosis is established by tissue biopsy

which shows characteristic epitheloidgranulomas. Occasionally caseation and acid fastbacilli may also be present

Microbiological diagnosis is established by cultureof the bacteria. This is highly specific but lacking insensitivity

The sensitivity can be increased by polymerasechain reaction

The culture can be accelerated with technology

such as BACTEC Manteaux test may corroborate the diagnosis

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The first line of management is a fourdrug regimen

Isoniazid, rifampicin, pyrazinamide andethambutol for 2 months followed by

isoniazid and rifampicin for 4 months It must also be borne in mind that nasal

tuberculosis can be associated withtuberculosis involving other sites in the

head and neck region. Therefore detailed examination of the

ears, larynx and neck must be done

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Conclusion Nasal tuberculosis can resemble other disorderssuch as malignancy

A biopsywith tubercular bacilli culture must be

done in all cases presenting with atypicalnasal masses

Diagnosis is made by an assessment of thehistory, clinical findings and histological findings

Once the diagnosis is made the appropriateregimen of antitubercular therapy must bestarted immediately

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REFERENCES[1] Waldman SR, Levin HL, Sebek BA et.al. Nasal tuberculosis : a forgotten entity.Laryngoscope:1981; 91:11-16.

[2] Goguen LA,Karmody CS. Nasaltuberculosis. Otolaryngol Head Neck Surg1995; 113:131135[3] Butt AA. Nasal tuberculosis in the 20th century: Am J Med Sci. 1997 Jun;313(6):332-335

[4] Chamberlain WB. Nasal tuberculosis. Ann Laryngol Rhinol Otol 1922;31:423-429.

[5] Prasad BK, Kejriwal GS, Sahu SN. Case report: Nasopharyngeal tuberculosis. Indian J RadiolImaging 2008; 18(1): 6365.

[6] Hale RG, Tucker D Head and neck manifestations of tuberculosis. Oral Maxillofac Surg ClinNorth Am. 2008 Nov; 20(4):635-642.

[7] Mohan K, RS Anand K, Sathiya M et.al. Primary nasal tuberculosis: a case report. Indianjournal of otolaryngology head and neck surgery. Jan-Mar 2006; 59(1): 87-89.

[8] Ramakant D, Lokendra. Primary Nasal Tuberculosis. Lung India. Apr-Jun; 25(2):102-103.

[9] Goldberg B. Clinical tuberculosis. Philadelphia: FA Davis Company Publishers; 1946.

[10] Antoni B, Anna R, Ewa O et. al. Tuberculosis of the head and neckepidemiological andclinical presentation. Jan 2013.

[11] Chodosh PL, Willis W .Tuberculosis of the upper respiratory tract. Laryngoscope 1970; 80:679696.

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a case of nasal tuberculosis mimicking

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