Orificial tuberculosis in an immunocompetent careworker.

Orificial tuberculosis has rarely been reported, especially in immunocompetent patients. It accounts for almost 2% of cases of cutaneous tuberculosis (1). The disease is characterized by one or more painful ulcerations involving mucous membranes and peri-orificial areas. CASE REPORT We report here the case of a 28-year-old Afro-Caucasian woman who presented with multiple ulcerations affecting both buccal and genital mucosa. The patient is a medical resident working in an infectious disease department in Accra, Ghana, West Africa. She first noticed inflammatory nodular lesions inside her mouth, which broke up one month later, becoming painful and ulcerated. At that time, she prescribed herself amoxicillin + clavulanic acid treatment (1 g three times a day for 7 days), despite which her condition worsened, with fever, asthenia and weight loss (3 kg in one month). She was therefore referred to the tropical diseases department in Bordeaux, France. At admission , her core temperature was 39°C. Clinical examination disclosed bilateral axillar inflammatory lymph nodes, 1 cm in diameter, associated with infra-centrimetric cervical adeno-pathies. Painful ulcerations were noted in the buccal (Fig. 1) and genital mucosa (Fig. 2), with different clinical manifestations. Three aphtoid lesions of less than 1 cm diameter were noted in the buccal mucosa, whereas there were multiple very painful ulcerations ranging in size from less than 1 cm to more than 2 cm in the genital area. Laboratory examinations were within normal limits, except for C-reactive protein at 40 mg/l. Serologies for sexually transmitted diseases, including syphilis and human immunodeficiency virus type 1 (HIV-1) and HIV-2, were negative. PCR for human herpes virus type 1 and type 2, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) from biopsy samples were negative. A vulvar biopsy disclosed pyo-epithelioid granulomas, although Ziehl-Neelsen staining was negative. Cultures and PCR from lymph node biopsy were positive for Mycobacterium tuberculosis. A thoraco-abdominal computed tomography scan revealed multiple cervical adenopa-thies without pulmonary and genital involvement. The patient was started on anti-tuberculosis treatment, with rifampicin, pyrazinamide, isoniazid and ethambutol for a total of 2 months, followed by an additional 4 months' therapy with isoniazid and rifampicin. One month after initiation of therapy, buccal and genital ulcerations, as well as other clinical symptoms, completely resolved. Six months later, the patient's local and general condition remained unremarkable. DISCUSSION Orificial tuberculosis usually results from autoinocula-tion of the infectious agent in patients with advanced internal tuberculosis of the lungs, gastrointestinal or genitourinary tract. Haematogenous or …