Diabetes Mellitus and Cutaneous Tuberculosis

JG Saluja*, Narendra Rege**, MS Ajinkya***, Leroy Rebello****, SS Khanna+

Abstract
The frequency of complication of diabetes mellitus in patients with pulmonary tuberculosis is
high. Lupus vulgaris is a progressive form of cutaneous tuberculosis that occur in a patient
with moderate or high degree of immunity. Cutaneous tuberculosis is an infrequent first sign of
disseminated tuberculosis. Cutaneous tuberculosis in immunocompetent diabetic patient
should be considered as a D/D of cutaneous abscess or ulcers due to fungal infection and tuber-
culoid. PCR is an efficient and sensitive method for the diagnosis of cutaneous tuberculosis.

Introduction complaining of painful erythematous ulceration with

oedema and oozing of watery fluid admixed with

P roblems associated with diabetic foot are

world wide. However there may be
regional variation among risk factors and
clinical presentation, differences concerning
age, diabetes duration, peripheral vascular
disease and precipitaing factors contributing
to injury are also considered. Clinical
presentation of cutaneous tuberculosis is
necrotic cheesy material on dorsum of left foot since
3 months was seen in surgery OPD of Shree
Mumbadevi Hom. Hospital.
Ulcers measuring 3 x 2 x 3 cms; indurated margin
with black discolouration, floor of the ulcer shows
necrotic yellowish cheesy material (Fig. 1).
P/H diabetes mellitus, insect bite. No H/O
Pulmonary Tuberculosis.

varying. There is an increasing trend of F/H no diabetes mellitus

cutaneous tuberculosis over the years.
Scrofuloderma was the most common clinical
presentation followed by lupus vulgaris,
tuberculosis verucca cutis and tuberculids.1
Cutaneous tuberculosis is an infrequent
first sign of disseminated tuberculosis. The
authors describe a case with cutaneous
tuberculous ulceration on the dorsum of left
foot.
Case Report
Mr. B Age 68 years retired, wireman by profession
*Professor and Head, Pathology Department,
Professor of Immunology, University of Mumbai.
**Honorary Orthopaedic Surgeon; ***Honorary
Professor of Pathology; ****Intern, CMP Medical
College, Shree Mumbadevi Homoeopathic Hospital,
Vile Parle, Mumbai 400 056. +Hon. Gastroenterologist,
Lilavati Hospital and Holy Family Hospital, Mumbai.
Reprinted from : BHJ 2005; 47 (3) : 273-75
O/E
No lymphadenopathy, BP 120/80 mm Hg in supine
position, RR 18/min, Pulse 88/min. RS, CVS-NAD
Laboratory work up revealed WBC 10,900, Hb 16.6
gm% N 70%, L 30%, FBS 79 mg%, PPBS 107.7 mg%.
Swab from wound for aerobic culture revealed
staphylococcus aureus, coagulase and catalase test
positive having maximum inhibition for gatifloxacin.
Glycosylated Hb 8.0% (Ion exchange resin) Normal
range : 4-7% Non diabetic, 8-9% Good Control, 9-10%
Poor control.
HIV status : normal, HBsAg : negative,
ECG : normal
Patient was followed up in surgical OPD for one
month with Inj. magnamycin, amikacin with no
marked improvement. Patient was referred to ortho
OPD for 2nd opinion. Surgical exploration with
debridement was done under GA, tissue was sent for
paraffin section.
The histopathological findings suggested
granulomatous changes with central necrosis and
Langhan giant cells (Fig. 2). Mycobacterium

Bombay Hospital Journal, Special Issue, 2009 21

Fig. 1 : Ulcer showing indurated margins, with
black discolouration. Floor shows necrotic
yellowish red cheesy material.
tuberculosis was identified from tissue by imprint
smear, staining with modified ZNCF method. A
tuberculin skin test showed 11 mm erythema. A
preclusive anti-tuberculosis chemotherapy AKT4 was
started with remarkable rapid remission of cutaneous
lesion.
Discussion
Our case was a diabetic clinically controlled
but still the healing was poor since the basic
pathology was due to atypical mycobacterium
tuberculosis probably scrofuloderma and due
to diabetes the local defence was modified
even though immunocompetent, because of
which the cutaneous mycobacterial infection
entered through the insect bite. The
pathogenesis of innoculation of cutaneous
tuberculosis requires a break in the skin
through minor abrasion allowing the entry
of organism.8
We speculated that in older patients and
in diabetics oxygen pressure alters in the
lower limbs 2 which may favour the growth of
organism like staphylococcus and tubercle
bacilli even the atherosclerotic changes of
vessels may enhance the pathogenesis.
Cutaneous tuberculosis in
immunocompetent diabetic patients should
22
Fig. 2 : (H.P. 400 X) H and E stained section shows
granulomatous changes with central
necrosis and Langhan’s giant cells.
be considered as a D/D of cutaneous abscesses
or ulcers due to fungal infection and
tuberculid 3,4 which are hypersensitivity
reaction to mycobacterium tubercle (MTB).5
Cutaneous tuberculosis is more frequent
in diabetes than in non-diabetic.6 Tuberculosis
aggravates diabetes and increases the
frequency of complication compared with
diabetics without tuberculosis.7
Atypical mycobacterium are important
human pathogens. Although they often cause
systemic disease, mycobacterium infection
may present solely as cutaneous lesion. It is
not easy to detect non-tuberculosis
mycobacterium by traditional, histochemical
Ziehl Neelsen stain or by culture on specific
media. 9 The author stresses the importance
of PCR (polymerase chain reaction) to identify
non-tubercle mycobacterium in skin lesion.
Since tuberculosis and diabetes frequently
coexist in the population at risk for
tuberculosis. Clinician should suspect
tuberculosis in the diabetics with or without
abnormality on chest roentgenogram.
Aggressive diagnostic measures and specific
chemotherapy should be given and monitored
to treat cutaneous tuberculosis.10
Bombay Hospital Journal, Special Issue, 2009
Acknowledgement 5. Jordaan HF, Schneider JW, Abdulla FA. Nodular
We thank Dr. NO Goel, the superintendent of the tuberculid - a report of four patients. Pediatr
hospital for giving permission to publish the data. We Dermatol 2000; 17 (3) : 183-8.
also express our thanks to Dr. Rakesh Gupta house 6. Almagro M, Del Pozo J, e t a l . Metastatic
surgeon for preparing case record. tuberculosis abscesses in an immunocompetent
patient. Clini Exp Dermatol 2005; 30 (3) : 247-9.
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