Tuberculosis: A Rare Cause of Linear Labial Ulceration

1. Abstract Introduction Oral location of tuberculosis is rare. It admits a clinical polymorphism and poses above all a problem of diagnosis. We report a caseoflabialtuberculosisina16-year-oldpatientwithunderlying lymph node localization.

Case report A16-year-old teenager with no notable history had a painless ulcerationinthelowerlipwhichgraduallyprogressedinsize.Itwas associated with mandibular tumefaction, elevated temperature, weakness, and significant weight loss. The physical examination revealed a linear ulceration of 3 cm, with a budding border and sitting on indurated base. Gingivitis was associated. Others mucous membranes were normal. Examination of the lymph nodes revealedbilateralmandibularlymphadenopathyandleftjugu- locarotid adenopathy. The biopsy of the ulceration revealed a tuberculoid granuloma without caseous necrosis. The hemogram and chest x-ray were normal. The tuberculin intra-dermoreaction was positive at 17mm. An adenectomy with histological study wasperformedobjectifyingepithelio-giganto-cellulargranulomas with central caseous necrosis.The diagnosis of tuberculous chancre was retained associated with secondary lymph node location. Thepatientunderwentanti-bacillarytreatment(2RHZ/7RH)with good progress and healing of ulceration.

Discussion The originality of our work lies in the rarity of labial localization during tuberculosis and its association with an underlying lymph nodelocation.Theoralmucosalocalizationisrarerepresents only 0.1to5%.Thediagnosisisconfirmedonclinical,biologicaland histologicalarguments.Thetreatmentisbasedonanti-bacillary drugs according to the 2RHZ / 4RH protocol when it is isolated and 2RHZ / 7RH when it is associated with other locations.

Keywords: Tuberculosis; Oral tuberculosis; Mucous membrane; Lip; Lymphnode tuberculosis

2. Introduction Tuberculos is isachronic in fectious disease that can affectany part of the body. The orallocationis rare. It admitsaclinical polymor- phism and poses above all a problem of diagnosis. We report a case of labialtuberculosisina16-year-oldpatientwithunderlying lymph node localization.

3. Case Report A16-year-old teenager with no notable history had a painless ulcerationonherlowerlipgraduallyincreasinginsize.Itwasassociatedwithelevatedtemperature,weakness,andsignificantweight loss.Therewerenopulmonaryorgastrointestinalsymptoms.Dermatological examination revealed a linear ulceration, of approximately3cm,withabuddingborderandsittingoninduratedbase. Gingivitis was associated. The remaining mucous membranes were normal. Examination of the lymph nodes revealed bilateral mandibular lymphadenopathy and left jugulocarotid adenopathy. Histopathological examination of the lip lesion revealed a tuberculoid granuloma without caseous necrosis. The hemogram and chest x-ray were normal.Atuberculin skin test was positive at 17 mminduration(evaluatedafter72h).Testforhumanimmunodeficiencyviruswasnegative.Anadenectomywithhistologicalstudy wasperformedobjectifyingepithelio-giganto-cellulargranulomas with central caseous necrosis. From the clinical, histopatholog-ic, and laboratory findings, the patient was diagnosed with labial tuberculosis revealing lymph node location. She underwent antituberculosis treatment (2 months of rifampicin/isoniazid/pyrazinamide and 7 months of rifampicin/isoniazid) with good progress and fibrous scarring of the ulceration.

4. Discussion The originality of our work lies in the rarity of primary labial tuberculosisrarelyseenandmostlyrecognizedthroughcasereports [1]. It is estimated that only 0.05% to 5% of total TB cases may presentwithoralmanifestations[2].Itremainsrareeveninacoun- try where the disease is widespread, such as Morocco where the prevalenceisreportedto30897casesin2017[3].OralTBlesions may be either primary or secondary in occurrence [4]. Primary lesions are uncommon, seen in younger patients, and present as single painless ulcer with regional lymph node enlargement. The secondary lesions are common, often associated with pulmonary disease, usually present as single, indurated, irregular, painful ulcercoveredbyinflammatoryexudatesinpatientsofanyagegroup but relatively more common in middle-aged and elderly patients [5]. It is believed that the intact oral mucosa, constant flow of sa- liva and its antibacterial properties protect from tubercle bacilli invasion to the oral tissues [6]. However, any local trauma can promote infection. Other local predisposing factors include poor oral hygiene, hyperkeratosis disorders such as leukoplakia, oral mucosa inflammation or even tooth extraction [7-9]. In our case, poor oral hygiene is incriminated. Histopathological assessment may reveal the presence of granulomatous inflammatory infiltration with Langhans giant cells and lymphocytes. Foci of caseous necrosis of the tissue can be observed. Mycobacteria can be demonstrated in the collected specimen [7,8,10-12]. Microbiological culture of sputum and of the material taken from the surface of the oral lesion should be done, but the results are obtained after 10 weeks.According to various studies only a small percentage (7.8%) of histopathology specimensstainpositiveforacidfastbacilli[13].Therefore,anegative result does not rule out completely the possibility of TB. In doubtfulcases,moleculartests(PCR)maybehelpful.Inourcase, histopathological examination of the lymph node biopsy was an importantaidinthediagnosisofthediseasebecausethefindingof caseous necrosis was highly suggestive of tuberculosis. Inourcountry,thetreatmentrequiresacombinationof3drugs(rifampicin, isoniazid and pyrazinamide) administered daily for the first2months,followedbyanadditional4monthswith2drugs(rifampicin, isoniazid). In our case, the patient underwent 9 months of treatment because she had associated lymph node location. Thepurposeofthiscasereportistohighlighttherareclinicalpresentation of tuberculosis and bring to the attention a differential diagnosisoftuberculosiswhiledealingwithchronicoralulcers.It is particularly relevant in a country like Morocco with one of the highest tuberculosis burdens

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Zineb Tazi Saoud. Tuberculosis: A Rare Cause of Linear Labial Ulceration. Annals of Clinical and Medical Case Reports 2022