Infection

DOI 10.1007/s15010-017-1087-z

IMAGES IN INFECTION

A 75‑year‑old woman presenting with nasal vestibulitis

Annalisa Saracino1   · Francesco Fortarezza2 · Danila Costa3 · Domenico Bonamonte4 

Received: 20 February 2017 / Accepted: 21 October 2017

© Springer-Verlag GmbH Germany 2017

An Italian diabetic 75-year-old woman presented with
nasal vestibulitis, which had worsened in the preceding
20 months despite multiple antibiotic cycles. No fever or
systemic symptoms were reported. Dermatological exami-
nation revealed infiltrative dermatitis of the nose on both
alar-sidewalls and apex, also extending to right cheek. The
skin was reddish-brown, slightly desquamating, swollen
and infiltrated upon palpation (Fig. 1a, b). A diascopy was
carried out, pressing a pocket hand lens on the lesion, thus
provoking a momentary ischemia, resulting in a yellow-
ish color at the periphery. Infection was spreading to nasal
mucosa, where crusting mucoid rhinorrhea and mild airway
obstruction were observed. Laboratory exams and chest
X-ray images were normal.
A biopsy of nasal vestibule was performed (Fig.  1c,
d). Histopathological analysis revealed multiple granu-
lomatous tubercles composed of epithelioid cells, giant
(Langhans) cells, and lymphocytes, with caseous necrosis.
Ziehl–Neelsen staining was negative. TST resulted in 10 mm
induration; QuantiferonTB Gold Test was undetermined;
microscopic examination yielded negative results. No pre-
vious tuberculosis (TB) or TB contact was reported. A total
body CT scan excluded the involvement of other organs.
Isoniazid, rifampin, ethambutol and claritromycin were ini-
tiated, to take into account non-tuberculous mycobacteria.
One month later, M. tuberculosis (fully susceptible to all
antitubercular drugs) was isolated, then claritromycin was
interrupted. A 6-month regimen is recommended for cutane-
ous TB (lupus vulgaris) treatment [1], which was sufficient
in our patient to obtain a complete resolution.
Cutaneous tuberculosis, which represents < 1–2% of all
cases of extra-pulmonary TB, is scarcely known by physi-
cians in areas with low prevalence, also because of the huge
variety of clinical presentations, often leading to treatment
delay [2, 3].

* Annalisa Saracino
annalisa.saracino@uniba.it
1
Department of Biomedical Science and Human Oncology,
Clinic of Infectious Diseases, University of Bari, 11, Piazza
Giulio Cesare, Bari 70124, Italy
2
Section of Pathological Anatomy, Department of Emergency
and Organ Transplantation, University of Bari, Bari, Italy
3
Mycobacteria Laboratory, Microbiology and Virology Unit,
University Hospital, Policlinico, Bari, Italy
4
Section of Dermatology, Department of Biomedical Science
and Human Oncology, University of Bari, Bari, Italy

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 A. Saracino et al.

Fig. 1  Infiltrative dermatitis of nose (a) and right cheek (b) and his- of epithelioid cells, giant cells (Langhans type) (black arrows), and
topathological examination of a biopsy specimen obtained from the lymphocytes (yellow arrows), with central caseous necrosis (white
nasal vestibule, hematoxylin and eosin stain, ×40 magnification (c) arrows) is showed (hematoxylin and eosin stain)
and ×100 magnification (d). A granulomatous infiltrate composed

Compliance with ethical standards  2. Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol.
2007;25:173–80.
3. Van Zyl L, du Plessis J, Viljoen J. Cutaneous tuberculo-
Ethical standards  The patient provided a written consent for the use
sis overview and current treatment regimens. Tuberculosis.
of her clinical data for scientific purposes.
2015;95:629–38.

Conflict of interest  The authors declare that they have no conflict

of interest.

References

1. Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM. Cuta-

neous tuberculosis: diagnosis and treatment. Am J Clin Dermatol.
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