European Journal of Cardiovascular Medicine

Tuberculosis affected 9.9 million people worldwide in 2020 and causing death of 1.3 million people1. National data shows, EPTB from 2019-2020 is 37.5-39.39% of total TB patients in India. Cutaneous or skin form of TB affects 1-1.5% of all EPTB2. It is only diagnosed in tertiary care hospitals where biopsy and different genotype and phenotype investigations are available. The primary source of TB can be endogenous or exogenous origin. A sinus tract is lined by granulation tissue extending from one epithelial surface to underneath tissue. In this study, at initial stage, postoperative patients presented after one month of surgery as discharging sinus are diagnosed as infection of unabsorbed suture materials and patients presented with same complained within one month as SSI3. Healthy young patients presented with sinus in axilla diagnosed as hidradenitis suppurativa and the female patients with peri areolar sinus of breast as duct ectasia. These patients are treated with excision of sinus tract at initial stage. All patients after treatment as per clinical diagnosis, sinus tract not healed. Further investigations are done and found as TB, NTM, monoresistance (INH) TB as cause of nonhealing sinuses4.

Operative patients contacted TB due to faulty sterilization and other cutaneous TB cases which clinically misguiding is reported.

Exclusion Criteria- Patients with present or past history of TB and HIV patient are excluded.

Diagnosis Criteria –Positive microscope finding of AFB, HPE and GeneXpert ultra-MTB/RIF positive, AFB culture with positive growth.

Due to faulty sterilization, healthy patients contacted TB during operation and tubercular sinuses of skin misdiagnosed as bacterial origin.

TABLE – 1

CASE 1

A 32-year-old female with no comorbidities presented with pain and recurrent discharge from scar of caesarean section for 1month (fig 1a). She had similar history of discharge from same wound 2 months back for which incision and drainage done. LSCS done 1 year ago. General examination normal and vitals stable. A transverse scar of 8cm length present 4cm above symphysis pubis having a sinus with Zero purulent discharge at the center and surrounding tenderness and induration. Liver, spleen, abdominal lump not palpable. Lymph nodes enlargement not significant and chest examination normal. X ray chest PA view normal, USG Whole abdomen and pelvis shows two intercommunicating subcutaneous tracts, one extending to right iliac fossa and other in the midline supra pubic region with no intra-abdominal (fig 1b) communication. Patient clinically diagnosed as unabsorbed stitch infection and excision of entire sinus tract done and specimen subjected to HPE, which shows tract lined by unhealthy granulation tissue and presence of histiocytes , lymphocytes , plasma cells , polymorphs as well as a well-defined collection of epithelioid cells , langhans giant cells ,and foreign body type of giant cells suggestive of granulomatous inflammation (fig 2b) of Koch’s etiology(fig 2b).GenexpertultraMTB/RIF and microscopic study for AFB negative. As no other cause was found ATT in combination of rifampicin 10mg/kg (R), Isoniazid 6mg/kg(I), Pyrazinamide 15mg/kg(P), Ethambutol 15mg/kg(E) as single dose started. After 1month patient not responded to ATT, sinus discharge is subjected to culture for AFB in L J medium and drug sensitivity. Culture growth identified as NTM of Mycobacterium fortuitum species (fig 2) sensitive to levofloxacin, amikacin. Combination of levofloxacin Tab 500 daily for 12months, Amikacin 500mg twice daily intra muscular for 6 weeks along with P plus E for 6 months. Wound healed (fig 1c), confirmed by no growth in culture media.

CASE 2:

A 45-Year-old male presented with pain and discharge of pus on and off at the scar of epigastric port site for 6 months (fig 3A), is a known case of type 2 diabetes under soluble insulin 3 times daily subcutaneous. He had laparoscopic cholecystectomy one year back. His general examination was normal. Abdomen shows an opening of 0.2x0.2 cm on the epigastric port site scar, 2 cm below xiphias sternum with active serous discharge. Induration, tenderness absent and no mass found, chest and lymph node examination normal. X ray chest PA view normal.

Microscopic study of discharge for AFB is negative. Initial clinical diagnosis is stitch infection. USG of whole abdomen and pelvis shows irregular tract of length 7.4 cm and thickness 1.5cm noted in subcutaneous plane at right hypochondrium extending up to anterior surface of liver. MRI abdomen confirms USG finding. Diagnostic laparoscopy done and tract from liver surface with adhered momentum (fig3B) excised and open excision of parietal tract done. Geneexpertultra MTB/RIF test is negative. Excised tissue subjected to HPE and AFB culture and drug sensitivity test. HPE report consistent with Koch’s etiology and culture sensitivity shows AFB resistant to Isoniazid, sensitive to kanamycin and Levofloxacin, pyrazinamide, ethionamide, rifampicin. Combination of R +P+E with levofloxacin 500 mg daily as single dose for 6 months and wound healed confirmed by no growth of AFB in culture media.

CASE 3

A 32year old female with no comorbidity, presented with pain and discharge from a wound over the scar of the caesarean section done 6 months back. General examination is normal, an opening of 0.2*0.2cm with serous discharge on the right end of LSCS Scar with mild tenderness without induration found. Liver, spleen and other lumps are not palpable. Cardio, respiratory, lymphatic system normal. USG of whole abdomen and pelvis shows sinus tract over the scar extending to right iliac fossa in sub cutaneous plane. MRI sinogram shows no intra-abdominal extension. Since LSCS wound not healed from the first day of operation, it is clinically diagnosed as surgical site infection. Excision of sinus tract done and subjected to HPE study which is positive for Koch’s pathology. Microscopic study of discharge of AFB is negative. GeneXpert ultra-MTB/RIF test is positive. First line of ATT(R+I+P+E) in combination as per body weight for 2 months followed by (R+I+P) for 5 months in DOTS clinic as per Government guidelines given, at the end the wound healed.

CASE 4

A 40year old female with no comorbidities presented with 2 discharging openings in the peri areolar region on upper and inner quadrant of right breast for 2 months. General examination and left breast examination is normal. On right breast 2 sinus openings of 0.2*0.1cm size on upper and inner quadrant peri areolar region at the distance of 1cm from each other with sero purulent discharge. No local rise of temperature and nontender, and no underneath lump felt. Bilateral axillary lymph nodes and cardio, respiratory system normal. Her initial clinical diagnosis is duct ectasia right breast. Excision of sinus tract done. Microscopic study of discharge for AFB is negative, GeneXpert ultra-MTB/RIF of tissue is positive. Excised tissue is subjected to HPE study which shows aggregates of epithelioid cells and occasional langhans type giant cells suggestive of Koch’s pathology. Patient treated with ATT (R+I+E+P) as per body weight for 2 months followed by (R+I+P) for 5 months and her wound healed.

CASE 5

A 35year old male with hypertension presented with intermittent discharge from left axilla for 2 months. His general examination is normal. Left axilla shows opening of 0.2*0.2cm at the center with sero purulent discharge. It is non tender, no local rise of temperature and induration. Small healed scar present surrounding the sinus. Right axilla, cardio pulmonary system normal. USG left axilla shows sinus tract extending 2 cm deep to the skin surface with enlarged central group of lymph nodes. Microscopic study of discharge for AFB is negative. Patient clinically diagnosed as hidradenitis suppurativa. Excision of Sinus tract with central group of lymph nodes is done. Excised tissue sent for GeneXpert ultra-MTB/RIF which is positive. HPE done and it revealed granulomatous inflammation of tubercular etiology. Patient started with ATT of (R+I+P+E) as per body weight for 2 months followed by R+I+P for 5 months in DOTS clinic and wound healed.

Figure 2:

1. Scanner view shows a granuloma consisting of histiocytic collection with lymphocyte collar.
2. High power view showing histiocyte collection and langhans type of giant cells.
3. Mycobacterium tuberculosis visualization using Ziehl-Neelsen stain.
4. Colonies of Mycobacterium fortuitum on Lowenstein-Jensen medium.

TABLE 1

TABLE 2

In this study postoperative patients presented with wound infection within 1 month of surgery , surgical site infection (ssi) is diagnosed and after 1 month of surgery it is diagnosed as infected unabsorbed stitch material. Middle aged women presented with peri areolar discharging sinus and young adult with discharging axillary sinus are diagnosed as duct ectasia of the breast and hidradenitis suppurativa of axilla respectively. All these patients undergone sinus tract excision but the wound not healed and further investigations suggested as Tubercular infection. The primary source of skin tuberculosis could be endogenous or exogenous5. In exogenous spread there is direct Mycobacterial tuberculosis bacilli inoculation through minor skin abrasions or broken skin at the site of

surgical incision using contaminated surgical instruments. Over 2-4 weeks of post inoculation it develops as a non tender nodule that erodes into painless sinus6. In endogenous route tuberculosis develops into skin sinus as a continuous extension of underlying lymphatic infection. The discharge is subjected to microscopic examination for AFB. In all the cases AFB not found due to paucity of bacilli in the sample, though the gold standard of diagnosis of TB is identification of AFB7. National data reveals EPTB from 2019-2022 microscopically confirmed is 9-25%. HPE Of excised tissue shows granuloma formation suggestive of Koch’s pathology. Additionally granuloma can be seen in fungal , brucellosis , syphilis infection , so cautious interpretation is required. As a gold standard biopsy positive all cases should undergo culture & sensitivity for AFB, for diagnosis and prevention of drug resistant TB8,9,10. But culture takes 4-8 weeks which does not help in early diagnosis and treatment. As compared to composite reference standard (CRS), HPE is 87.2% sensitive11.

GenexpertultraMTB/RIF is positive in few cases which not confirm live bacilli. Multiplex real time polymerase chain reaction (mrt –pcr) has sensitivity of 90-95% but limited scope in a resource limited setting. Diagnosis of tuberculosis done in combination of test results of HPE, Culture and sensitivity of AFB, GenexpertultraMTB/RIF. But use of both mrtPCR and GenexpertultraMTB/RIF identify more rapidly and effectively both mycobacterium tuberculosis and NTM along with drug resistant TB so that treatment can be given with sensitive anti tubercular drugs12,13. Most effective drugs in MDR as per WHO guidelines is 6months regime based on newer drug Bed aquiline + Protionamide + Linezolid (BPaL) in combination with Moxy floxacillin is costly and not available. It is still in research mode and given in exceptional cases. In this study some of the factors responsible for tuberculosis are improper instrument cleaning leads to retained clots and charred tissues in joints, inadequate sterilization of reusable laparoscopic instruments with 2% glutaraldehyde.

Rinsing instruments with boiled water is a source of NTM.

Due to increased turnover of surgical patients and inadequate sterilization of instruments, normal patients are infected with tuberculosis which creates dilemma to the surgical team in diagnosing the cause of infection. The case series highlights the importance of TB as an etiology in chronic non healing sinus of breast and axilla. Rapid drug sensitivity testing like line probe assay strips for early diagnosis and treatment of TB should be utilized. NTM Is difficult to diagnose, takes long time for treatment. In operation theatre staff should be sensitized for proper sterilization of instruments and ultrasonic technology used for cleaning instruments thoroughly. FDA has approved ethylene oxide, plasma sterilization and liquid sterilization with glutaraldehyde and peracetic acid for heat sensitive items. All packed sterile instruments kept with proper precaution to avoid environmental contamination. For sporicidal action glutaraldehyde should be more than of 2.4% solution with contact period of 8.2-10 hours and metallic cannula by proper autoclave.

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