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| CASE REPORT |
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| Year : 2020 | Volume
: 34
| Issue : 1 | Page : 47-49 |
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A rare presentation of nasal tuberculosis
Santosh Kumar Swain1, Ishwar Chandra Behera2
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar-751003, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar-751003, Odisha, India
| Date of Submission | 15-Apr-2019 |
| Date of Decision | 29-Aug-2020 |
| Date of Acceptance | 17-Sep-2020 |
| Date of Web Publication | 16-Nov-2020 |
Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital,Siksha “O” Anusandhan University (Deemed to be) Bhubaneswar-751003, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jms.jms_26_19
Tuberculosis is a chronic granulomatous disease common in developing countries resulting in significant morbidity and mortality. It has varied clinical presentations, and it varies from common pulmonary tuberculosis to the rare lone like tuberculosis of the nose involving the columella like in this case. Primary nasal tuberculosis is an extremely rare clinical entity even in developing countries where tuberculosis is common. Early diagnosis and treatment will definitely reduce the morbidity of the disease. It becomes more difficult to diagnose if presenting with nonspecific symptoms which are not associated with classical nasal tuberculosis. Here, we report the diagnosis and treatment of a rare case of primary nasal tuberculosis in the columella region.
Keywords: Antitubercular treatment, columella, nasal cavity, tuberculosis
How to cite this article:
Swain SK, Behera IC. A rare presentation of nasal tuberculosis. J Med Soc 2020;34:47-9 |
| Introduction | |  |
Tuberculosis is a chronic infectious disease of the human being caused by Mycobacteriumtuberculosis. Tuberculosis is an infection caused by M. tuberculosis which is an intracellular acid-fast bacillus, demonstrated by different acid-fast stains such as Kinyoun and commonly used Ziehl–Neelsen staining.[1] Tuberculosis at the upper airway is extremely rare and accounts for 1.8% of all patients suffering from tuberculosis.[2] Tuberculosis affecting other than lungs is called extrapulmonary tuberculosis. Extrapulmonary tuberculosis is common and can occur in the head-and-neck region. Tuberculosis has worldwide presence and no part of the human organ is immune to it and the most common site being involved is lungs. Approximately 10% of tuberculosis cases have head-and-neck manifestations.[3] Other than neck nodes and larynx, tuberculosis of the head-and-neck region makes up 2%–6% of extrapulmonary and 0.1%–1% of all forms of tuberculosis.[4] Extrapulmonary tuberculosis has a prolonged clinical course of the disease and often difficult to diagnose. Isolated nasal tuberculosis affects any part of the nasal cavity without involving lungs or any other organs of the body. Isolated nasal tuberculosis is an extremely rare clinical incidence, particularly affecting the anterior most part like columella and nasal vestibule. Most clinicians do not consider tuberculosis in their differential diagnosis when the patient presents with otorhinological symptoms, so often miss diagnosis and lead to inappropriate treatment.[5] A high index of suspicion is needed when the patient presents with otorhinolaryngeal tuberculosis as it often runs an indolent course and its presentations can vary according to the anatomical site and adjacent areas. Here, we present a case of a 35-year-old female with swelling at the columella with mild tenderness near the nasal vestibular area and subsequently diagnosed as a tubercular lesion caused by M.tuberculosis.
| Case Report | | |
A 35-year-old female attended the outpatient department of otorhinolaryngology with complaints of swelling near the columella of the nasal cavity for 2 months [Figure 1]. There is no complaint of discharge from the nasal cavity or any nasal obstruction except with mild tenderness over the mass with little fluctuation. She was taking intermittent oral antibiotics from local physicians without any resolution of the symptoms. Diagnostic nasal endoscopy revealed normal bilateral nasal cavity. The patient was planned for incision and drainage. On incision and drainage, scanty pus comes out, which was sent for bacterial culture, and a small piece of granulomatous tissue was sent for histopathological examination. The pus which was sent for bacterial culture showed no growth. Histopathological examination showed squamous epithelium with granulomatous inflammation. Acid-fast bacillus stain was positive for acid-fast bacilli [Figure 2].]. There was no evidence of any malignant cells. Real-time polymerase chain reaction (PCR) of the formalin-fixed paraffin-fixed paraffin-embedded tissue was positive for M.tuberculosis. The positive for M.tuberculosis was surprising, and then, the patient was properly evaluated by a pulmonologist. The patient denied any fever, cough, weight loss, or hemoptysis. He had no history of exposure to tuberculosis. Her routine laboratory findings such as complete blood count, liver function test, erythrocyte sedimentation rate, and serum creatinine were normal. However, QuantiFERON-TB Gold was positive. Computed tomography (CT) scan of the paranasal sinus was within normal limits. After confirmation of tuberculosis, the patient was started with antitubercular treatment (ATT) as per the Revised National Tuberculosis Control Program guidelines. After completion of 8 weeks of treatment, she showed substantial regression of the swelling at the nasal columella region. Treatment of this lesion was treated for extrapulmonary tuberculosis which included rifampicin 600 mg daily, isoniazid 300 mg daily, pyrazinamide 2000 mg daily, and ethambutol 1600 mg daily for 2 months. The isoniazid and rifampicin were continued for the next 8 months. The swelling and the wound healed, and there was no evidence of recurrence after course of ATT. | Figure 1: Tubercular lesions in the anterior part of the nasal cavity near columella
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 | Figure 2: (a) Histopathological examination showing granuloma formation with caseous necrosis. (b) Ziehl–Nielsen staining from biopsy specimens showing acid-fast bacilli
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| Discussion | | |
Tuberculosis is a chronic granulomatous disease caused by M.tuberculosis and one of the common infectious diseases seen in developing countries like India. Currently, the incidence of tuberculosis is rising in developing and in some developed nations of the world. The World Health Organization Statistical Information System documented that the developing country like India has the highest incidence of tuberculosis in the world.[6] Approximately 25% of these patients present extrapulmonary tuberculosis, and out of which, 10%–35% is found in the head-and-neck area.[7] The nose is least affected by tuberculosis of any part of the respiratory tract as mucosa, respiratory movements of cilia, and bactericidal nasal secretion. However, the nose may be affected by direct air current by sneezing of other people or coughing or direct inoculation by finger and by instrumentation. The nose may be infected with tuberculosis indirectly through the blood and lymphatic vessels.[8] It is common among males than females and seen in people living in unhygienic environment with poor health.[8] In the nasal cavity, the inferior turbinate is a common site for tuberculosis, whereas the posterior part of the nasal cavity is rarely involved and the nasal floor is almost spared.[9] The infection from the nasal cavity may spread ethmoidal sinus directly and sometimes spread into the sphenoid sinus, frontal sinus, or maxillary sinus. The orbit may be affected by tuberculosis from the nasal cavity and may extend into the cranial cavity. In this case, the area affected was the anterior part of the nasal cavity near columella which is an extremely rare location for tuberculosis and the only symptom was swelling with mild tenderness similar to abscess presentation. The diagnosis of nasal tuberculosis is often difficult as signs and symptoms are nonspecific.[10] A definite diagnosis is done by isolating the tuberculous bacilli from the lesions during cytological examination. The histopathological examinations showing noncaseating granuloma are often led to misdiagnosis of Wegener's granulomatosis.[11] The definitive diagnosis of nasal tuberculosis is done by biopsy, and the biopsy from the nasal cavity or nose should be conducted before doing the imaging for not disturbing the continuity of the lesion. Granulomatous inflammation with caseous necrosis and epithelioid giant cells are pathological findings in tuberculosis. Isolated tubercular lesion at the anterior part of the nasal cavity is a rare clinical incidence even in an endemic zone of tuberculosis.[12] Histopathological examination shows granulomatous inflammation with epithelioid giant cells and caseous necrosis. Ziehl–Neelsen staining often directly detects acid-fast bacilli. The PCR test is also used for the diagnosis of nasopharyngeal tuberculosis. In case of strong clinical suspicion of tuberculosis and negative cultures, the sample should be sent for PCR testing.[13] CT and magnetic resonance imaging (MRI) are valuable imaging in head-and-neck tuberculosis. CT and MRI help to demonstrate the sites, extension, and pattern of the disease.[13] The diagnosis of isolated tuberculosis lesion at the columella of the nasal cavity was rare and surprising. In our case, the patient had no history of fever, cough, weight loss, or hemoptysis. Her routine blood investigations such as complete blood count, liver function test, and serum creatinine were within normal limits. HIV serology testing of this patient was negative. The QuantiFERON-TB Gold in-tube testing for latent tuberculosis was positive. The treatment is ideally medical treatment with antitubercular therapy of regimens of isoniazid (300 mg), rifampicin (450 mg), ethambutol (800 mg), and pyrazinamide (750 mg). Our case responded well to antitubercular therapy. Early diagnosis and treatment in this case is paramount to help for preventing morbidity and complications. Hence, if treated properly and early, it carries an excellent prognosis and gives rise to complete resolution of the tubercular lesion at the nose. As per current trends for the management of tuberculosis, otorhinolaryngologists, as well as infectious specialist, should keep in mind for considering tuberculosis as a potential entity when encountering an unusual lesion in the nose.[14]
| Conclusion | | |
Tuberculosis at the columella of the nose is an extremely rare clinical entity and needs multidisciplinary approach for managing this disease. The patient needs standard antitubercular therapy even the patient is immunocompetent. This case highlights the rare clinical presentation of tuberculosis and brings attention to a rare location of tuberculosis which is possible in a region like India where tuberculosis is the highest burden in the world. In case of abscess of the anterior part of the nose resistant to routine antibiotic treatment, the clinician should rule out suspicion for tuberculosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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