|LETTER TO EDITOR
|Year : 2010 | Volume
| Issue : 1 | Page : 45-47
Finger ulceration in a healthcare professional
Syed Hasan Harris1, Roobina Khan2, AK Verma1, Sharique Ahmad1
1 Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, UP, India
2 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, UP, India
|Date of Web Publication||20-Apr-2010|
Syed Hasan Harris
Hafeez Manzil, Marris Road, Aligarh - 202 001, UP
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Harris SH, Khan R, Verma A K, Ahmad S. Finger ulceration in a healthcare professional. Ann Afr Med 2010;9:45-7
Lupus vulgaris is the commonest form of cutaneous tuberculosis accounting for about 1.5% of all cases of extra-pulmonary tuberculosis  and involves usually the head and neck region or the lower extremities. Mycobacterium tuberculosis, Mycobacterium bovis and rarely BCG vaccine causes tuberculosis involving the skin.
A 22-year-old female technical staff posted in a cytology section of the department of pathology presented with a non-healing 2 Χ 2 cm ulcer with irregular, indurated ulcer with undermined edges over her left ring finger [Figure 1] for the past 8 weeks. In spite of her repeated courses of antibiotics and debridement the ulcer did not heal. On taking a detailed clinical history, she recapitulated getting a needle prick about 3 weeks prior to the development of the ulcer while doing fine needle aspiration (FNA). On examination, epitrocheal lymph nodes were palpable. Fine needle aspiration cytology (FNAC) from the epitrocheal lymph nodes showed epithelioid-like cells with necrosis raising the possibility of cutaneous tuberculosis. Biopsy from the ulcer margin demonstrated the presence of epithelioid granuloma with Langhan's giant cells, foci of caseous necrosis and dense lymphocytic infiltration in the dermis. Overlying epithelium showed ulceration [Figure 2]. The diagnosis was confirmed by polymerase chain reaction (PCR) for tuberculosis. Ziehl Neelson (ZN) staining was negative for acid fast bacilli (AFB). X-ray chest was normal and Mantoux test was non-reactive.
Antitubercular chemotherapy (ATT) was started with four drugs, rifampicin, isoniazid, ethambutol and pyrazinamide for two months after which the ulcer completely healed [Figure 3] and continued with rifampicin and isoniazid for another four months.
The patient has been on regular follow-up and is free of any symptoms.
Lupus vulgaris, though rare, is the commonest manifestation of cutaneous tuberculosis  and a high index of suspicion is required for its diagnosis. Mycobacterium does not have the ability to penetrate the intact skin and the inoculation of the bacteria is usually not a noticeable event. Once the bacterium breaches the integrity of the intact skin by needle puncture, it multiplies in macrophages at the site of injury and the lymph nodes may become involved depending upon the host immune response.
Lupus vulgaris of the prepuceal skin in an infant after ritual circumcision has been reported as early as in 1913. 
The Prosector's wart, acquired by pathologist from tuberculous cadavers has been noticeable for primary inoculation tuberculosis in healthcare professionals. 
After an exhaustive search in Medline, however, there has been no case report of cutaneous inoculation tuberculosis in a cytopathology healthcare worker as a result of an accident during aspiration cytology.
The differential diagnosis may include fungal infection, leprosy and sarcoidosis. Fungal granulomas have foreign body giant cells, neutrophilic infiltration and presence of fungal colonies. Sarcoidosis and leprosy have non-caseating granulomas with leprosy having granulomas especially around dermal appendages.
The treatment of LV is no different from the pulmonary form of infection and a short course of anti-tubercular therapy completely cures the disease. Extended treatment with surgical debridement may be required in selected refractory cases.
Training in laboratory practice is a very important aspect of staff protection. The guidelines published by Center for Disease Control (CDC) in preventing the transmission of tuberculous infection in healthcare settings must be adhered to. 
| References|| |
|1.||Sethuraman G, Ramesh V, Ramam M, Sharma VK. Skin tuberculosis in children: Learning from India. Dermatol Clin 2008;26:285-94. [PUBMED] [FULLTEXT] |
|2.||Haller D, Reisser C. Lupus vulgaris manifestation as a destructive nose and facial tumor. HNO 2009;57:364-7. [PUBMED] [FULLTEXT] |
|3.||Holt LE. Tuberculosis acquired through ritual circumcision. J Am Med Assoc 1913;61:99-102. |
|4.||Chandramukhi A, Manjunath MV, Veenakumari HB, Mahadevan A, Shivaraja G, Buggi S. Tuberculous skin ulcer following needle-prick injury in a health care professional. J Assoc Physicians India 2005;53:825-6. [PUBMED] |
|5.||Jensen PA, Lambert LA, Iademarco MF, Ridzon R. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54:1-141. |
[Figure 1], [Figure 2], [Figure 3]