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Non-healing tuberculous ulcer of the great toe in a health care professional Non-healing tuberculous ulcer of the great toe in a
health care professional
Nagoba B, Jagtap A, Patil A, Wadher B & Selkar S
Abstract
This case report describes a 25-year-old health care professional with a non-healing ulcer of the great toe, not responding to two
years of conventional treatment. The ulcer was diagnosed as a tuberculous ulcer of the great toe. Rapid healing of the ulcer was
observed in response to oral anti-tuberculosis (TB; anti-Koch) therapy and local application of 3% citric acid ointment for 25 days.
Complete healing of the ulcer was noted without any complications.
Keywords: non-healing ulcer, tuberculosis, citric acid treatment. Introduction
(<0.1% of all TB cases). We report an interesting case of a tuberculous ulcer of the great toe.
Cutaneous tuberculosis (TB) is essentially an invasion of the skin by Mycobacterium tuberculosis. Cutaneous TB is a Case report
relatively uncommon form of extrapulmonary TB. Even in A 25-year-old male doctor (MBBS graduate) presented with India where TB is commonly seen, cutaneous TB is very rare an ulcer of the great toe, which had failed to heal over two years. In those two years he had received numerous Nagoba Basavraj *
antibiotics from different classes as well as daily wound care PhD, Assistant Dean, Research and Development with antiseptic agents (hydrogen peroxide and povidone iodine as Betadine). The patient did not chew tobacco or smoke and did not consume alcohol. Physical examination revealed a single ulcer on the right great toe (Figure 1).
bsnagoba@indiatimes.com Mobile +91 09423 075786 Fax +91 02382 227246 Jagtap Ajit
MS, Consultant Surgeon, Apex Hospital
Latur, India
Patil Anand
DVD, Consultant Dermatologist and Venereologist
Skin Care Clinic, Latur, India
Wadher Bharat
Figure 1. TB ulcer of the great toe – before application of citric acid ointment. PhD, Professor of Microbiology, Medical Microbiology Research Laboratory, PG Dept of All haematological investigations were within normal limit. Microbiology, RTM Nagpur University, India An x-ray of the chest was normal. The culture and sensitivity Selkar Sohan
of pus discharge from the ulcer yielded Staphylococcus albus MPTh, Assoc Prof in Physiotherapy, MIMSR susceptible to ampicillin, erythromycin, gentamicin, amikacin, tetracycline, carbenicillin, cloxacillin, cephalexin, cefuraxime, ciprofloxacin, pefloxacin and vancomycin, and resistant to co-trimoxazole. Acid fast staining of pus discharge from the ulcer revealed numerous acid fast bacilli (4+). ELISA for anti- Non-healing tuberculous ulcer of the great toe in a health care professional Mycobacterium tuberculosis antibodies showed 140 units of After the confirmation of diagnosis, anti-Koch therapy and citric acid were used. The choice of citric acid was based on literature showing it can be highly effective in the treatment Based on these results, the case was diagnosed as a non- of a variety of chronic wound infections not responding healing tuberculous ulcer of the great toe. As there had been to conventional parenteral or oral antibiotic therapy and no response to various antibiotics and local wound care more usual local wound care management5-7. This approach over two years, a decision was made to start anti-TB (anti- resulted in rapid healing of the ulcer.
Koch) treatment. Rifampicin 450 mg, isoniazide 300 mg, pyrazinamide 1.5 gm and ethambutol 800 mg were used. For These results indicate that when an ulcer does not heal in local wound care, daily application of 3% citric acid ointment spite of conventional antibiotic therapy and local wound was substituted for the previous antiseptic agents. This care for long durations, chronic TB ulceration needs to be treatment resulted in complete healing of the ulcer after 25 considered in a country where TB is endemic, or in those applications of the citric acid ointment (Figure 2). No adverse either visiting or migrating from such a region.
effects of the 3% citric acid ointment were noted. The anti-Koch therapy was continued for a full six months.
References
1. Chandramukhi A, Mnajunath MV, Veenakumari HB, Mahadevan A,
Shivaraja G & Buggi S. Tuberculous skin ulcer following needle-prick injury in a health care professional. Jour Asso Phy Ind 2005; 53:825–6.
2. Sharma VK, Kumar B, Radotra BD & Kaur S. Cutaneous inoculation tuberculosis in laboratory personnel. Int J Dermatol 1990; 29:293-4.
3. Hoyt EM. Primary inoculation tuberculosis. J Am Med Assoc 1981; 4. Nagoba BS, Gandhi RC, Wadher BJ et al. A simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades. Int Wound J 2010; 7:153–158.
5. Nagoba BS, Wadher BJ & Chandorkar AG. Citric acid treatment of non- healing ulcers in leprosy patients. British J Dermatol 2002; 146:1101.
6. Nagoba BS, Gandhi RC, Hartalkar AR, Wadher BJ & Selkar SP. Simple, effective and affordable approach for the treatment of burns infections. Burns 2010; 36:1242–7.
7. Nagoba BS, Wadher BJ, Rao AK et al. Simple and effective approach for the treatment of chronic wound infections caused by multiple antibiotic resistant Escherichia coli. J Hosp Infect 2008; 69:177–180.
Australian Wound
Management Association
Figure 2. TB ulcer of great toe – healed ulcer after 25 applications of citric acid ointment. Membership information
Membership of the Australian Wound Management Association Discussion
may be achieved in two ways:• Membership of a state wound care association – the annual Cutaneous TB is a relatively uncommon form of extra- subscription rate varies from state to state in the range $20 to pulmonary TB. In most of the reported cases, it has been • Direct membership of the Australian Wound Management primary cutaneous TB that occurs as a result of primary inoculation of TB bacilli in individuals with no previous With either form of membership, members will automatically exposure to tuberculous infection, and often affecting health receive copies of Wound Practice and Research, the Australian care professionals1-4. In our case, fomites may have caused journal of wound management, which is published every three months.
this primary cutaneous TB through a skin abrasion on the Please direct enquiries regarding membership to: Tabatha RandoEmail membership@awma.com.au The case was treated by conventional antibiotics and local The membership secretary will send you the membership wound care therapy for two years without the possibility of form appropriate for your state and include details of direct TB being considered as there were normal haematological findings and no other clinical symptoms suggesting TB.

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