13 COTD “31/08/2018”

Simon Dalton

13.1 Case and Questions

16yr male afghan refugee, left kabul 2010.

Positive mantoux and normal CXR -> isoniazid monotherapy

Then later he developed an inflammatory lesion of the helix of the right ear. Was biopsied and showed granulomas, multinucleate giant cells.

He was diagnosed with cutaneous tb, lupus vulgaris. So he was upgraded to 4 drug therapy and improved.

But a few years later his ear got worse again. Still just the ear.

Q’s: TB? Not TB? If TB how do you treat? If not TB how might you confirm? And Treat?

Non-TB Causes?

The caseating granuloma narrows this down though.

PCR for leishmaniasis was positive (leishmaniasis recidivans)

This is a chronic protozoan disease, spread by the bite of infected sandfly. Kabul has the highest rates in the world.

In kabul it’s called “saldana” - the one year sore, it would wax and wane over a year

The granuloma is an inadequate cell mediated form, resulting in granuloma.

Absence of leishmania parasites seen doesnt meen absence of leishmania

Leishmania and cutaneous TB overlap a lot clinically and histologically

It can be diagnosed by failed anti-TB treatment, or leishmania PCR.