13

Primary Tuberculosis: An Unusual Finding in the Oral Cavity

Renu Tanwar
1
, Asha R Iyengar
2
, KS Nagesh
3
, Parul Jhamb
4
1
1MDS. Senior Lecturer, Department of Oral Medicine and Radiology.*
2
MDS. Professor.

MDS. !ead of
Department and Principal.
"
MDS. Senior Lecturer, Department of Oral Pat#ology.*
* S$% Dental &ollege, 'ud#era, $urgaon, !aryana, (ndia.
Department of Oral Medicine and Radiology, D)PMR* Dental &ollege, 'angalore, (ndia.
Abstract
The unusual involvemen o! he oral "aviy in uber"ulosis an# he non$s%e"i!i" naure o! is %resenaions mean ha
#iagnosis o! uber"ulosis is o!en #elaye# an# is an une&%e"e# !in#ing' The aim o! his %a%er is o %resen a "ase o! %ri$
mary uber"ulosis an# #is"uss he im%li"aions o! he mani!esaions an# #iagnosis o! oral uber"ulosis' This %a%er %res$
ens an unusual "ase o! a %ainless, %a%illary, eryhemaous lesion in he anerior region o! a ma&illary e#enulous ri#ge'
(hen he %aien "on"erne# was !irs seen by he auhor, he lesion ha# been %resen !or si& monhs' There was "ervi"al
lym%ha#eno%ahy an# i was #iagnose# iniially as a malignan lesion' )venually, a!er bio%sy an# ulrasoun# e&amina$
ion, he #iagnosis o! %rimary oral uber"ulosis was rea"he#' The %aien was manage# solely by ani$uber"ular #rug
hera%y'
+ey ,ords- Primary %u.erculosis, Lang#ans &ell, $iant &ells, $ranulomatous Lesion, Oral
%u.erculosis
Introduction
"are an# le# o #iagnosis o! oral uber"ulosis' In
Tuber"ulosis is an in!e"ious #isease "ause# by
"onras o he %ublishe# re%ors o! oral uber"ulo$
Myco.acterium tu.erculosis. I is ransmie# %ri$
sis, in whi"h i %resene# as oral ul"eraion or was
marily hrough he res%iraory ra"' Tuber"ulosis is
lo"ae# in he vesibular area near he "orner o! he
a global healh %roblem, wih eigh million %eo%le
mouh or lower li% *+,,-, his lesion was %resen in
newly in!e"e# annually an# hree million %eo%le
he ma&illary bu""al vesibule an# #i# no involve
#ying !rom #iseases relae# o "om%li"aions aris$
he alveolar bone'
ing !rom he #isease' Is in"i#en"e in un#er#evel$
o%e# "ounries is in"reasing, an# his is hough o Case Report
be be"ause o! asso"iae# %oor hygiene "on#iions A 4.$year$ol# In#ian !emale %aien o! lower
so"io$ *1,2-' e"onomi" saus re%ore# wih a "om%lain
o! an ill$ Tuber"ulosis mainly a!!e"s he %ulmonary !iing u%%er #enure as a resul o! a growh,
whi"h sysem bu i "an also involve e&ra$%ulmonary ha# been %resen !or si& monhs' The
%aien also sies, in"lu#ing he hea# an# ne"/ region' A review "om%laine# o! muli%le %ea$sha%e#
swellings in her o! he )nglish$language lieraure suggess ha oral ne"/, whi"h ha# been %resen !or
nine monhs' A uber"ulosis generally has been regar#e# as a rare hrough me#i"al hisory #i# no
reveal any evi$ eniy 0a!!e"ing a%%ro&imaely 1'1+2 o +'112 o! #en"e o! weigh loss, "hills, nigh
sweas, or "ough' %aiens wih he #isease3' Thus, he #isease rarely 4n e&ra$oral e&aminaion,
muli%le u%%er "ervi"al !eaures in he #i!!erenial #iagnoses o! hea# an# lym%h no#e enlargemens
were observe# wih ma&$ ne"/ lesions *3$5-' imum o! 2 "m in si6e
an# %al%aion reveale# ma$ A "ase re%or o! a uber"ulosis lesion in he e#, non$en#er an# non$
!i&e# lym%h no#es o! he
oral "aviy is %resene# here, wih an unusual "lini$ subman#ibular an# anerior "ervi"al "hain on boh
"al %resenaion o! a %ainless eryhemaous growh si#es 0/igure 13. An inra$oral e&aminaion
in he anerior region o! a ma&illary e#enulous reveale# a soliary, eryhemaous, ill$#e!ine# %a%il$
ri#ge ha "ause# he %aien o see/ %ro!essional lary growh ha was granular in a%%earan"e, wih
7orres%on#ing auhor8 9r Renu Tanwar, (:+52;<1, Naraina =ihar, New 9elhi$11112,, In#ia> e$mail8
renuom#r?gmail'"om or #rashaiyengar?yahoo'"o'in
4@9A $ =ol' 11 $ No' 1 $ Aar"h, 2112
14
#imensions o! 1 "m & 3 "m' I was lo"ae# in he
ma&illary !a"ial vesibule an# e&en#e# along he
e#enulous ri#ge !rom 14 o 24' I oblierae# he
vesibule an# #i# no involve he ma&illary ri#ge
su%erio$in!eriorly 0/igure 2a an# .3' The sur!a"e o!
he growh was shiny> no blee#ing, ul"eraion, or
%us #rainage were observe#' I was no en#er an#
was so! in "onsisen"y when %al%ae#'
Figure 1. &er0ical lymp#adenitis.
Figure 2 a, b. 1ryt#emous gro2t# in ma3illary
facial 0esti.ule.
The %aien gave a %as #enal hisory o!
e&ra"ion o! u%%er !ron eeh one year %reviously'
She ha# no a/en any me#i"aion !or he lesion'
@er !amily hisory was non$relevan' Rouine
haemaologi"al an# bio"hemi"al invesigaions an#
a "hes ra#iogra%h were un#era/en on he #ay ha
he %aien re%ore# o he #e%armen> hey #i# no
reveal any abnormaliy' No ra#iogra%hi" evi#en"e
o! involvemen o! un#erlying bone was seen on an
o""lusal ra#iogra%h' Blrasoun# e&aminaion o! he
enlarge# lym%h no#es was %er!orme# hree #ays
a!er he !irs visi o! he %aien' I reveale# hy%er$
e"hoi", mae# lym%h no#es, suggesive o! uber"u$
losis 0/igure 3.
Figure 3. 4ltrasound picture of left cer0ical
lymp# nodes.
Three wee/s a!er he !irs visi, serologi"al
ess were %er!orme# !or sy%hilis an# human
immuno#e!i"ien"y virus 0@I=3, ogeher wih a
s%uum e&aminaion, in"lu#ing :ielhCNeelsen
saining' They gave negaive resuls' ;io%sy o! he
inra$oral lesion was hen un#era/en' The subse$
Duen hiso%ahologi"al e&aminaion showe# srai$
!ie# sDuamous e%ihelium an# "onne"ive issue,
revealing "rushing ari!a"s, wih he %resen"e o!
muli%le ne"roising e%ihelioi# "ell uber"ulous
granuloma an# Eanghans y%e o! gian "ell 5/igure
"6. A"i#$!as ba"eria 0AF;3 saining was also
!oun# o be negaive in he bio%sy s%e"imen'
The %aien was re!erre# o 9e%armen o!
General Ae#i"ine a he General @os%ial in
;angalore an# a muli#rug ani$uber"ular regimen
was sare#' This ani$uber"ular hera%eui" regi$
men was a#minisere# !or si& monhs an# !ollow$
u% showe# "om%lee resoluion o! he oral lesion
wih no re"urren"e a!er wo years, suggesing a
su""ess!ul ou"ome'
The %aien gave wrien "onsen !or her %hoo$
gra%hs an# hose o! he lesion an# is hiso%aho$
logi"al images o be use# in his "ase re%or'
Figure 4. Lang#ans giant cell containing nuclei
arranged in a #orses#oe7s#aped pattern at cell
perip#ery.
The ani$uber"ulous regimen !or he %aien
was as !ollows' In he iniial %hase, he !ollowing
#rugs were given !or wo monhs8 ehambuol
hy#ro"hlori#e 0)38 +11 mg, wi"e #aily> isonia6i#
0IN@38 1+1 mg, wi"e #aily> %yra6inami#e 0:38 5+1
mg, wi"e #aily> ri!am%i"in 0RIF38 311 mg, wi"e
#aily' The iniial %hase was !ollowe# by "oninua$
ion %hase whi"h #uring whi"h he !ollowing #rugs
were given !or a !urher !our monhs8 IN@8 1+1
mg, wi"e #aily> RIF8 311 mg, wi"e #aily'
9uring !ollow$u%, he si6e o! enlarge# lym%h
no#es re#u"e# !rom 2 "m o 1 "m a!er he !irs
hree monhs o! reamen an# were o! normal si6e
a!er one year' The si6e o! inra$oral lesion re#u"e#
an# hen "om%leely heale#' Si& monhs a!er he
"om%le$ ion o! ani$uber"ulous hera%y, he %aien
was re!erre# o 9e%armen o! Prosho#oni"s !or
he "on$ sru"ion o! a new #enure' No re"urren"e
o! he lesion was observe# in he !ollow$u% %erio#
o! wo years a!er "om%leion o! #rug regimen
0/igure 83'
Figure 5. Resol0ed oral mucosal lesion after anti7
tu.ercular t#erapy.
Discussion
Tuber"ulous involvemen o! he oral "aviy is
e&remely rare, wih in"i#en"e ranging !rom
1'1+2$+'112 *4,.-' Tuber"ulous lym%ha#eniis
"onsiues a "om%onen o! hea# an# ne"/ #isease
in u% o .12 o! %aiens an# %resens as single or
muli%le enlarge# lym%h no#es ha may be !irm,
!lu"uan, or mae# wih !isula !ormaion *+,.$11-'
The (orl# @ealh 4rgani6aion 0(@43 esi$
maes a%%ro&imaely 21 million a"ive "ases o!
uber"ulosis, ,12 o! whi"h o""ur in he #evelo%ing
"ounries' The regions wih he highes in"i#en"e o!
uber"ulosis are he In#ian sub"oninen, Souh$
)as Asia, an# A!ri"a' The e%i#emiology o! uber$
"ulosis #i!!ers "onsi#erably wih ehni"iy' Age has
also been im%li"ae# as an im%oran ris/ !a"or, as
well as #i!!ering ehni" an# so"io$e"onomi" grou%$
ing *12-' Poorer %o%ulaions are wi"e as li/ely o
have uber"ulosis an# hree imes less li/ely o
a""ess "are !or his #isease *13-'
4ral uber"ulosis mos "ommonly resuls !rom
"ona" o! he oral issues wih in!e"e# s%uum or
haemaogenous #isseminaion in an ol#er in#ivi#$
ual wih %ulmonary #isease' In "onras, "ases o!
%rimary in!e"ion arising hrough #ire" mu"osal
invasion by my"oba"eria are un"ommon an# y%i$
"ally are seen in young %aiens, who o!en %resen
wih "ervi"al lym%ha#eno%ahy wih or wihou
"uaneous sinus !ormaion *H-' An ina" an#
healhy oral mu"osa seems o %rovi#e a su!!i"ien
barrier o my"oba"eria, wih saliva also hel%ing o
"onrol he organisms *,-'
The sies #emonsraing he mos !reDuen
involvemen wih %rimary uber"ulosis are he gin$
givae, vesibular mu"osa, an# e&ra"ion so"/es'
Au"osal la"eraions an# #enal e&ra"ions have
been im%li"ae# as %re#is%osing an in#ivi#ual o
he #evelo%men o! oral uber"ulosis *5-'
Tra#iionally, he #iagnosis o! uber"ulosis has
been ma#e on he basis o! "lini"al an# ra#iogra%h$
i" !in#ings' The #iagnosis o! oro!a"ial uber"ulosis
"an be Duie "hallenging, mainly be"ause o! a la"/
o! #e!inie signs an# sym%oms' A""or#ing o
Pan#i et al. 01..+3, when "onsi#ering he overall
%revalen"e o! uber"ulosis in he In#ian %o%ulaion,
he %resen"e o! e%ihelioi# "ell granuloma is
in#i"a$ ive o! he #isease unless %roven
oherwise, whi"h is similar o our !in#ings' I is
also re%ore# ha he
%er"enage o! "ases showing AF; %osiiviy
#e"lines when more e%ihelioi# "ell granulomas are
observe# *14-'
9imira/o%oulos et al. 01..13 re%ore# wo
"ases o! %rimary uber"ulosis o! he oral "aviy
where smears an# "ulure !or AF;, !rom he oral
lesion an# he s%uum, were negaive *1+-' They
"on!irme# he #iagnosis solely on he basis o! his$
ory an# hiso%ahologi" e&aminaion, whi"h only
reveale# gian "ells an# e%ihelioi# "ells' In heir
manus"ri%, hey have Duoe# various reasons "ie#
by #i!!eren auhors !or he #i!!i"uly in mi"robio$
logi" #ee"ion o! he uber"le ba"illi' This may be
#ue o 0a3 high immuniy o! he %aien resuling in
#esru"ion o! he ba"illi, 0b3 heir en"losure by
lo"al issue rea"ion an# he very small numbers o!
uber"le ba"illi in oral lesions, whi"h is why #ire"
e&aminaion o! s"ra%ings saine# wih he :iehlC
Neelsen sain are usually negaive, an# 0"3
%revious long$erm reamen wih anibioi"s
*11,1+-'
In our %aien, he hiso%ahology reveale# he
%resen"e o! an e%ihelioi# "ell granuloma, whi"h is
very y%i"al o! uber"ulosis' I was noe# ha he
%aien was res%on#ing o reamen' Also in he
%resen "ase, he %aien was manage# solely wih
ani$uber"ular "hemohera%y'
4ral "aviy uber"ulosis is #i!!i"ul o #i!!eren$
iae !rom oher "on#iions on he basis o! "lini"al
signs an# sym%oms alone' (hen evaluaing su"h
"ases, "lini"ians shoul# "onsi#er boh in!e"ious
%ro"esses, su"h as %rimary sy%hilis an# #ee% !ungal
#iseases, an# non$in!e"ious %ro"esses su"h as
"hroni" raumai" ul"er an# sDuamous "ell "ar"ino$
ma' I! here is no sysemi" involvemen, an e&"i$
sional bio%sy is in#i"ae# o esablish a #e!iniive
#iagnosis *H,1H-'
Aulinu"leae# gian "ells o! Eanghans y%e
are !reDuenly seen in various granulomaous
lesions su"h as ba"erial, !ungal an# auoimmune
#iseases, in"lu#ing uber"ulosis, le%rosy, sy%hilis,
sar"oi#osis, 7rohnIs #isease, eosino%hili" granulo$
ma, "heiliis granulomaosis an# "erain !ungal #is$
eases *15-'
In "ase o! any #is"or#an"e in hiso%ahologi"
#iagnosis, a :iehlCNeelsen sain, a "om%lee me#$
i"al an# #enal hisory, a "lini"al "orrelaion an# an
immune$base# assay "an be use# o rule ou oher
lesions wih Eanghans y%e o! gian "ells' For
e&am%le, unli/e uber"ulosis, sar"oi#osis la"/s
"aseous ne"rosis an# a"i#$!as organisms'
I! sy%hilis is sus%e"e# hiso%ahologi"ally,
vas"ular "hanges su"h as %roli!eraive en#areriis
an# a %roli!eraion o! en#ohelial "ells resuling in
"onsri"ion o! he vas"ular lumen are seen'
(arhinCSarry sain "an be use# o i#eni!y he
"ausaive organism'
Ee%rosy lesions are asso"iae# wih he
involvemen o! su%er!i"ial nerves lea#ing o anaes$
hesia an# %araeshesia, whi"h may "ause unre$
alise# rauma lea#ing o ul"ers an# se"on#ary
in!e"ion *15,1,-'
7heiliis granulomaosis involves only li%s,
mos o!en he lower li%, bu s/in an# mu"ous
membrane remain ina"' @iso%ahologi"ally, sar$
"oi#$li/e non$"aseaing granulomas are %resen'
7rohnIs #isease mani!ess isel! as granuloma$
ous no#ules an# ul"ers in he oral "aviy along
wih asso"iae# gasroinesinal sym%oms'
@iso%ahology reveals he %resen"e o! non$"asea$
ing e%iheloi# granulomas wih Eanghans gian
"ells' S"haumann an# aseroi# bo#ies may also be
%resen *15,1,-'
Fungal lesions su"h as hiso%lasmosis, blaso$
myosis an# "o""i#iomy"osis shoul# also be "onsi#$
ere# #uring #iagnosis o! an oral uber"ulosis lesion'
Ai"ros"o%i"ally, organisms "an be i#eni!ie# wih
sains su"h as haemao&ylin an# eosin 0@J)3,
%ara$ aminosali"yli" a"i# 0PAS3, or mehenamine
silver' S%orangia may be !oun# !ree wihin ne"roi"
issue or wihin he e%iheloi# "ells an# gian "ells
o! he granuloma' Fungal "ulures "an be an ai# in
i#eni$ !i"aion o! s%e"i!i" !ungal s%e"ies *15,1,-'
The same basi" %rin"i%les !or he reamen o!
%ulmonary uber"ulosis a%%ly o e&ra$%ulmonary
uber"ulosis' For uber"ulosis a any sie, a "ourse
o! reamen o! !rom si& o nine monhs wih regi$
mens ha in"lu#e IN@ an# RIF is re"ommen#e#>
he single e&"e%ion is meningiis, !or whi"h . o
12 monhs o! reamen is re"ommen#e#
*.,1H,1.,21-'
In he %resen "ase, he %aien re%ore# wih a
%ainless eryhemaous lesion in he ma&illary !a"ial
vesibule' This is an unusual %resenaion !or oral
uber"ulosis be"ause mos "ases re%ore# in liera$
ure are relae# o %ain!ul ul"eraion, wih he mos
"ommonly involve# sies being eiher ongue or
gingivae' As he %aien gave a hisory o! raumai"
e&ra"ion in relaion o ma&illary anerior eeh,
in!lame# an# irriae# mu"osa "oul# have !avoure#
lo"alisaion o! he organisms lea#ing o #evelo%$
men o! his lesion' The #iagnosis o! %rimary oral
uber"ulosis in our %aien was ma#e by bio%sy
be"ause he "lini"al !eaures o! he oral lesions
were non$s%e"i!i" an# "hes ra#iogra%hs an#
s%uum
e&aminaion, in"lu#ing :ielhCNeelsen saining,
were negaive !or %ulmonary involvemen'
@iso%ahology o! he lesion #emonsrae# mulin$
u"leae# gian "ells, es%e"ially Eanghans gian "ells
an# hisio"yes' Blrasoun# invesigaion o! "ervi$
"al lym%h no#es #emonsrae# he si6e o! he
enlarge# lym%h no#es an# he %resen"e o! "enral
hy%o#ensiy' An ani$uber"ular hera%eui" regi$
men was a#minisere# !or si& monhs an# !ollow$
u% showe# "om%lee resoluion o! oral lesion wih
no re"urren"e a!er wo years, suggesing a su""ess$
!ul ou"ome'
Conclusion
Tuber"ulosis remains a #evasaing #isease
hroughou he worl#' )!!ors o era#i"ae i have
been hware# by %overy, la"/ o! healh"are
a""ess, #rug resisan"e, immuno$su%%resse# %o%u$
laions 0e'g', @I=$in!e"e# %ersons3, an# global
migraion' As %resene# in his %a%er, in "ases o!
in!lammaory or malignan lesions o! he oral "avi$
y, oral uber"ulosis shoul# be "onsi#ere# wihin a
#i!erenial #iagnosis an# in"isional bio%sy shoul#
be %er!orme#' In or#er o #i!!ereniae beween he
%ossibiliies o! %rimary versus se"on#ary uber"u$
losis o! he oral "aviy, a ra#iogra%h o! he "hes
shoul# be a/en' In "ases o! %rimary or se"on#ary
oral uber"ulosis, early #ee"ion, #iagnosis, an#
reamen are o! he umos im%oran"e' )!!e"ive
managemen reDuires %rom% re"ogniion using a
"ombinaion o! "lini"al, ra#iogra%hi", mi"robiolog$
i"al, an# hiso%ahologi" signs an# he iniiaion o!
a%%ro%riae muli#rug hera%y' In a##iion o e!!e"$
ive reamen o! %aiens wih a"ive uber"ulosis,
%ubli" healh managemen sraegies in"lu#e "on$
a" invesigaion an# esing o! %ersons who "ame
ino "lose "ona" wih %aiens wih a"ive uber"u$
losis be!ore iniiaion o! hera%y an# re#u"ion o!
he %o%ulaion$base# bur#en o! uber"ulosis
hrough imely reamen an# !ollow$u%'
Acno!ledgement
The auhors han/ he sa!! o! he 9e%armen o!
4ral Pahology, 9APAR= 9enal 7ollege,
;angalore !or assisan"e in he hiso%ahologi"
e&aminaion o! he lesion'
Contributions o" each author
K AA "ommissione# wor/, gave a#vi"e an#
"he"/e# #ra!s'
K ;; gave a#vi"e an# "he"/e# #ra!s'
K RT, ARI an# KSN all wroe se"ions o! he
manus"ri%'
K RT a""esse# an# %re%are# he !igures'
K PJ %rovi#e# he hiso%ahologi" #iagnosis
o! he s%e"imens'
#tatement o" con"lict o" interest
As !ar as he auhors are aware, here is no "on!li"
o! ineress'
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