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Suggest treatment for chronic granulomatous bacterial infection

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Posted on Wed, 13 May 2015
Question: Hi Doctor,

Myself Rajath and i am from XXXXXXX

Few years back i had leg fracture near right ankel,gone from treatment and tats fine. But from past 3 months i have pain in same place and i used to get wound and pus from it. I been for doctor had bone test,skin test(Biopsy), and also doctor suggested me for mauntox test too... and results are normal for both bone and skin test and mautox test shows negative.
Even doctor was not know properly whats the problem.
Can you please suggest on it. If u want i can send my right ankel photo
doctor
Answered by Dr. Kakkar S. (2 hours later)
Brief Answer:
Kindly upload image as well as investigations

Detailed Answer:
Hello. Thank you for writing to us

I have taken note of your query and I hope to help you in best possible way.

I would like you to upload an Image.

You may upload an image either at "Reports Section"

Or else

You may also mail me the image at YYYY@YYYY
Kindly mention the subject of this mail as Attention Dr.kakkar.

Kindly attach the X ray report. Does X ray suggest any bone involvement or it limited only to skin and soft tissue?

Kindly also attach skin biopsy report, pus culture and sensitivity report.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kakkar S. (11 hours later)
Hello Doctor,

Thanks for your feedback.

As per your response received I sent the respective reports to the mail id YYYY@YYYY with subject line as Attention Dr.Kakkar.
sent 2 XXXXXXX with 10 attachments.

Please analyse and let me know the solution.
Awaiting for your response.

Regards,
Rajath
doctor
Answered by Dr. Kakkar S. (2 hours later)
Brief Answer:
I would suggest repeat investigations

Detailed Answer:
Hi.

I have reviewed the attachments.

I can see an ankle swelling with an open wound and I can also see that there is also a crusted verrucous growth which is probably crusted granulation tissue covering the sinus opening.
I can also see residual scaring from previously healed lesions, both above and below the active sinus.

-I want to know is it painful?
-Do you notice any discharge of colored granules/ grains from the wound?
-I want to know what was the Biopsy report for special stains i.e for PAS and AFB?


This type of clinical picture can be caused by various underlying causes. I would keep a few differential diagnosis of..

-Botryomycosis, which is a chronic granulomatous bacterial infection of the skin and subcutaneous tissue.
-Cutaneous Tuberculosis, particularly Scrofuloderma.
-Mycetoma (actinomycetoma Or eumycetoma)

I have reviewed the investigations.

Your investigations so far have not revealed anything conclusive as yet. However, sometimes diagnosis is not easy therefore repeated investigations are warranted in these cases because management would vary depending on the underlying cause.
Therefore repeat investigations are required in your case too in a bid to find the underlying cause .

I would suggest repeat Gram's stain for bacteria and ZN stain to look for mycobacteria.
Exudate/ discharge should be sent for bacterial, mycobacterial culture and fungal culture.

I would suggest a repeat tissue biopsy and tissue should be sent for routine histopathology (i.e H& E staining) as well as for special stains for AFB and fungus i.e PAS.

I would also send tissue for culture (bacterial, mycobacterial, atypical mycobacterial as well as fungal culture).
Tissue can also be sent for PCR for mycobacteria. It is highly sensitive and specific for tuberculosis.

Hopefully these investigations would reveal a cause.

Montoux test can be negative in scrofuloderma and is not a reliable test to rule out cutaneous tubercuolosis.

However, In case investigations are still inconclusive and if Tuberculosis is still highly suspected.. a therapeutic trial with ATT can be considered for 2 months to see how the lesion responds.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kakkar S. (5 hours later)
Hi Doctor,

Thanks for your response.

Here is the answers for your questions:

-I want to know is it painful?
No, it wont be painful too much, little pain will be there(once in while)

-Do you notice any discharge of colored granules/ grains from the wound?
When the wound was opened i got PUS,later its been stooped.. but i used to get Blood( Blood with water) other than this no other granules will get discharge.

-I want to know what was the Biopsy report for special stains i.e for PAS and AFB
As i attached in the reports sent, Biopsy report and PAS culture reports were also there.
As Pathologist said nothing(No organisms found) was there in PAS and Biopsy report.

And one thing to say i forgot earlier-Doctor suggested me some tablets(mentioned below) 25 days back.. i had those tablets and the wound has become dry and no pain found. So can i continue with the same tablets?
-MOXICULLAU 625mg
-TOLPA D

As i gone through your analysis- mean to say i have to go through again for the tests(BIOPSY,SKIN) rite.

Regards,
Rajath
doctor
Answered by Dr. Kakkar S. (14 hours later)
Brief Answer:
Yes, Need to investigate again.

Detailed Answer:
Hi.

Thank you for clarifications..

This seems like a granulomatous condition with sinus formation rather than a simple bacterial infection and I doubt the antibiotics you have been taking have been able to resolve it completely apart from just drying out the pus.

Since investigations have failed to reveal any cause till now therefore I suggest you to repeat a few investigations in a bid to find out the same..

I have kept 3 possibilities of..

-Botryomycosis, which is a chronic granulomatous bacterial infection of the skin and subcutaneous tissue.
-Cutaneous Tuberculosis, particularly Scrofuloderma.
-Mycetoma (actinomycetoma Or eumycetoma)

I would suggest a repeat tissue biopsy and tissue should be sent for routine histopathology (i.e H& E staining) as well as for special stains for AFB (ZN stain) and fungus ( PAS stain).

I would also like to send tissue for culture (bacterial, mycobacterial, atypical mycobacterial as well as fungal culture).
Tissue can also be sent for PCR for mycobacteria. It is highly sensitive and specific for tuberculosis.

I would suggest repeat Gram's stain from discharge (if any) for bacteria and ZN stain to look for mycobacteria.
Exudate/ discharge (if any) should be sent for bacterial, mycobacterial culture and fungal culture.

Hopefully these investigations would reveal a cause.

Regards
Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Kakkar S. (26 hours later)
Hi Doctor,

Thank you for your feedback.

Will go through certain tests as you mentioned and will contact you.

Hope if possible can you provide me your personal mail id/contact number.
Regards,
Rajath.
doctor
Answered by Dr. Kakkar S. (29 minutes later)
Brief Answer:
You are welcome

Detailed Answer:
Hi.

Sure, you can get back to me with test results.

Let me know your email ID.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
Answered by
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Dr. Kakkar S.

Dermatologist

Practicing since :2002

Answered : 9430 Questions

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Suggest treatment for chronic granulomatous bacterial infection

Brief Answer: Kindly upload image as well as investigations Detailed Answer: Hello. Thank you for writing to us I have taken note of your query and I hope to help you in best possible way. I would like you to upload an Image. You may upload an image either at "Reports Section" Or else You may also mail me the image at YYYY@YYYY Kindly mention the subject of this mail as Attention Dr.kakkar. Kindly attach the X ray report. Does X ray suggest any bone involvement or it limited only to skin and soft tissue? Kindly also attach skin biopsy report, pus culture and sensitivity report. Regards