Aims To report a rare case of primary nasal tuberculosis and raise awareness about the disease in an era of rising rates of extra-pulmonary tuberculosis in UK.
Case report A 12 year old UK-born boy of Pakistani ethnic group presented to the ENT surgeon with epistaxis and the sensation of a blocked right nostril. There was a history of being hit on the nose 5 months previously with onset of symptoms then and worsening nasal discomfort since. Examination revealed deviated nasal septum with markedly reduced nasal airway, and bleeding points in Little's area bilaterally. The bleeding points were cauterised. 3 months later an ulcer was visible on the right Little's area. Treatment with nasal antibiotic was prescribed. 6 weeks later symptoms were persistent but no bleeding points were seen. Examination under anaesthesia 3 weeks later revealed an ulcerative area confined to the columella and over both Little's areas. Biopsy of the ulcer revealed granulomatous inflammation and areas of necrosis, on histological examination. Tissue sections were negative for acid-fast bacilli on Ziehl-Neelsen staining. Mycobacterium tuberculosis was identified on culture. Subsequent investigations for other foci of tuberculosis were negative. The patient responded well to quadruple anti-tuberculous drug treatment with complete remission of the nasal lesion.
Discussion In England, the proportion of tuberculosis cases with only extra-pulmonary disease increased from 41% in 2000 to 46% in 2008. The rate of tuberculosis however has remained relatively stable; a rate of 15.5 per 100 000 was observed in 2008. Nasal tuberculosis may develop secondarily to a tuberculous focus in the lungs or larynx, or in association with lupus vulgaris. In rare instances like this case, primary infection can occur at the nose. The nasal mucosa is inherently very resistant to tubercle bacillus but trauma and atrophic changes can facilitate successful lodging of bacilli within the nasal lining. Primary nasal tuberculosis is a rare form of tuberculosis even in areas with high tuberculosis incidence.
Conclusion An index of suspicion for tuberculosis as an aetiology should always be present for any mass or ulcerative lesion. Appropriate histological and microbiological specimens need to be taken for diagnosis.