Indian J Sex Transm Dis Indian J Sex Transm Dis
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CASE REPORT
Year : 2007  |  Volume : 28  |  Issue : 1  |  Page : 38-39
 

Vulval lymphangiectasia secondary to tubercular lymphadenitis


Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India

Correspondence Address:
Devinder Mohan Thappa
Department of Dermatology and STD, JIPMER, Pondicherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.35712

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   Abstract 

A 25-year-old married woman presented with swelling of vulva with oozing of watery fluid from vulval skin surface for the past 8 years. She also complained of swelling in the inguinal region (occasionally painful) on both sides for the past 8 years. Local genital examination revealed diffuse indurated swelling of the labia majora with overlying skin studded with papulo-vesicles and oozing of milky fluid. Nontender, firm, matted lymph nodes involving both horizontal and vertical groups of inguinal lymph nodes were found bilaterally. Histopathology of the lesion was consistent with lymphangiectasia. Fine needle aspiration cytology from the right inguinal lymph node showed caseating epitheliod cell granulomas with calcification consistent with tuberculosis. Acid-fast bacilli and parasites were not seen. Hemogram was normal except for raised erythrocyte sedimentation rate (35 mm in the first hour). Mantoux test was highly reactive (15  15 mm). A final diagnosis of lymphangiectasia of the vulva secondary to tubercular lymphadenitis was made. The patient was started on anti-tubercular drug therapy. There was a partial recovery in the genital lesions.


Keywords: Tubercular lymphadenitis, vulval lymphangiectasia


How to cite this article:
Singh N, Kumari R, Thappa DM. Vulval lymphangiectasia secondary to tubercular lymphadenitis. Indian J Sex Transm Dis 2007;28:38-9

How to cite this URL:
Singh N, Kumari R, Thappa DM. Vulval lymphangiectasia secondary to tubercular lymphadenitis. Indian J Sex Transm Dis [serial online] 2007 [cited 2019 Nov 13];28:38-9. Available from: http://www.ijstd.org/text.asp?2007/28/1/38/35712



   Introduction Top


Lymphatic malformations are mostly congenital, whereas the acquired cutaneous lymphangiectasias arise due to obstruction of deeper lymphatic vessels secondary to radiation, surgery, trauma, tumor or infections (filariasis, lymphogranuloma venereum, lymph node tuberculosis, recurrent erysipelas). [1],[2] Vulval lymphangiectasias following cancer treatment (radiotherapy, surgery), tuberculous inguinal lymphadenopathy and genital involvement with Crohn's disease have been described. [3] Herein we report a case of vulval lymphangiectasia secondary to tubercular lymphadenitis


   Case Report Top


A 25-year-old married woman presented with swelling of vulva with oozing of watery fluid from vulval skin surface for the past 8 years. She also complained of swelling in the inguinal region (occasionally painful) on both sides for the past 8 years. There was no history of genital ulcer or trauma. She also gave history of evening rise of temperature and weight loss. She had three healthy children. Her menstrual cycles were regular. Local genital examination revealed diffuse indurated swelling of the labia majora with overlying skin studded with papulo-vesicles and oozing of milky fluid [Figure - 1]. Nontender, firm, matted lymph nodes involving both horizontal and vertical groups of inguinal lymph nodes were found bilaterally. Abdominal palpation revealed no organomegaly. Systemic examination was otherwise normal.

A representative biopsy was taken from the affected area. Histopathology of the lesion was consistent with lymphangiectasia. Fine needle aspiration cytology (FNAC) from the right inguinal lymph node showed caseating epitheliod cell granulomas with calcification consistent with tuberculosis. Acid-fast bacilli and parasites were not seen. Hemogram was normal except for raised erythrocyte sedimentation rate (35 mm in the first hour). Mantoux test was highly reactive (15  15 mm). Liver function tests and renal function tests were within normal limits. Chest X-ray showed no abnormality. Serology for HIV antibodies and filariasis was found to be negative.

A final diagnosis of lymphangiectasia of the vulva secondary to tubercular lymphadenitis was made. The patient was started on anti-tubercular (ATT) drug therapy. The patient was put on ATT drug therapy for 6 months: four drugs (isoniazid 300 mg, rifampicin 600 mg, pyrazinamide 1500 mg and ethambutol 800 mg) daily for the first 2 months and two drugs (isoniazid 300 mg and rifampicin 600 mg) daily for the next 4 months. There was a partial recovery in the genital lesions.


   Discussion Top


Acquired lymphangiectasias are simple dilatation of surface lymphatics. These are not true neoplasms or hamartomas. [3] The lymphatic vessels of the superficial dermal plexus drain a fixed area of skin through the vertical collecting lymphatics to the deep plexus. Damage to the deep lymphatic vessels leads to back-pressure and dermal backflow, with subsequent dilatation of upper dermal lymphatics. [3],[4] It is clinically characterized by thin-walled vesicles, mostly filled with clear colorless fluid (resembling frog spawn). The vesicles may occasionally be tinged with varying quantities of blood, and sometimes smooth flesh-colored nodules can occur. They are often misdiagnosed as herpes, genital warts or molluscum contagiosum. They are histologically composed of large endothelium-lined spaces filled with eosinophilic protein-like material in the upper dermis. [1],[3],[5]

The vulva is an uncommon site for the development of lymphangiectasia but has been described secondary to chronic lymphedema due to infective, obstructive (secondary to radiotherapy or surgery) and neoplastic diseases. [6] Infectious diseases are less commonly implicated as cause of lymphangiectasia of the vulva than surgery, radiation and neoplasms. [2],[5],[7] Among infections, tuberculosis is one of the major infections affecting the lymph nodes and lymphatics in developing countries such as India, especially in the current scenario of increasing human immunodeficiency virus infection. [1],[6] Vulval lymphangiectasia due to tuberculosis is rarely reported. [1],[2]

In cases where infection is responsible, treatment should be instituted as early as possible so as to lessen damage to the lymphatics and relieve lymphatic obstruction. Ablative modalities such as surgery, electrocautery, cryosurgery and argon laser surgery can be used for treatment for residual lymphangiectasia but are associated with frequent recurrences unless the deep lymphatic cisterns are adequately treated. [5]

 
   References Top

1.Mendiratta V, Harjai B, Sardana K. Tubercular lymphadenitis with lymphangiectases of the vulva. J Eur Acad Dermatol Venereol 2005;19:264-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Heuvel NV, Stolz E, Notowicz A. Lymphangiectases of the vulva in a patient with lymph node tuberculosis. Int J Dermatol 1979;18:65-6.  Back to cited text no. 2  [PUBMED]  
3.Mortimer PS. Disorders of lymphatic vessels. In : Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology, 7 th ed. Blackwell Science: Oxford; 2004. p. 51.25-51.26  Back to cited text no. 3    
4.Mallett RB, Curley GK, Mortimer PS. Acquired lymphangioma: Report of four cases and a discussion of the pathogenesis. Br J Dermatol 1992;126:380-2.  Back to cited text no. 4  [PUBMED]  
5.Harwood CA, Mortimer PS. Acquired vulval lymphangiomata mimicking genital warts. Br J Dermatol 1993;129:334-6.   Back to cited text no. 5  [PUBMED]  
6.Vergili A, Corazza M. Lymphangioma and lymphangiectases of the vulva. J Eur Acad Dermatol 1997;8:229-32.   Back to cited text no. 6    
7.Kennedy CT. Lymphangiectasia of the vulva following hysterectomy and radiotherapy. Br J Dermatol 1990;123:92-3.  Back to cited text no. 7    


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