Rare Gingival Manifestation of Primary Tuberculosis - A Case Report

 Introduction

Mycobacterium tuberculosis is responsible for tuberculosis, a chronic granulomatous infection that poses a major public health challenge in many developing countries. While extrapulmonary tuber-culosis is uncommon, occurring in only 10% to 15% of cases, it has the potential to affect various parts of the body, including the oral cavity.¹ There are two types of oral tuberculosis: Primary and Secondary. Primary oral tuberculous lesions are relatively uncommon and typically affect young adults. The lesion itself normally causes no discomfort, typically affecting the gingiva and is linked to caseation of the dependent lymph nodes.² The tongue, palate, lips, buccal mucosa, gingiva, and frenulum are the most frequently impacted areas by this condition.³ We report a case of primary tuberculous gingival growth without involvement of local lymph nodes or signs of systemic tuberculosis.

Case Presentation

A 22 -year-old male patient reported to the Department of Periodontics, Institute of Dental Sciences, Bareilly with a chief complaint of gingival bleeding from the past three months. On recording the history, the patient seemed to be systemically healthy, with a positive family history of mother’s death due to tuberculosis. On general examination, the patient was poorly built with significant tenderness in submandibular lymph nodes. During the intra-oral examination, erythematous marginal gingiva was observed, extending across both the arches (Figure 1), with evidence of bleeding on probing even on slight provocation as measured by gingival index.¹ Oral prophylaxis was performed using piezoelectric ultrasonic scaler and oral hygiene instructions were given. The patient was recalled after one month for post-operative maintenance therapy, which revealed no improvement in the gingival inflammation (Figure 2); this was an unlikely outcome, as most patients typically show significant improvement in inflammation. This led to further evaluation of persistent inflammation in gingiva.

Investigations

All the haematological investigations were performed, which yielded results within normal limits. The card test for HIV was also conducted which came negative. Serum angiotensin converting enzyme values were within normal levels (68 microns/mL). A series of diagnostic tests were performed to detect acid fast bacilli in sputum sample and Mantoux test also showed negative results. A tissue biopsy was taken from the upper labial gingiva near the maxillary right central incisor, lateral incisor, and canine for diagnostic purposes. The section stained with H&E revealed dermis showing granulation tissue consisting of lymphocytes, plasma cells. Connective tissue also consisted of multinucleated giant cells and a few Langhans giant cells. Stroma also showed plump to spindle fibroblast, collagen fibres and endothelial lined blood vessels with extravasated RBCs (Figure 3). Overall features were suggestive of tubercular gingivitis.

Differential Diagnosis

Various differential diagnosis were considered for routine treatment resistant gingivitis i.e. linear gingival erythema associated with HIV infection and granulomatous diseases like tuberculosis, sarcoidosis, desquamative gingivitis, Wegener’s granulomatosis and Crohn’s disease.

Treatment

Considering the patient's family history of tuberculosis, physicians at Rohilkhand Medical College, Bareilly, recommended a six-month anti-tubercular therapy (ATT) regimen. The initial two-month phase involved thrice-weekly administration of Isoniazid (600 mg), Rifampicin (450 mg), and Pyrazinamide (1500 mg). This was followed by a four-month continuation phase with Isoniazid (600 mg) and Rifampicin (450 mg) administered thrice weekly.

Outcome and Follow-up

On the recall visits, complete resolution of the gingival lesions was observed following the therapeutic regimen (Figure 4).

During the treatment phase, patient was routinely monitored and there were no noticeable side effects to ATT.

Discussion

Tuberculosis has become a global health problem and is the leading cause of death among individuals above five years of age. Moreover, approximately eight million people are affected by the disease each year and around three million succumb to complications associated with it.² The incidence of primary tuberculosis in the oral cavity is quite rare.³

The most common causative organism associated with tuberculosis of oropharynx, lungs and lymph nodes is Mycobacteria tuberculosis and less commonly Mycobacteria bovis.⁴ The prevalence of oral lesion in tuberculosis patients is 0.8% to 3.5% and very rarely the oral lesions are identified before the detection of pulmonary tuberculosis.⁵ The predisposing factors in most developing countries are poverty, malnutrition, econ-omic recession, poor oral hygiene, tooth extraction and lack of awareness among the affected individuals.⁶ The primary form of oral tuberculosis is very rare which occurs mostly in young adults and it is usually painless causing caseation of the involved lymph nodes. In contrast, the secondary form occurs in slightly older individuals accounting for 0.5% to 1.5% of the cases.⁷ The most common site of involvement in primary oral tuberculosis is the tongue, followed by lips, cheek, soft palate, uvula, gingiva and alveolar mucosa.⁷ The primary diagnostic challenge in most of the cases is due to its numerous clinical presentations which may take forms of a granuloma, ulcer, erosions, patches, nodules, fissures, vesicles and plaques.⁷ The pathogenesis is influenced by an intact mucosal epithelium and the antimicrobial properties of saliva, which act as barriers to the direct invasion of bacilli. However, factors such as minor mucosal erosions, tissue inflammation or injury, bone abnormalities, or an open extraction socket can create favourable conditions for the organism to localize and proliferate.⁶ Whenever, gingival lesions in the form of erosions are noted, a range of differential diagnosis like desquamative gingivitis, linear gingival erythema and granulomatous lesions must be considered. Biopsy is essential for confirming the diagnosis. However, if the histopathological features overlap with those of other granulomatous lesions, supplementary tests such as smear, culture, Mantoux test, and ELISA can aid in accurately identifying the disease and guiding patient management.⁸ The recommended treatment for tuberculosis includes three of the four antituberculosis agents (Rifampicin, Ethambutol, Pirazinamide and Isoniazid) administered daily for two months (eight weeks), followed by a four months (16 weeks) continuation phase in which two drugs are administered daily, twice a week, or three times a week.²

The present case report describes a young male patient presenting with areas of gingival inflammation. The likelihood of diagnosing primary tuberculosis was minimal due to negative findings from multiple diagnostic tests and investigative procedures. However, anti-tubercular therapy was initiated to address the potential presence of oral tuberculosis. Therefore it is recommended to record a detailed medical history and conduct necessary investigations to rule out the possibility of various infectious diseases before their systemic outcomes.

Conflict of Interest

Nil