Tuberculosis has countless clinical presentations, especially in immunosuppressed patients, and vulvar involvement is extremely rare ‒ occurring in about 1%–2% of patients diagnosed with genital tuberculosis, with increased risk in HIV coinfection. This report describes a case of a patient living with HIV, with treatment abandonment, with a chronic genital ulcer due to tuberculosis. A 33-year-old woman, experiencing homelessness and diagnosed with HIV for 10 years, without treatment, is taken to the hospital after suffering sexual violence. She had a previous diagnosis of pulmonary tuberculosis, with two treatment abandonments. At admission, sputum smear microscopy and TRM-TB were positive, culture grew M. tuberculosis , and LF-LAM was positive in urine. She had a CD4 lymphocyte count of 10 and HIV viral load of 5,100,000 copies/mL. She started treatment with RIPE, tenofovir, lamivudine, and dolutegravir and received prophylaxis after sexual violence. She had vulvar edema and a traumatic grade 2 perineal laceration, but stated she already had a chronic ulcer at the vaginal introitus. There was grayish leukorrhea and purulent drainage from the laceration; PCR for gonococcus and chlamydia and Tzanck cytology were negative. She was treated for pelvic inflammatory disease with ceftriaxone, azithromycin, and metronidazole, in addition to acyclovir. A punch biopsy of the ulcer edge was performed, with TRM-TB positive and histopathology showing a nonspecific chronic inflammatory process in activity. Imaging tests (computed tomography and magnetic resonance imaging) showed a 3.5 mL perirectal collection and a moderate amount of free fluid in the pelvis, blurring of intra-abdominal fat and bilateral inguinal lymph nodes, in addition to diffuse thickening of the vaginal wall and labia majora, with contrast enhancement. During hospitalization, she evolved with important improvement of the vulvar ulcer. This case illustrates the occurrence of a rare manifestation of tuberculosis, usually not considered in the differential diagnosis of chronic genital ulcers, with relevance for the institution of appropriate treatment especially in PLHIV.
Logarezzi et al. (Sun,) studied this question.