Cutaneous tuberculosis presenting as necrotizing fasciitis in an elderly patient

We report a case of cutaneous tuberculosis presenting as cellu litis and necrotizing fasciitis of the bilateral lower legs. The patient was a 79-year-old male who denied any history of chronic medical diseases such as hypertension, diabetes or old cerebrovascular accident. He had developed itchy skin papules since August 2008. His clinical cellulitis failed to respond to antibiotic therapy. Subsequent investigations involving both acid-fast bacilli cultures and smears of neck lymph nodes were positive, and established the alternative diagnoses of cutaneous tuberculosis, hyper-IgE syndrome and eosinophilia. The skin eruption cleared after treatment with isoniazid, rifampicin and pyrazinamide. This case represents a most unusual presentation of tuberculosis in the skin. The atypical features may reflect the patient's general medical state.