Perforation of the hard palate due to tuberculosis
A 7-year-old boy presented with difficulty in swallowing solid foods, low-grade fever and loss of weight for 11/2 month. His mother was on antituberculous therapy for pulmonary TB. There was no history of cough, abdominal pain, vomiting, diarrhea, or urinary complaints. On admission, his heart rate was 104/min, the respiratory rate was 28/min and blood pressure was 98/60 mmHg. His weight was 13 kg, and height was 104 cm (both below the fifth percentile for age and sex). Mild pallor was present. Oral cavity examination showed perforation of the hard palate, 3 × 3 cm with an irregular, undermined margin, and a necrotic base []. Bilateral matted cervical lymphadenopathy was present. Respiratory system examination showed crepitations on the right side anteriorly. Rest of the systemic examinations were normal. The Mantoux test was positive (28 mm). Investigations showed: Hemoglobin 8.8 g/dL, total leucocyte count 9000/cumm (neutrophils 40%, lymphocytes 60%), erythrocyte sedimentation rate 80 mm at the end of 1 h. His liver and renal functions tests were normal. Serology for human immunodeficiency virus was negative. His blood culture and urine culture did not show any growth. Computed tomography scan of the oral cavity showed erosion and scalloping of the posterior part of the hard palate on the right-side []. Chest X-ray showed homogeneous opacity in the upper-right zone. Gastric lavage for acid fast bacilli was positive. High power view of papanicolou stain of fine-needle aspiration of the lymph nodes showed granular caseous necrosis and granuloma composed of epitheliod cells and histiocytes []. Patient's relatives did not give consent for biopsy of the palatal lesion. However, in view of the clinical presentation and evidence of pulmonary and lymph node TB, the palatal perforation was most likely due to TB. He was started on antituberculous therapy (isoniazid, rifampicin, pyrazinamide, and ethambutol) and is on regular follow-up with the oral surgeons for repair of the palatal perforation.