Cutaneous Vulvar Tuberculosis Over an Episiotomy Scar in an Immunocompetent Patient

Cutaneous tuberculosis is an uncommon extrapulmonary manifestation of Mycobacterium tuberculosis infection. Vulvar involvement is an exceptionally rare clinical entity that poses significant diagnostic challenges due to its similarity to other dermatologic and gynecologic conditions. We present the case of a 25-year-old immunocompetent woman with an 18-month history of a vulvar and perineal lesion that developed over the scar of a previous episiotomy. The patient was initially managed for a recurrent bacterial soft-tissue infection and received multiple antibiotic regimens without a therapeutic response. Upon admission, a raised, erythematous, granulomatous plaque with fistulization was observed. Definitive diagnosis was established through histopathological examination, which revealed chronic granulomatous inflammation and a Ziehl-Neelsen stain positive for acid-fast bacilli. To further complement the diagnostic workup, an interferon-gamma release assay was performed and was reactive; the tuberculin skin test was deferred due to the patient's prior BCG vaccination. Standard four-drug antituberculous therapy was initiated, resulting in a favorable clinical evolution. Vulvar tuberculosis should be considered in the differential diagnosis of chronic, ulcerated, or granulomatous genital lesions unresponsive to conventional antibiotic therapy, particularly in patients from endemic areas. Early clinical suspicion and timely biopsy are crucial to prevent morbidity associated with delayed diagnosis.