The ulcer that would not heal: a rare cutaneous clue to miliary tuberculosis

Cutaneous tuberculosis (TB) is a rare manifestation of extrapulmonary TB, accounting for only 1-1.5% of cases. Among its various forms, cutaneous miliary TB is exceptionally uncommon and often presents with nonspecific clinical features. This makes early diagnosis challenging, especially in individuals who are immunocompromised. We report the case of a 67-year-old woman who presented with a 6-month history of multiple painful, nonhealing ulcers over the mons pubis, perivulvar area and left upper arm. Despite multiple courses of antibiotics, there was no improvement. Clinical examination revealed multiple well-defined ulcers with yellowish discharge. The patient had no history of bacille Calmette-Guérin vaccination. Tissue GeneXpert analysis from the ulcer confirmed Mycobacterium tuberculosis, and chest radiography revealed bilateral pulmonary nodules consistent with miliary TB. Imaging of the spine also showed features of spinal TB. The patient was diagnosed with miliary TB and was initiated on standard antitubercular therapy. Significant clinical improvement was noted within 1 month of treatment. This case highlights the importance of considering cutaneous TB, including its rare miliary form, in the differential diagnosis of chronic nonhealing ulcers, particularly in endemic areas or in patients with systemic symptoms. Early diagnosis and appropriate therapy are crucial for favourable outcomes.