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 A 16 years old Myanmar boy presented with a
non healing ulcer of the right cheek of 4
months duration in late April 2007.
 The ulcer is not associated with pain.
 The ulcer measuring about 1 x 1 cm in greatest
dimension is seen on the right cheek directly
below the ala – tragus line. The surrounding
tissue is erythematous and indurated.
 Slough and pus noted. The base of the ulcer
appears raw The central portion of the ulcer is
fixed to the underlying muscles.
 Intra-orally the was no communication with the
buccal mucosa. 46 retained root noted intra
orally, no pus discharge, swelling or sinus noted.
On percussion no tenderness noted on 46.
 On full physical examination, patient appears
healthy with no signs of jaundice or anemia.
Patient looks well hydrated. There are no
similar lesions noted in any part of his body.
 Right Submandibular lymph nodes are not
palpable, the deep cervical lymph nodes are
not palpable bilaterally.
 Patient complaint of having cough about 4
months ago. The symptom resolved without
any medication after one month. He has no
high risk habits.
 Patient past medical history revealed no
significant event.
 Patient is currently working

 Diagnostic Radiology

 46 retained root with periapical lesion noted. No

other pathological lesion present on the mandible

or maxilla

 Two radiolucent lesions seen on the apex of the

left lung.
 Blood investigation
 Full blood count

 White blood cell count 9.9 x 10*9/ l

 Differential count
Neutrophils 8.0 x 10*9/l ( 2 - 7.5 x 10*9/l)
 Hb 11.5 g/dl
 PCV 0.33
 ESR 86mm/hr ( 3 - 5 )

 Tissue samples were taken for bacteriology study.

The samples were sent to HKL pathology lab for
direct smear, Institute of medical research for
histopathology examination and institute of
respiratory medicine for culture and sensitivity
specific for mycobacterium tuberculosis.

 No acid fast bacilli were noted on direct smear, the

histopathological findings were non specific ulcer
with microscopic finding negative for acid fast bacilli
or fungal, but showed a few clusters of foreign body
type multinucleated giant cells present.
 The first culture result from IPR dated 15 June 2007
showed growth morphologically resembling
Mycobacterium Tuberculosis. The second report dated
23 August 2007 confirmed the culture to be
mycobacterium tuberculosis complex.
 Sensitivity test revealed that the culture consist of
highly and moderately resistant colony of bacteria.
 Patient was refer to IPR for further
investigation and treatment

 He was started on anti tuberculosis

chemotherapy in May 2007