Two tuberculides in one patient—a case report of papulonecrotic tuberculide and erythema induratum occurring together

A patient is described in whom erythema induratum and papulonecrotic tuberculide occurred simultaneously. Clinical and histological appearances were characteristic as was the response to antituberculous chemotherapy.     

硬红斑皮损中结核杆菌DNA的检测

为了探讨皮肤血管炎和结核杆菌的关系。应用PCR技术对硬红斑病理组织进行了结核杆菌DNA的检测,结果显示4例作为阳性对照的淋巴结结核中3例呈阳性,正常皮肤组织及5例硬红斑均呈阴性,表明完整的结核杆菌在硬红斑并不多见,可能部分由其产生的蛋白或细菌碎片引起的变态反应所致。     

Papulonecrotic tuberculid. Identification of Mycobacterium tuberculosis DNA by polymerase chain reaction.

Sections from 22 formalin-fixed, paraffin-embedded skin biopsies from 12 patients with papulonecrotic tuberculid (PNT) were examined for the presence of Mycobacterium tuberculosis DNA with use of the polymerase chain reaction. All patients had a positive tuberculin skin test and a compatible clinical picture and responded to antituberculous therapy. Histological examination showed the typical morphology of PNT lesions with dermal necrosis surrounded by an ill-formed granulomatous infiltrate. Mycobacterial DNA was detected in 11 of the 22 biopsies. None of the negative controls showed positive DNA identification by amplification. Great care was taken in avoiding false-positive results due to contamination. After reviewing the literature, we believe this is the first time that PNT lesions have been investigated by PCR for the presence of mycobacterial DNA. These findings provide direct proof that mycobacterial products are present in PNT lesions and support the theory that this organism is in some way responsible for the development of PNT.     

Detection of Mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids

BACKGROUND:The objective of this study was to explore the role of the polymerase chain reaction (PCR) fo the detection of Mycobacterium tuberculosis DNA as a diagnostic aid in cutaneous tuberculosis using routinely processed skin biopsy specimens. METHODS AND RESULTS: A wide range of clinical specimens representing different forms of cutaneous tuberculosis and so-called tuberculids were studied. A sensitive and specific PCR assay targeting the sequence IS6110 of Mycobacterium tuberculosis complex was used. The specimens were categorized as follows. 1 Acid-fast bacilli (AFB) positive on biopsy (nine specimens from seven patients who were immunocompromised). PCR was positive in five specimens. Of these, one specimen was culture positive and three specimens were culture negative. 2 AFB negative on biopsy: (a) tuberculosis verrucosa cutis (23 specimens); (b) lupus vulgaris (three specimens); (c) cutaneous tuberculosis clinically suspected (six specimens). PCR was negative in all specimens. 3 Tuberculids.' (a) erythema induratum/nodular vasculitis (20 specimens); (b) papulonecrotic tuberculid (two specimens); (c) erythema nodosum (20 specimens). PCR was negative in all specimens. CONCLUSIONS: The role of PCR in clinical dermatologic practice, at this stage, may be in differentiating between cutaneous tuberculosis and atypical mycobacterial infections in the context of an immunocompromised patient where AFB can be demonstrated on biopsy and cultures may be negative. In this clinical situation, PCR allows the prompt diagnosis and early institution of appropriate therapy. We have not found PCR to be a useful complement to the clinical and histologic diagnosis of "paucibacillary" forms of cutaneous tuberculosis.     

Detection of Mycobacterium tuberculosis complex DNA by the polymerase chain reaction for rapid diagnosis of cutaneous tuberculosis

Summary We assessed the polymerase chain reaction (PCR) technique to detect Mycobacterium tuberculosis complex DNA In 48 paraffin-embedded specimens from 32 patients with different variants of cuttineous tuberculosis, and compared the resuts with those of culture. A 123 bp product of the 1S6110 insertion sequence specific of M. tuberculosis complex was amplified and confirmed by digestion with Sall restriction endonuclease. The time required for the procedure was 3 days. Thirty-seven samples (77.1%) were positive for M. tuberculosis complex DNA. No false positive results were obtained in nine negative controls, Of the 20 specimens tested by PCR and culture, the frequency of positivity was 90% for DNA amplification and 65% for culture. In seven cases of lupus vulgaris, the figures were 100% and 57% respectivety. In the 11 specimens culture negative or not microbiologically tesled and PCR negative, evidence for tuberculous infection was provided hy the correlation of various relative fmd absolute criteria. These results show that PCR amplification of the IS6110 insertion fragment is a rapid and accurate means for the detection of M. tuberculosis complex DNA in paraffin-embedded skin biopsies from patients with cutaneous tuberculosis, especially in paucibacillary lesions.     

Lupus miliaris disseminatus faciei—the DNA of Mycobacterium tuberculosis is not detectable in active lesions by polymerase chain reaction

There has been a controversy as to the origin of lupus miliaris disseminatus faciei (LMDF). It was originally thought to be associated with tuberculosis, due to its histopathological similarity. Recently, this association has been doubted, although there remain reported cases of LMDF associated with Mycobacterium tuberculosis. Three patients with the clinical and histopathological features of LMDF are described. Skin from these patients was analysed by polymerase chain reaction (PCR) using two different oligoprimers for the detection of 123 bp and 165 bp DNA fragments specific for M. tuberculosis complex. With these two PCR systems, no M. tuberculosis DNA was detected in any of the LMDF patients. It was present in all positive controls and absent in all negative controls. In this study we could not demonstrate an association between LMDF and tuberculosis.     

A case of panniculitis caused by Mycobacterium massiliense mimicking erythema induratum

Among nontuberculosis mycobacteria (NTM), rapidly growing mycobacteria (RGM) are the most common causative agents of soft tissue infection. Mycobacterium massiliense, a new species of NTM, was isolated in 2004. Due to the lower virulence of RGM, M. massiliense infection is rare in the general population. Here, we report a case of multiple infective panniculitis, due to M. massiliense, mimicking erythema induratum in a patient with Cushing syndrome. The organism was identified using traditional mycobacterial culturing and staining methods as well as molecular approaches, including erythromycin ribosome transferase gene polymerase chain reaction. The patient was treated with clarithromycin for 9 months, based on antibiotic susceptibility testing.     

Identification of herpes simplex virus DNA in lesions of erythema multiforme by the polymerase chain reaction.

An association between erythema multiforme and herpes simplex virus infection has been supported by clinical studies and by the detection by immunofluorescence of herpes viral antigen in sera and skin biopsy specimens of patients with erythema multiforme. In rare cases, the virus has also been isolated in cultures of skin biopsy specimens of erythema multiforme. To investigate further the association between erythema multiforme and herpes simplex virus, we used the polymerase chain reaction for herpes simplex virus to examine skin lesions from patients with erythema multiforme. In this study herpes simplex virus DNA was detected in 11 of 31 biopsy specimens of erythema multiforme; six additional cases showed equivocal amplification results, which is suggestive of low amounts of viral DNA. Seven skin and mucosal biopsy specimens with the histologic changes of herpes virus infection served as positive controls: all were positive for herpes simplex virus DNA. Viral DNA was not detected in control biopsy specimens from skin excised for unrelated conditions. These studies support the association of herpes simplex virus in the pathogenesis of some cases of erythema multiforme. The polymerase chain reaction provides a quick and effective method of detecting herpes simplex virus in lesions of herpes-associated erythema multiforme. Furthermore, the polymerase chain reaction may delineate those cases of erythema multiforme that are etiologically related to herpes virus infection and therefore might be treated with acyclovir to prevent recurrence.     

Detection of HSV-specific DNA in biopsy tissue of patients with erythema multiforme by polymerase chain reaction

Formalin-fixed paraffin-embedded skin biopsies of lesions of erythema multiforme (EM) from 32 patients and 13 controls were examined for the presence of herpes simplex virus (HSV) by polymerase chain reaction (PCR) and for histological findings by direct immunofluorescence and staining with haematoxylin and eosin. HSV-specific DNA was detected in 23 (72%) patients. A history of recurrent skin rash was present in 59% of the PCR-positive cases, while 55% had had suspected HSV infections. Only two PCR-positive specimens were found in patients without a history of recurrent rash and/or previous oral lesions. One biopsy was positive for HSV by conventional cell cultures. There was no significant difference in histology between HSV-related and HSV-negative cases of EM. In the 13 control specimens [bullous pemphigoid (3), dermatitis herpetiformis (2), lichen planus (1), aphthous ulcer (1), fixed-drug eruption (1), varicella-zoster (1), hypereosinophilic syndrome (1), photocontact dermatitis (1), contact dermatitis (1), and cellulitis (1)], no HSV-DNA was detected.     

Orificial tuberculosis: detection by polymerase chain reaction

Summary Orificial tuberculosis (OT) is a rare manifestation of cutaneous tuberculosis in immunocompromised individuals. Due to its variable clinical features, the diagnosis may be missed at the onset of the disease. We report a 53-year-old patient who had OT and miliary spread of Mycobacterium tuberculosis to the lungs, liver, bones and skin. The diagnosis was established by polymerase chain reaction (PCR) amplification of a Mycobacterium -specific gene segment, and confirmed by culture. PCR allows the detection of mycobacterial DNA within a few days, whereas culture takes many weeks. PCR may improve the accurate diagnosis of skin tuberculosis and allow early treatment.     

Erythema induratum of bazin: role of polymerase chain reaction in diagnosis

A 55‐year‐old man presented with recurrent multiple ulcerative nodules and plaques of 1‐year duration over the lower extremities. They were recalcitrant to topical (hydrocortisone cream) and systemic (pentoxyfylline, cefotiam) drugs. Skin surface examination of the affected areas showed the skin to be studded with violaceous nodules and/or plaques. A few of these had draining ulcers. The nature of the fluid was serosanguous. The lesions were located on the shins of the legs ( Fig. 1 ). They were bilateral and asymmetrical. In addition, nontender, erythematous nodules of annular configuration were located on the right knee and elbow, and a few toes. The arterial pulsation was within normal limits. Serial hematoxylin‐eosin stained sections prepared from a representative lesion were marked by the presence of palisading granulomatous dermatitis ( Fig. 2 ). A granulomatous folluculitis in the deep dermis and a thrombotic arteriole in the subcutis were also found. Sections counter‐stained for the presence of acid‐fast bacilli were negative. Paraffin‐embedded biopsy specimens were subjected to DNA analysis using the IS6110 gene as a polymerase chain reaction (PCR) primer, and were found to be positive. Serial chest X‐rays taken at an interval of 4 months showed findings indicative of active pulmonary tuberculosis. Anti‐tubercular therapy (ATT) comprising 450 mg of rifampicin, 300 mg of isoniazid, 800 mg of pyrazinamide and 1500 mg of ethambutol was administered for a period of 2 months followed by 450 mg of rifampicin and 300 mg of isoniazid for another 2 months. There was perceptible healing of the lesions, leaving atrophic and hyperpigmented scars.

Figure 1 Open in figure viewer PowerPoint Multiple, violaceous, ulcerated plaques and nodules on the shins of both legs     

Mycobacterium tuberculosis found at both skin lesions and Mantoux testing site in a patient with erythema induratum of Bazin

Mycobacterium tuberculosis is very rarely found in erythema induratum of Bazin; recently, we found an unusual case with positive acid‐fast bacilli and polymerase chain reaction for detecting M. tuberculosis in both skin lesions of the extremities and the site of Mantoux test.     

Facial granulomatous diseases: a study of four cases tested for the presence of Mycobacterium tuberculosis DNA using nested polymerase chain reaction

The histopathologic diagnosis of cutaneous tuberculosis (CTB) is often troublesome, because there are several other entities (tuberculids, demodicidosis, granulomatous rosacea, and acne agminata) that may display granulomatous inflammation with caseation necrosis. The current study describes four cases of granulomatous disease of the face. The final diagnosis (assessed on the basis of the clinical response to therapy) was CTB in three cases and granulomatous rosacea in one case. Histologically, epithelioid granulomas were a constant feature; in one case of CTB, they displayed a palisading (granuloma annulare-like) arrangement. Caseation necrosis was a prominent feature only in the case of granulomatous rosacea. Routinely processed biopsy specimens were evaluated with nested polymerase chain reaction (nPCR) for Mycobacterium tuberculosis (MBT) DNA. The correlation between nPCR results and clinical outcome was less than optimal; in fact, one case showed an excellent clinical response to the antituberculous drug therapy despite the absence of MBT DNA amplification. In granulomatous diseases of the face, the importance of evaluating not only nPCR but the overall clinicopathologic picture so as to avoid diagnostic misinterpretations is emphasized.